Editing Urinary Tract Infections (section)

=== Unresolved UTIs ===
* Indicates that initial therapy has been inadequate in eliminating symptoms and/or bacterial growth in the urinary tract.
* '''If the symptoms of UTI do not resolve by the end of treatment or if symptoms recur shortly after therapy, urinalysis and urine culture with susceptibility testing should be obtained.'''
** If the patient’s symptoms are significant, empirical therapy with a fluoroquinolone is appropriate, pending results of the culture and susceptibility testing.
* '''Causes of Unresolved Bacteriuria, in Descending Order of Importance'''
*# '''Pre-existing bacterial resistance''' to the drug selected for treatment
*# '''Development of resistance from initially susceptible bacteria'''
*# '''Bacteriuria caused by 2 different bacterial species with mutually exclusive susceptibilities'''
*# '''Rapid re-infection with a new, resistant species''' during initial therapy for the original susceptible organism
*# '''Renal failure''' (inability to deliver an adequate concentration of antibiotics into the urinary tract)
*# '''Papillary necrosis from analgesic abuse''' (defects in the medullary concentrating ability dilutes the antibiotic)
*# '''Staghorn calculi''' (large mass of bacteria)
*# '''Self-inflicted infections or deception in taking antimicrobial drugs''' (a variant of Munchausen syndrome)
* '''The first 4 causes that are associated with resistant bacteria require no further evaluation. However, if re-culture shows that the bacteria are sensitive to the antimicrobial agent the patient is taking, renal function and radiologic evaluation should be performed to identify renal or urinary tract abnormalities.'''
* '''Management'''
** '''Initial empirical antimicrobial selection for unresolved UTI should be based on the assumption that the bacteria are resistant and an''' antibiotic different from the original agent should be selected.
*** Fluoroquinolones offer excellent coverage in most cases and should be given for 7 days.
** When the bacterial susceptibilities are available, adjustments can be made if necessary.
** Urine cultures should be performed during and 7 days after therapy to ensure microbiologic efficacy.