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Urinary Tract Infections

In adults with urinary tract infections (UTI's) there are specific symptoms such as dysuria, hematuria or flank pain referable to the urinary tract. Keep in mind that not all UTI's are created equal. Some are uncomplicated and will self-resolve and require no additional workup or treatment. However, in the elderly patient, they may be very symptomatic and even have acute altered mental status. Complicated UTI's can cause some pretty dramatic confusion and even hallucinations in an otherwise lucid individual. UTI Induced delirium is a real thing in the older populations. The incidence of UTI's is much higher in females as compared to males. It is all based on anatomical differences, specifically the length of the urethra. As an EMS provider, medical calls with vague complaints (very common in UTI's) force us to cast a wide net regarding a differential diagnosis. Yes - we diagnose, don't let anyone tell you otherwise.

In pediatric patients' fever and acute illness without a defined origin are an indication, as bacterial UTI's is the most common serious occult (hidden) infection in this age group. In small children, development of urinary incontinence or prolonged enuresis (bed wetting at night) is also generally evaluated to exclude an infectious etiology. This history can many times be elicited from a parent as part of your history of present illness documentation.

Regardless of age, UTI's can easily fulminate into urosepsis and carry life threatening consequences. Most of these patients become very dehydrated and may benefit from generous fluid resuscitation en route to the hospital. Looks at their mucous membranes as a quick clue during your detailed physical exam.

Keep in mind that the urinary tract should be sterile. Just like your CSF, and your lower respiratory tract. However, bacteria are frequently seen in the urine. Keep in mind that accidental contamination from the vaginal vault or rectum is also common. Bacteria is not the only causative agent of UTI's thought. Certain yeasts/fungi can also cause serious infections especially in those patients that are immunocompromised -- in those cases their normal flora (good bacteria are altered in number or non-existent all together).

Many times, you enter a patient's primary residence, or a nursing home facility and the patient may have an indwelling catheter in place. This helps drain the bladder of urine, but also makes it easier for an infection to setup shop anywhere along the tract -- from the urethra to the bladder (cystitis) to the ureter, and even up to the kidney (pyelonephritis). Take a look at the catheter/foley bag-- the urine may be brown, it may be bloody or turbid, it may also have a strong, pungent odor. All outward signs that the internal sterility of the tract is no more.

Catheter associated UTI's (CAUTI's) costs the healthcare system a lot of money. Nearly every institution monitors these illnesses and troubleshoots them -- their main focus is staff/patient education and means of prevention. The laboratories will culture the urine to isolate what exact bacterial or fungal species is causing the infection. They will then screen the microorganisms against a host of antibiotics or antifungals. The patient will likely remain on these medications for days and hopefully the urine will begin to clear up and their overall clinical course improves.

You can almost guarantee an overnight admission to the hospital if any of the following are present

  • Ill appearance/concern for urosepsis/concerning vital signs

  • Moderate/severe dehydration

  • Vomiting, inability to tolerate oral fluids or antibiotics

  • Concern for follow-up

  • Infants < 3 months have any extremely low thresholds

In the acute EMS setting maintaining volume status is KEY. If they look dry - provide fluids - there is nothing wrong with 20ml/kg NSS boluses if you suspect septicemia. Remember you have many tools at your disposal to help determine SIRS + full blown sepsis, and MD degree is not required.

Do they have:

  • Tachycardia

  • Tachypnea

  • Temperature > 100.4 F

  • Profound hypotension or shock index (HR/SBP) > 1.0

If YES - be proactive + call the sepsis alert, this is a time sensitive emergency, no different than STEMI or Strokes.

May 6, 2024

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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