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Summary Table

Category	Key Features
Risk Factors	Sexual activity, spermicide use, postmenopausal estrogen deficiency, controlled diabetes, recurrent UTI history; Pregnancy, male sex, uncontrolled diabetes, immunosuppression, prematurity, neonate; Renal insufficiency, polycystic kidney disease; Ureteral obstruction, short-term catheter, asymptomatic bacteriuria, controlled neurogenic bladder; Long-term catheter, unresolved obstruction, uncontrolled neurogenic bladder
Etiology	Uncomplicated UTI: E. coli 70 to 95%, S. saprophyticus 5 to >20%. Complicated UTI: broader spectrum including Citrobacter, Enterobacter, Pseudomonas aeruginosa, Enterococci, Staphylococcus aureus, Klebsiella, Proteus mirabilis (urease producer, alkaline urine, struvite stones)
Patient Presentation	Lower tract: dysuria, urgency, frequency, hematuria, foul-smelling urine, suprapubic pain. Upper tract: fever, chills, flank pain, nausea, vomiting, with or without lower tract symptoms
Classic Physical Exam	Costovertebral angle (CVA) tenderness, suprapubic tenderness, fever in pyelonephritis. Digital rectal exam for suspected prostatitis (boggy, tender prostate; prostatic massage is contraindicated to avoid bacteremia and sepsis)
Key Diagnostic Results	Urine dipstick: positive leukocyte esterase, positive nitrite. Microscopy: pyuria >5 to 10 WBC/HPF after centrifugation at 2000 rpm for 5 minutes.
Management	Uncomplicated cystitis: fosfomycin, pivmecillinam, or nitrofurantoin as first-line. Acute uncomplicated pyelonephritis outpatient: short-course fluoroquinolone first-line. Inpatient pyelonephritis: IV antimicrobial regimen, switch to oral once tolerated.
Keywords	"Disuria akut, urgensi, frekuensi"; "nyeri ketok sudut kostovertebra"; "leukocyte esterase positif, nitrit positif"; "wanita muda aktif seksual" (cystitis); "bakteriuria bermakna ≥10⁵ CFU/mL"; "ISK komplikata vs nonkomplikata"; "qSOFA" (urosepsis screen); "ASB pada kehamilan"

1. Pathophysiology

UTI severity reflects the balance between host defense and uropathogen virulence. The ascending route is the dominant mechanism, with uropathogenic bacteria from the lower gut colonizing periurethral tissue, ascending through the urethra to the bladder, and potentially reaching the upper urinary tract. Female susceptibility is amplified by a shorter urethra, perineal colonization by enteric organisms, vaginal pH changes, increased bacterial adherence to vaginal epithelium, and reduced cervicovaginal antibodies. In uncircumcised boys, the prepuce serves as a reservoir for uropathogens. Hematogenous infection is uncommon outside the first months of life and persistent bacteremia. Lymphatic spread is rare and generally not a meaningful route.

The classic clinical picture maps onto inflammation. Lower tract irritation produces dysuria, frequency, urgency, suprapubic pain, and hematuria. Once pathogens ascend to the kidney, an intense inflammatory response causes fever, flank pain, costovertebral tenderness, and may produce renal scarring. Bacterial biofilm formation is a central mechanism behind persistent infection in patients with stones, urethral diverticula, infected paraurethral glands, and indwelling catheters; biofilms protect organisms from antimicrobial penetration and are a key reason for relapse.

E. coli dominates both uncomplicated and complicated UTI, with acidic urine (pH <4.5) as a possible clue because E. coli produces acid. Proteus species produce urease, splitting urea to ammonia and alkalinizing urine (pH >8.0), predisposing to struvite stone formation. Asymptomatic bacteriuria generally represents low-virulence commensals that may even act as biological prophylaxis against pathogenic colonization, which is a key reason routine treatment is avoided in most populations.

A central concept is the ORENUC risk stratification to define complicated outcomes. Patients in the E (extra-urogenital with severe outcomes), N (nephropathy), and C (unresolved urological) categories carry the highest risk of progression and require a more aggressive approach. All UTI in men, pregnant women, children, and immunocompromised patients are considered complicated because of the risk of progression to renal damage or sepsis.

2. Classification & Clinical Manifestations

Classification	Definition
Asymptomatic bacteriuria (ABU)	One or more bacterial species in urine ≥10⁵ CFU/mL on 2 consecutive samples (1 sample sufficient in men), without signs or symptoms of UTI
Uncomplicated UTI	Acute, sporadic, or recurrent lower (cystitis) and/or upper (pyelonephritis) UTI limited to non-pregnant women without known relevant anatomic or functional abnormality, normal renal function, and competent immune system
Complicated UTI	All UTI not meeting uncomplicated criteria: men, pregnant women, children, anatomic/functional abnormality, indwelling catheter, renal disease, comorbidity weakening defense (diabetes, sepsis), or failed response after 48 hours of antibiotics
Recurrent UTI (rUTI)	At least 3 UTI per year or 2 UTI in the last 6 months. In children: ≥2 episodes acute pyelonephritis, OR 1 acute pyelonephritis plus ≥1 acute cystitis, OR ≥3 acute cystitis episodes
Catheter-associated UTI (CA-UTI)	UTI in patients currently catheterized or catheterized within the past 48 hours
Urosepsis	Life-threatening organ dysfunction caused by dysregulated host response to infection from the urinary tract or male genital organs
Acute bacterial prostatitis (ABP) / Chronic bacterial prostatitis (CBP)	Clinical diagnosis with evidence of bacterial inflammation localized to the prostate. ABP: predominantly E. coli (Enterobacteriaceae). CBP: broader spectrum, may include atypical organisms
Urethritis	Inflammation of the urethra with discharge, pruritus, dysuria. Primary or secondary (catheter, stricture). Divided into gonococcal (GO) and non-gonococcal

3. Diagnostic Workup

Diagnostic Test Summary

Test	Purpose	Findings
Urinalysis (dipstick)	Initial triage; suggestive of UTI when leukocyte esterase and nitrite both positive	Leukocyte esterase (+), Nitrite (+) if Gram (-).
Urine microscopy	Confirms inflammation and bacteriuria	Pyuria: WBC >5 to 10/HPF after centrifugation at 2000 rpm for 5 minutes (sensitivity 95%, less specific). Squamous epithelial cells >15 to 20/HPF suggest contamination
Urine culture	Gold standard for definitive diagnosis and antibiotic guidance	See below for quantitative criteria
Blood culture	Suspected urosepsis or pyelonephritis with systemic features	Two sets before antimicrobial therapy
qSOFA	Rapid identification of patients at risk of sepsis	RR ≥22/min, altered consciousness (GCS <15), SBP ≤100 mmHg. ≥2 criteria suggests severe infection
Renal/pelvic ultrasound	First-line imaging for pyelonephritis to rule out obstruction or stones; ideally within 24 hours	Hydronephrosis, abscess, stones, residual urine volume
CT scan (pre- and post-contrast)	Most accurate imaging for poor response after 72 hours, suspected abscess, complicated cases	Spiral CT pre-contrast detects stones, calcifications, gas. Post-contrast at 90 to 120 seconds (tubular venous phase) for parenchymal evaluation
MRI	Imaging of choice in pregnancy to avoid radiation	Same indications as CT in non-pregnant patients

Quantitative Bacterial Counts for UTI Diagnosis

Collection Method	Quantitative Criterion (CFU/mL)
Voided clean catch, asymptomatic (men or women)	≥10⁵ (women: 2 consecutive samples recommended)
Voided clean catch, women with acute uncomplicated cystitis	≥10³
Voided clean catch, women with pyelonephritis	≥10⁴
Voided clean catch, symptomatic men	≥10³
External condom catheter	≥10⁵
In-and-out catheter	≥10²
Indwelling catheter, asymptomatic	≥10⁵
Indwelling catheter, symptomatic	≥10²
Suprapubic or percutaneous aspiration	Any growth

The Workup, Step by Step

For a healthy non-pregnant woman with classic lower urinary tract symptoms, the diagnosis of uncomplicated cystitis is largely clinical based on dysuria, frequency, urgency, and absence of vaginal discharge or irritation. Urine dipstick is an acceptable alternative to confirm the diagnosis. Urine culture is mandatory in the following situations: suspected acute pyelonephritis; symptoms not resolving or recurring within 4 weeks of completing therapy; women presenting with atypical symptoms; pregnant women; and any suspected UTI in men.

For acute uncomplicated pyelonephritis, do a routine urinalysis with assessment of leukocytes, erythrocytes, and nitrite; urine culture with antimicrobial sensitivity testing; and urinary tract imaging to rule out urgent urological abnormalities. Outpatient candidates are those tolerating oral intake, hemodynamically stable, and reliable for follow-up.

Indications for hospitalization in pyelonephritis include inability to maintain hydration or tolerate oral antibiotics, severely ill or debilitated patient, failure of outpatient oral therapy, need for further investigation, predisposition to complicated UTI, and comorbidities such as pregnancy, diabetes, or advanced age.

Imaging is escalated when patients fail to defervesce after 72 hours of appropriate therapy, when clinical deterioration occurs, or when complicated features are suspected. Ultrasound is the initial imaging modality for pyelonephritis. CT is performed if findings are inconclusive or if abscess, perinephric collection, or emphysematous pyelonephritis is suspected. Plain abdominal radiography may be used when ultrasonography shows pelvicalyceal dilation without a visible stone.

Urological evaluation is recommended in: men presenting with their first UTI episode; all complicated UTI or bacteremia; suspected obstruction or kidney stones; UTI with hematuria or renal colic; failure to respond to appropriate antibiotics; recurrent infection; persistent hematuria; and isolation of unusual organisms such as Pseudomonas or Proteus.

For ASB in pregnancy, screening is performed by midstream urine culture once at the first trimester visit (or first prenatal visit if later). Positive culture is defined as ≥10⁵ CFU/mL. If the initial screen is negative, no further screening is required. Where culture is unavailable, dipstick and microscopy may serve as alternatives. A negative dipstick (no LE, nitrite, protein, no microscopic findings) does not require further work-up. Positive findings require confirmatory culture before treatment.

For suspected urosepsis, qSOFA assessment for early sepsis identification; urine culture and two sets of blood cultures before starting antimicrobial therapy. Sonography and CT scan are performed early upon arrival.

4. Management & Treatment

Clinical Scenario	Antimicrobial	Dose & Duration
Asymptomatic bacteriuria (general population)	No screening, no treatment	-
ASB in pregnancy	Treat after positive culture	Antibiotics for 5 to 7 days
ASB before urological procedures with mucosal trauma	Prophylaxis	Per local protocol
Acute uncomplicated cystitis (women)	First Line: Fosfomycin trometamol, pivmecillinam, or nitrofurantoin	Fosfomycin 3 g PO single dose Nitrofurantoin 50 to 100 mg PO QID for 5 days
Acute uncomplicated cystitis (women)	Alternative: TMP-SMX, ciprofloxacin, levofloxacin, trimethoprim, amoxicillin, amoxicillin-clavulanate, cephalexin, cefuroxime axetil, cefixime, doxycycline	TMP-SMX 160/800 mg PO BID for 3 days Ciprofloxacin 250 mg BID or 500 mg OD for 3 days Levofloxacin 250 to 500 mg OD for 3 days Trimethoprim 100 mg PO BID for 3 days
Cystitis in pregnancy	Nitrofurantoin (avoid late pregnancy and G6PD deficiency); cephalexin; fosfomycin	Nitrofurantoin 100 mg PO every 12 hours for 5 to 7 days; cephalexin 250 to 500 mg PO every 8 hours for 5 to 7 days Fosfomycin 3 g PO single dose TMP-SMX 800/160 mg every 12 hours for 5 to 7 days (avoid 1st trimester and near term) avoid amoxicillin and ampicillin empirically because of high E. coli resistance
Acute uncomplicated pyelonephritis	Short-course fluoroquinolone	Ciprofloxacin 500 mg PO BID or 1000 mg OD for 7 days Levofloxacin 750 mg PO OD for 5 days
Acute uncomplicated pyelonephritis	TMP-SMX, oral beta-lactam (only if susceptibility confirmed)	TMP-SMX 160/800 mg PO BID for 7 to 14 days Cephalexin 500 mg PO QID for 14 days Cefixime 400 mg OD for 14 days Cefuroxime axetil 500 mg BID for 14 days Amoxicillin-clavulanate 500 to 875 mg BID for 14 days. Avoid nitrofurantoin, oral fosfomycin, and pivmecillinam (do not reach kidney tissue)
Pyelonephritis (inpatient IV)	IV regimen initially, transition to oral when clinically improved and tolerating intake	Ceftriaxone 1 to 2 g IV OD; cefotaxime 1 g IV every 8 hours Ciprofloxacin 400 mg IV every 12 hours for 7 days Levofloxacin 750 mg IV OD for 5 days Gentamicin or tobramycin 3 to 5 mg/kg IV OD ± ampicillin 1 g every 4 to 6 hours Ertapenem 1 g IV OD Meropenem 500 mg IV every 6 hours Piperacillin-tazobactam 3.375 g IV every 6 hours
Complicated UTI	Combination empiric therapy	Amoxicillin + aminoglycoside OR 2nd-generation cephalosporin + aminoglycoside OR 3rd-generation IV cephalosporin. Use ciprofloxacin only if local resistance <10% for fully oral regimens, no hospitalization needed, or beta-lactam anaphylaxis
Urosepsis	High-dose broad-spectrum parenteral antimicrobials within 1 hour of clinical sepsis	Cefotaxime 2 g TID for 7 to 10 days; ceftriaxone 1 to 2 g OD Cefepime 2 g BID Piperacillin-tazobactam 4.5 g TID Ceftolozane-tazobactam 1.5 g TID Ceftazidime-avibactam 2.5 g TID Gentamicin 5 mg/kg OD Amikacin 15 mg/kg OD Ertapenem 1 g OD Imipenem-cilastatin 0.5 g TID Meropenem 1 g TID Source control is mandatory: drainage of obstruction or abscess, removal of foreign body
Recurrent UTI	Postcoital prophylaxis, continuous low-dose prophylaxis (3 nights per week for 3 to 6 months), or self-treatment	Continuous nightly: Nitrofurantoin 50 mg TMP-SMX 40/200 mg daily or alternate days Cephalexin 500 mg Norfloxacin 200 mg alternate days Ciprofloxacin 125 mg Trimethoprim 100 mg Postcoital single dose: TMP-SMX 40 to 200 or 80 to 400 mg, trimethoprim 100 mg, nitrofurantoin 50 to 100 mg, cephalexin 250 mg, norfloxacin 200 mg, ciprofloxacin 125 mg. Pregnant women: cephalexin

Step-by-Step Management

Acute uncomplicated cystitis in non-pregnant women is treated empirically. The first-line agents are fosfomycin trometamol, pivmecillinam, or nitrofurantoin. Short-course (3-day) regimens are preferred for most patients; 7-day regimens are reserved for those with risk factors associated with lower cure rates (symptoms longer than 7 days, age over 65 years, diaphragm use). For cystitis in men prostate involvement is common, so agents that penetrate the prostate (TMP-SMX or fluoroquinolones) for at least 7 days are preferred, ideally guided by sensitivity testing because cystitis in men is classified as complicated.

For acute uncomplicated pyelonephritis, outpatient candidates receive short-course fluoroquinolone first-line (ciprofloxacin 500 mg PO BID for 7 days or levofloxacin 750 mg PO OD for 5 days). If hypersensitivity or resistance is present, TMP-SMX 160/800 mg PO BID for 7 to 14 days is acceptable. Oral cephalosporins reach lower blood and urine concentrations than IV cephalosporins, which limits their role. Nitrofurantoin, oral fosfomycin, and pivmecillinam must be avoided because they do not achieve adequate renal tissue concentrations. If the clinical response is poor at 48 to 72 hours, re-evaluate for complicating factors and effectiveness, and consider switching agent or route.

For inpatient pyelonephritis, start IV antimicrobials initially and switching to oral therapy when the patient has clinically improved and tolerates oral intake. In men with febrile UTI, pyelonephritis, or recurrent infection, treatment duration is at least 2 weeks, preferably with a fluoroquinolone because of likely prostatic involvement.

ASB in pregnancy is treated with antibiotics for 5 to 7 days using agents sensitive against E. coli, Proteus, and Klebsiella. Pregnancy drug avoidances include: avoid empirical amoxicillin and ampicillin because of high E. coli resistance; TMP-SMX is avoided in the first trimester and near term unless no alternative exists; nitrofurantoin is avoided near term and in G6PD deficiency (risk of pulmonary toxicity and hemolytic anemia). Pregnant women with pyelonephritis require hospitalization because of risk of preterm labor (20 to 40%), with IV antibiotics and supportive care.

Complicated UTI management requires combination empiric therapy: amoxicillin plus aminoglycoside, second-generation cephalosporin plus aminoglycoside, or third-generation IV cephalosporin for systemic features. Manage the underlying urological abnormality alongside antibiotics. Total duration is typically 7 to 14 days, longer if prostatitis is present (14 days). For hemodynamically stable patients afebrile for 48 hours, a 7-day course may be sufficient.

The next best step in urosepsis is to perform qSOFA, obtain urine culture and two sets of blood cultures, then administer high-dose broad-spectrum parenteral antimicrobials within 1 hour of clinical recognition; source control through drainage of obstruction or abscess and removal of foreign bodies (such as stones or catheters) is a key element and is performed urgently; provide adequate life support immediately. Supportive measures include: fluid resuscitation with crystalloid or albumin if crystalloid is insufficient, leg elevation as a prediction of fluid responsiveness; norepinephrine as the primary vasopressor with dobutamine for myocardial dysfunction; hydrocortisone if fluid and vasopressors fail to achieve MAP ≥65 mmHg; transfusion to Hb 7 to 9 g/dL; glucose target around 180 mg/dL; DVT prophylaxis with low-molecular-weight heparin; PPI for stress ulcer prevention; enteral nutrition started early (<48 hours).

Recurrent UTI prevention includes: counseling to avoid risk factors, non-antimicrobial measures, and antimicrobial prophylaxis. Address residual urine volume (clean intermittent catheterization where appropriate). Three antimicrobial strategies are listed: postcoital single-dose prophylaxis (most useful when episodes are intercourse-related), continuous low-dose prophylaxis 3 nights per week for 3 to 6 months in women with more than 3 episodes per year, and patient self-initiated treatment with TMP-SMX or ciprofloxacin (a 3-day course) for women who travel or have less frequent recurrences. Pregnant women may receive cephalexin for prophylaxis.

ASB management exceptions emphasize that screening and treatment should be avoided in: women without risk factors, well-controlled diabetes, postmenopausal women, hospitalized elderly patients, lower urinary tract dysfunction or reconstruction, renal transplant recipients, pre-arthroplasty patients, and patients with recurrent UTI. Screen and treat only in pregnancy (with short-course standard treatment) and before urological endoscopic procedures.

5. Differential Diagnosis & Distractors

Differential Diagnosis	Why It's Similar	Key Discriminator
Vaginitis (candidal, bacterial, trichomonal)	Dysuria and urinary irritation in women	External (vulvar) dysuria, vaginal discharge, pruritus, dyspareunia; pelvic exam reveals discharge; wet mount shows clue cells (bacterial vaginosis), hyphae with KOH (candida), or motile trichomonads; whiff test positive in bacterial vaginosis
Urethritis (gonococcal vs non-gonococcal)	Dysuria and urinary symptoms in sexually active patients	Sexual history with new partners; mucopurulent urethral discharge; Gram stain showing >5 WBC/HPF with intracellular gram-negative diplococci confirms gonococcal urethritis; NAAT is the confirmatory test.
Pelvic inflammatory disease (PID)	Lower abdominal pain, fever in women	Cervical motion tenderness, adnexal tenderness, mucopurulent cervical discharge; complications include tubal fibrosis, ectopic pregnancy, infertility
Nephrolithiasis	Flank pain, hematuria	Colicky pain radiating to groin, patient writhing in pain (versus lying still); CT shows stone; afebrile unless infected. CT pre-contrast detects stones reliably
Acute bacterial prostatitis (men)	Dysuria, frequency, fever	Boggy, exquisitely tender prostate on digital rectal exam; prostatic massage is contraindicated because of risk of bacteremia and sepsis; treat at least 7 days, longer (14 days or more) if chronic prostatitis; E. coli dominates ABP, broader spectrum in CBP including possibly C. trachomatis
Interstitial cystitis (painful bladder syndrome)	Frequency, urgency, suprapubic pain	Negative cultures despite chronic symptoms; cystoscopy may show Hunner ulcers
Renal tuberculosis	Pyuria, hematuria, flank pain	Sterile pyuria with negative routine culture; constitutional symptoms; AFB on early-morning urine
Glomerulonephritis	Hematuria, possible flank pain	RBC casts, dysmorphic RBCs, proteinuria, hypertension, edema; recent infection (post-streptococcal)
Renal cell carcinoma or urothelial cancer	Hematuria, flank pain	Painless hematuria, weight loss, palpable mass
Atrophic vaginitis	Dysuria in postmenopausal women	Pale, thin vaginal mucosa, dyspareunia; responds to topical estrogen
Appendicitis	Right lower quadrant pain, fever, possible pyuria from contiguous inflammation	Migratory pain (periumbilical to RLQ), McBurney point tenderness, Rovsing sign; pyuria without bacteriuria

6. Traps & High-Yield Pearls

The most common ways students miss UTI questions cluster around the same traps. First, treating asymptomatic bacteriuria. There are eight populations where ASB screening and treatment should be avoided: women without risk factors, well-controlled diabetes, postmenopausal women, hospitalized elderly, lower urinary tract dysfunction or reconstruction, renal transplant, pre-arthroplasty, and patients with recurrent UTI. The two exceptions where treatment is mandatory are pregnancy (screen at first trimester visit, treat ≥10⁵ CFU/mL for 5 to 7 days) and before urological procedures with mucosal trauma.

Second, mismanaging UTI in pregnancy. Memorize the trimester-related drug rules from Tabel 11: avoid empirical amoxicillin and ampicillin because of high E. coli resistance; TMP-SMX is avoided in the first trimester and near term; nitrofurantoin is avoided near term and in G6PD deficiency. Acceptable agents are nitrofurantoin (in trimester 1 and 2), cephalexin, fosfomycin, amoxicillin-clavulanate, and cefuroxime. Pyelonephritis in pregnancy mandates hospitalization with IV ceftriaxone or another IV regimen; preterm labor risk is 20 to 40%.

Third, missing the pivot from cystitis to pyelonephritis. Fever, flank pain, CVA tenderness, and white blood cell casts mean upper tract disease, longer treatment duration, and a different antibiotic class. Nitrofurantoin, oral fosfomycin, and pivmecillinam are contraindicated for pyelonephritis because they fail to reach kidney tissue. Cystitis in men is essentially always considered complicated because of likely prostatic involvement; first-line agents are TMP-SMX or fluoroquinolone for at least 7 days.

Fourth, failing to escalate when antibiotics fail. Poor clinical response after 48 to 72 hours of pyelonephritis therapy requires re-evaluation for complicating factors and consideration of antimicrobial change or route change. Imaging (ultrasound first, CT if inconclusive) is escalated to rule out obstruction, abscess, or emphysematous pyelonephritis. An obstructed infected kidney is a urological emergency requiring drainage (percutaneous nephrostomy or ureteral stent) alongside antibiotics. Source control is needed in urosepsis, alongside antibiotics within 1 hour.

Several high-yield pearls round out the topic. The qSOFA is the rapid bedside tool for sepsis identification: respiratory rate ≥22/min, GCS <15, and SBP ≤100 mmHg. ≥2 criteria signal high mortality risk. E. coli dominates in essentially every UTI category; secondary organisms map to context: S. saprophyticus in young sexually active women, Proteus with alkaline urine and struvite stones, Pseudomonas in catheter-associated and hospital-acquired UTI, and Enterococcus, S. aureus in complicated UTI. Pyuria has many other causes including tuberculosis, analgesic nephropathy, interstitial nephritis, perinephric or cortical abscess, and fungal infection. Squamous epithelial cells >15 to 20/HPF indicate contamination. Fluoroquinolones are restricted as empiric therapy for complicated UTI to settings where local resistance is below 10%; recent ciprofloxacin use within 6 months is a contraindication.

The core competency tested is stratification using the ORENUC framework and matching it to the right empiric drug, duration, setting of care, and follow-up imaging. Master that decision tree along with the quantitative culture criteria the questions become reliably answerable.

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