Urinary Tract Infections

Chapter 61 Urinary Tract Infections




Clinical Case Problem 1 A 27-Year-Old Woman with Spina Bifida and Bilateral Costovertebral Angle Pain


A 27-year-old woman presents to the emergency department with a 4-day history of fever, chills, and bilateral costovertebral angle (CVA) pain. She has an indwelling urinary catheter and describes to you “at least 12 of these episodes before this current one.” She has been seeing the same family physician since birth and has been diagnosed as having “nervous bladder and kidney syndrome.” He has prescribed some over-the-counter “kidney pills” in the past for these symptoms. She tells you that they “never really worked,” and she often has found herself bedbound with symptoms for several weeks before the fever broke.


You, the emergency department physician on shift, are somewhat skeptical about the nervous bladder and kidney syndrome.


On examination, the patient is flushed. Her temperature is 40° C. She has intermittent shaking rigors. She has CVA tenderness bilaterally. Her abdomen is somewhat tender to palpation. There is blood in the catheter collection bag.



Select the best answer to the following questions




1. What is the most likely diagnosis in this patient?


a. nervous bladder and kidney syndrome

b. acute hemorrhagic cystitis

c. acute urethritis

d. acute pyelonephritis

e. spina bifida bladder spasm syndrome

2. What would be the most likely organism in this patient?


a. a gram-positive coccus

b. a gram-positive rod

c. an anaerobic organism

d. a fungal organism

e. a gram-negative organism

3. Which of the following bacteria would not be considered highly probable of causing this problem?


a. Pseudomonas aeruginosa

b. Klebsiella pneumoniae

c. Enterobacter species

d. group A β-hemolytic streptococci

e. Proteus species

4. After obtaining a urinalysis and a urine specimen for culture and sensitivity, you now should treat the patient with which of the following?


a. over-the-counter kidney pills

b. ciprofloxacin 500   mg three times a day by mouth (outpatient)

c. Septra DS two tabs two times a day by mouth (outpatient)

d. intravenous (IV) antibiotics in a hospital

e. no medications are indicated at this time

5. Which of the following antibiotics would not be of first choice for this patient?


a. IV ceftriaxone (Rocephin) or cefotaxime (Claforan)

b. IV trimethoprim-sulfamethoxazole (TMP-SMX)

c. IV ciprofloxacin

d. IV ampicillin and gentamicin

e. IV piperacillin-tazobactam

6. The investigations that should be performed on this patient at this time include which of the following?


a. serum blood urea nitrogen (BUN) and creatinine

b. renal ultrasound

c. blood cultures

d. complete blood count (CBC) with differential

e. all of the above

7. The renal ultrasound study shows small, shrunken kidneys, with no enlargement of the ureters and no stones. What is the most likely diagnosis in this patient?


a. chronic pyelonephritis

b. ureterovesical reflux

c. hydronephrosis

d. vesicular diverticula

e. none of the above

8. Which of the following statements regarding chronic prophylaxis in this patient is true?


a. chronic prophylaxis is not indicated

b. chronic prophylaxis is unlikely to be of any benefit

c. chronic prophylaxis may make a significant difference in the preservation of this patient’s renal function

d. chronic prophylaxis is unlikely to be difficult because of resistant organisms

e. none of the above


Clinical Case Problem 2 A 34-Year-Old Woman with Hematuria, Dysuria, Increased Urinary Frequency, and Nocturia


A 34-year-old woman presents with a 3-day history of hematuria, dysuria, increased urinary frequency, and nocturia. She has had no fever, chills, or back pain.


On examination, she does not look ill. Her temperature is 37.5° C. Her abdomen is nontender. There is no CVA tenderness.



9. What is the most likely diagnosis?


a. Berger disease (immunoglobulin A nephropathy)

b. acute hemorrhagic cystitis

c. acute hemorrhagic urethritis

d. acute glomerulonephritis

e. acute cystitis with concomitant coagulation disorder

10. What is the treatment of choice for this patient?


a. a 10-day course of ampicillin and probenecid

b. a 7-day course of ampicillin and probenecid

c. a 3-day course of TMP-SMX

d. a 1-day course of TMP-SMX

e. a single dose of ampicillin 3.5   g and probenecid 1   g

11. Which of the following is the most appropriate plan in this case?


a. do not give antibiotics; send urine for culture, and do not start antibiotics until infection is confirmed and sensitivities are established

b. start antibiotic treatment right away; perform further testing only if the symptoms do not resolve or she has recurrent episodes

c. do not give antibiotics right away; send urine and call laboratory and put a priority rush on the result

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Urinary Tract Infections

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