Urinary tract infection
A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney infection (pyelonephritis). Symptoms from a lower urinary tract infection include pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder. Symptoms of a kidney infection include fever and flank pain usually in addition to the symptoms of a lower UTI. Rarely the urine may appear bloody. In the very old and the very young, symptoms may be vague or non-specific.
|Urinary tract infection|
|Other names||Acute cystitis, simple cystitis, bladder infection, symptomatic bacteriuria|
|Multiple white cells seen in the urine of a person with a urinary tract infection using a microscopy|
|Symptoms||Pain with urination, frequent urination, feeling the need to urinate despite having an empty bladder|
|Causes||Most often Escherichia coli|
|Risk factors||Female anatomy, sexual intercourse, diabetes, obesity, family history|
|Diagnostic method||Based on symptoms, urine culture|
|Differential diagnosis||Vulvovaginitis, urethritis, pelvic inflammatory disease, interstitial cystitis|
|Treatment||Antibiotics (nitrofurantoin or trimethoprim/sulfamethoxazole)|
|Frequency||152 million (2015)|
The most common cause of infection is Escherichia coli, though other bacteria or fungi may sometimes be the cause. Risk factors include female anatomy, sexual intercourse, diabetes, obesity, and family history. Although sexual intercourse is a risk factor, UTIs are not classified as sexually transmitted infections (STIs). Kidney infection, if it occurs, usually follows a bladder infection but may also result from a blood-borne infection. Diagnosis in young healthy women can be based on symptoms alone. In those with vague symptoms, diagnosis can be difficult because bacteria may be present without there being an infection. In complicated cases or if treatment fails, a urine culture may be useful.
In uncomplicated cases, UTIs are treated with a short course of antibiotics such as nitrofurantoin or trimethoprim/sulfamethoxazole. Resistance to many of the antibiotics used to treat this condition is increasing. In complicated cases, a longer course or intravenous antibiotics may be needed. If symptoms do not improve in two or three days, further diagnostic testing may be needed. Phenazopyridine may help with symptoms. In those who have bacteria or white blood cells in their urine but have no symptoms, antibiotics are generally not needed, although during pregnancy is an exception. In those with frequent infections, a short course of antibiotics may be taken as soon as symptoms begin or long-term antibiotics may be used as a preventive measure.
About 150 million people develop a urinary tract infection in a given year. They are more common in women than men. In women, they are the most common form of bacterial infection. Up to 10% of women have a urinary tract infection in a given year, and half of women have at least one infection at some point in their lifetime. They occur most frequently between the ages of 16 and 35 years. Recurrences are common. Urinary tract infections have been described since ancient times with the first documented description in the Ebers Papyrus dated to c. 1550 BC.
Signs and symptoms
Lower urinary tract infection is also referred to as a bladder infection. The most common symptoms are burning with urination and having to urinate frequently (or an urge to urinate) in the absence of vaginal discharge and significant pain. These symptoms may vary from mild to severe and in healthy women last an average of six days. Some pain above the pubic bone or in the lower back may be present. People experiencing an upper urinary tract infection, or pyelonephritis, may experience flank pain, fever, or nausea and vomiting in addition to the classic symptoms of a lower urinary tract infection. Rarely, the urine may appear bloody or contain visible pus in the urine.
In young children, the only symptom of a urinary tract infection (UTI) may be a fever. Because of the lack of more obvious symptoms, when females under the age of two or uncircumcised males less than a year exhibit a fever, a culture of the urine is recommended by many medical associations. Infants may feed poorly, vomit, sleep more, or show signs of jaundice. In older children, new onset urinary incontinence (loss of bladder control) may occur. About 1 in 400 infants of 1 to 3 months of age with a UTI also have bacterial meningitis.
Urinary tract symptoms are frequently lacking in the elderly. The presentations may be vague with incontinence, a change in mental status, or fatigue as the only symptoms, while some present to a health care provider with sepsis, an infection of the blood, as the first symptoms. Diagnosis can be complicated by the fact that many elderly people have preexisting incontinence or dementia.
It is reasonable to obtain a urine culture in those with signs of systemic infection that may be unable to report urinary symptoms, such as when advanced dementia is present. Systemic signs of infection include a fever or increase in temperature of more than 1.1 °C (2.0 °F) from usual, chills, and an increased white blood cell count.
Uropathogenic E. coli from the gut is the cause of 80–85% of community-acquired urinary tract infections, with Staphylococcus saprophyticus being the cause in 5–10%. Rarely they may be due to viral or fungal infections. Healthcare-associated urinary tract infections (mostly related to urinary catheterization) involve a much broader range of pathogens including: E. coli (27%), Klebsiella (11%), Pseudomonas (11%), the fungal pathogen Candida albicans (9%), and Enterococcus (7%) among others. Urinary tract infections due to Staphylococcus aureus typically occur secondary to blood-borne infections. Chlamydia trachomatis and Mycoplasma genitalium can infect the urethra but not the bladder. These infections are usually classified as a urethritis rather than urinary tract infection.
In young sexually active women, sexual activity is the cause of 75–90% of bladder infections, with the risk of infection related to the frequency of sex. The term "honeymoon cystitis" has been applied to this phenomenon of frequent UTIs during early marriage. In post-menopausal women, sexual activity does not affect the risk of developing a UTI. Spermicide use, independent of sexual frequency, increases the risk of UTIs. Diaphragm use is also associated. Condom use without spermicide or use of birth control pills does not increase the risk of uncomplicated urinary tract infection.
Women are more prone to UTIs than men because, in females, the urethra is much shorter and closer to the anus. As a woman's estrogen levels decrease with menopause, her risk of urinary tract infections increases due to the loss of protective vaginal flora. Additionally, vaginal atrophy that can sometimes occur after menopause is associated with recurrent urinary tract infections.
Chronic prostatitis in the forms of chronic prostatitis/chronic pelvic pain syndrome and chronic bacterial prostatitis (not acute bacterial prostatitis or asymptomatic inflammatory prostatitis) may cause recurrent urinary tract infections in males. Risk of infections increases as males age. While bacteria is commonly present in the urine of older males this does not appear to affect the risk of urinary tract infections.
Urinary catheterization increases the risk for urinary tract infections. The risk of bacteriuria (bacteria in the urine) is between three and six percent per day and prophylactic antibiotics are not effective in decreasing symptomatic infections. The risk of an associated infection can be decreased by catheterizing only when necessary, using aseptic technique for insertion, and maintaining unobstructed closed drainage of the catheter.
A predisposition for bladder infections may run in families. This is believed to be related to genetics. Other risk factors include diabetes, being uncircumcised, and having a large prostate. In children UTIs are associated with vesicoureteral reflux (an abnormal movement of urine from the bladder into ureters or kidneys) and constipation.
Persons with spinal cord injury are at increased risk for urinary tract infection in part because of chronic use of catheter, and in part because of voiding dysfunction. It is the most common cause of infection in this population, as well as the most common cause of hospitalization. Additionally, use of cranberry juice or cranberry supplement appears to be ineffective in prevention and treatment in this population.
The bacteria that cause urinary tract infections typically enter the bladder via the urethra. However, infection may also occur via the blood or lymph. It is believed that the bacteria are usually transmitted to the urethra from the bowel, with females at greater risk due to their anatomy. After gaining entry to the bladder, E. Coli are able to attach to the bladder wall and form a biofilm that resists the body's immune response.
Escherichia coli is the single most common microorganism, followed by Klebsiella and Proteus spp., to cause urinary tract infection. Klebsiella and Proteus spp., are frequently associated with stone disease. The presence of Gram positive bacteria such as Enterococcus and Staphylococcus increased.
In straightforward cases, a diagnosis may be made and treatment given based on symptoms alone without further laboratory confirmation. In complicated or questionable cases, it may be useful to confirm the diagnosis via urinalysis, looking for the presence of urinary nitrites, white blood cells (leukocytes), or leukocyte esterase. Another test, urine microscopy, looks for the presence of red blood cells, white blood cells, or bacteria. Urine culture is deemed positive if it shows a bacterial colony count of greater than or equal to 103 colony-forming units per mL of a typical urinary tract organism. Antibiotic sensitivity can also be tested with these cultures, making them useful in the selection of antibiotic treatment. However, women with negative cultures may still improve with antibiotic treatment. As symptoms can be vague and without reliable tests for urinary tract infections, diagnosis can be difficult in the elderly.
A urinary tract infection may involve only the lower urinary tract, in which case it is known as a bladder infection. Alternatively, it may involve the upper urinary tract, in which case it is known as pyelonephritis. If the urine contains significant bacteria but there are no symptoms, the condition is known as asymptomatic bacteriuria. If a urinary tract infection involves the upper tract, and the person has diabetes mellitus, is pregnant, is male, or immunocompromised, it is considered complicated. Otherwise if a woman is healthy and premenopausal it is considered uncomplicated. In children when a urinary tract infection is associated with a fever, it is deemed to be an upper urinary tract infection.
To make the diagnosis of a urinary tract infection in children, a positive urinary culture is required. Contamination poses a frequent challenge depending on the method of collection used, thus a cutoff of 105 CFU/mL is used for a "clean-catch" mid stream sample, 104 CFU/mL is used for catheter-obtained specimens, and 102 CFU/mL is used for suprapubic aspirations (a sample drawn directly from the bladder with a needle). The use of "urine bags" to collect samples is discouraged by the World Health Organization due to the high rate of contamination when cultured, and catheterization is preferred in those not toilet trained. Some, such as the American Academy of Pediatrics recommends renal ultrasound and voiding cystourethrogram (watching a person's urethra and urinary bladder with real time x-rays while they urinate) in all children less than two years old who have had a urinary tract infection. However, because there is a lack of effective treatment if problems are found, others such as the National Institute for Health and Care Excellence only recommends routine imaging in those less than six months old or who have unusual findings.
In women with cervicitis (inflammation of the cervix) or vaginitis (inflammation of the vagina) and in young men with UTI symptoms, a Chlamydia trachomatis or Neisseria gonorrhoeae infection may be the cause. These infections are typically classified as a urethritis rather than a urinary tract infection. Vaginitis may also be due to a yeast infection. Interstitial cystitis (chronic pain in the bladder) may be considered for people who experience multiple episodes of UTI symptoms but urine cultures remain negative and not improved with antibiotics. Prostatitis (inflammation of the prostate) may also be considered in the differential diagnosis.
Hemorrhagic cystitis, characterized by blood in the urine, can occur secondary to a number of causes including: infections, radiation therapy, underlying cancer, medications and toxins. Medications that commonly cause this problem include the chemotherapeutic agent cyclophosphamide with rates of 2 to 40%. Eosinophilic cystitis is a rare condition where eosinophiles are present in the bladder wall. Signs and symptoms are similar to a bladder infection. Its cause is not entirely clear; however, it may be linked to food allergies, infections, and medications among others.
A number of measures have not been confirmed to affect UTI frequency including: urinating immediately after intercourse, the type of underwear used, personal hygiene methods used after urinating or defecating, or whether a person typically bathes or showers. There is similarly a lack of evidence surrounding the effect of holding one's urine, tampon use, and douching. In those with frequent urinary tract infections who use spermicide or a diaphragm as a method of contraception, they are advised to use alternative methods. In those with benign prostatic hyperplasia urinating in a sitting position appears to improve bladder emptying which might decrease urinary tract infections in this group.
Using urinary catheters as little and as short of time as possible and appropriate care of the catheter when used prevents catheter-associated urinary tract infections. They should be inserted using sterile technique in hospital however non-sterile technique may be appropriate in those who self catheterize. The urinary catheter set up should also be kept sealed. Evidence does not support a significant decrease in risk when silver-alloy catheters are used.
For those with recurrent infections, taking a short course of antibiotics when each infection occurs is associated with the lowest antibiotic use. A prolonged course of daily antibiotics is also effective. Medications frequently used include nitrofurantoin and trimethoprim/sulfamethoxazole (TMP/SMX). Methenamine is another agent used for this purpose as in the bladder where the acidity is low it produces formaldehyde to which resistance does not develop. Some recommend against prolonged use due to concerns of antibiotic resistance.
In cases where infections are related to intercourse, taking antibiotics afterwards may be useful. In post-menopausal women, topical vaginal estrogen has been found to reduce recurrence. As opposed to topical creams, the use of vaginal estrogen from pessaries has not been as useful as low dose antibiotics. Antibiotics following short term urinary catheterization decreases the subsequent risk of a bladder infection. A number of vaccines are in development as of 2018.
The evidence that preventive antibiotics decrease urinary tract infections in children is poor. However recurrent UTIs are a rare cause of further kidney problems if there are no underlying abnormalities of the kidneys, resulting in less than a third of a percent (0.33%) of chronic kidney disease in adults. Whether routine circumcision prevents UTIs has not been well studied as of 2011.
Some research suggests that cranberry (juice or capsules) may decrease the number of UTIs in those with frequent infections. A Cochrane review concluded that the benefit, if it exists, is small. Long-term tolerance is also an issue with gastrointestinal upset occurring in more than 30%. Cranberry juice is thus not currently recommended for this indication. As of 2015, probiotics require further study to determine if they are beneficial. The role of the urinary microbiome in maintaining urinary tract health is not well understood as of 2015.
The mainstay of treatment is antibiotics. Phenazopyridine is occasionally prescribed during the first few days in addition to antibiotics to help with the burning and urgency sometimes felt during a bladder infection. However, it is not routinely recommended due to safety concerns with its use, specifically an elevated risk of methemoglobinemia (higher than normal level of methemoglobin in the blood). Acetaminophen (paracetamol) may be used for fevers. There is no good evidence for the use of cranberry products for treating current infections.
Those who have bacteria in the urine but no symptoms should not generally be treated with antibiotics. This includes those who are old, those with spinal cord injuries, and those who have urinary catheters. Pregnancy is an exception and it is recommended that women take 7 days of antibiotics. If not treated it causes up to 30% of mothers to develop pyelonephritis and increases risk of low birth weight and preterm birth. Some also support treatment of those with diabetes mellitus and treatment before urinary tract procedures which will likely cause bleeding.
Uncomplicated infections can be diagnosed and treated based on symptoms alone. Antibiotics taken by mouth such as trimethoprim/sulfamethoxazole (TMP/SMX), nitrofurantoin, or fosfomycin are typically first line. Cephalosporins, amoxicillin/clavulanic acid, or a fluoroquinolone may also be used. However, resistance to fluoroquinolones among the bacteria that cause urinary infections has been increasing. The Food and Drug Administration (FDA) recommends against the use of fluoroquinolones when other options are available due to higher risks of serious side effects. These medications substantially shorten the time to recovery with all being equally effective. A three-day treatment with trimethoprim, TMP/SMX, or a fluoroquinolone is usually sufficient, whereas nitrofurantoin requires 5–7 days. Fosfomycin may be used as a single dose but has been associated with lower rates of efficacy.
With treatment, symptoms should improve within 36 hours. About 50% of people will recover without treatment within a few days or weeks. Fluoroquinolones are not recommended as a first treatment. The Infectious Diseases Society of America states this due to the concern of generating resistance to this class of medication. Amoxicillin-clavulanate appears less effective than other options. Despite this precaution, some resistance has developed to all of these medications related to their widespread use. Trimethoprim alone is deemed to be equivalent to TMP/SMX in some countries. For simple UTIs, children often respond to a three-day course of antibiotics. Women with recurrent simple UTIs are over 90% accurate in identifying new infections. They may benefit from self-treatment upon occurrence of symptoms with medical follow-up only if the initial treatment fails.
Complicated UTIs are more difficult to treat and usually requires more aggressive evaluation, treatment and follow-up. It may require identifying and addressing the underlying complication. Increasing antibiotic resistance is causing concern about the future of treating those with complicated and recurrent UTI.
Pyelonephritis is treated more aggressively than a simple bladder infection using either a longer course of oral antibiotics or intravenous antibiotics. Seven days of the oral fluoroquinolone ciprofloxacin is typically used in areas where the resistance rate is less than 10%. If the local resistance rates are greater than 10%, a dose of intravenous ceftriaxone is often prescribed. Trimethoprim/sulfamethoxazole or amoxicillin/clavulanate orally for 14 days is another reasonable option. In those who exhibit more severe symptoms, admission to a hospital for ongoing antibiotics may be needed. Complications such as urinary obstruction from a kidney stone may be considered if symptoms do not improve following two or three days of treatment.
Urinary tract infections are the most frequent bacterial infection in women. They occur most frequently between the ages of 16 and 35 years, with 10% of women getting an infection yearly and more than 40–60% having an infection at some point in their lives. Recurrences are common, with nearly half of people getting a second infection within a year. Urinary tract infections occur four times more frequently in females than males. Pyelonephritis occurs between 20–30 times less frequently. They are the most common cause of hospital acquired infections accounting for approximately 40%. Rates of asymptomatic bacteria in the urine increase with age from two to seven percent in women of child-bearing age to as high as 50% in elderly women in care homes. Rates of asymptomatic bacteria in the urine among men over 75 are between 7–10%. Asymptomatic bacteria in the urine occurs in 2% to 10% of pregnancies.
Urinary tract infections may affect 10% of people during childhood. Among children, urinary tract infections are most common in uncircumcised males less than three months of age, followed by females less than one year. Estimates of frequency among children, however, vary widely. In a group of children with a fever, ranging in age between birth and two years, two to 20% were diagnosed with a UTI.
Society and culture
In the United States, urinary tract infections account for nearly seven million office visits, a million emergency department visits, and one hundred thousand hospitalizations every year. The cost of these infections is significant both in terms of lost time at work and costs of medical care. In the United States the direct cost of treatment is estimated at 1.6 billion USD yearly.
Urinary tract infections have been described since ancient times with the first documented description in the Ebers Papyrus dated to c. 1550 BC. It was described by the Egyptians as "sending forth heat from the bladder". Effective treatment did not occur until the development and availability of antibiotics in the 1930s before which time herbs, bloodletting and rest were recommended.
Urinary tract infections are more concerning in pregnancy due to the increased risk of kidney infections. During pregnancy, high progesterone levels elevate the risk of decreased muscle tone of the ureters and bladder, which leads to a greater likelihood of reflux, where urine flows back up the ureters and towards the kidneys. While pregnant women do not have an increased risk of asymptomatic bacteriuria, if bacteriuria is present they do have a 25–40% risk of a kidney infection. Thus if urine testing shows signs of an infection—even in the absence of symptoms—treatment is recommended. Cephalexin or nitrofurantoin are typically used because they are generally considered safe in pregnancy. A kidney infection during pregnancy may result in premature birth or pre-eclampsia (a state of high blood pressure and kidney dysfunction during pregnancy that can lead to seizures). Some women have UTIs that keep coming back in pregnancy and currently there is not enough research on how to best treat these infections.
- "Urinary Tract Infection". Centers for Disease Control and Prevention (CDC). 17 April 2015. Archived from the original on 22 February 2016. Retrieved 9 February 2016.
- Flores-Mireles, AL; Walker, JN; Caparon, M; Hultgren, SJ (May 2015). "Urinary tract infections: epidemiology, mechanisms of infection and treatment options". Nature Reviews. Microbiology. 13 (5): 269–84. doi:10.1038/nrmicro3432. PMC 4457377. PMID 25853778.
- Colgan R, Williams M, Johnson JR (1 September 2011). "Diagnosis and treatment of acute pyelonephritis in women". American Family Physician. 84 (5): 519–26. PMID 21888302.
- Nicolle LE (2008). "Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis". Urol Clin North Am. 35 (1): 1–12, v. doi:10.1016/j.ucl.2007.09.004. PMID 18061019.
- Caterino, Jeffrey M.; Kahan, Scott (2003). In a Page: Emergency medicine. Lippincott Williams & Wilkins. p. 95. ISBN 9781405103572. Archived from the original on 24 April 2017.
- Salvatore S, Salvatore S, Cattoni E, Siesto G, Serati M, Sorice P, Torella M (June 2011). "Urinary tract infections in women". European Journal of Obstetrics, Gynecology, and Reproductive Biology. 156 (2): 131–6. doi:10.1016/j.ejogrb.2011.01.028. PMID 21349630.
- GBD 2015 Disease and Injury Incidence and Prevalence, Collaborators. (8 October 2016). "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1545–1602. doi:10.1016/S0140-6736(16)31678-6. PMC 5055577. PMID 27733282.
- GBD 2015 Mortality and Causes of Death, Collaborators. (8 October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1459–1544. doi:10.1016/S0140-6736(16)31012-1. PMC 5388903. PMID 27733281.
- Lane, DR; Takhar, SS (August 2011). "Diagnosis and management of urinary tract infection and pyelonephritis". Emergency Medicine Clinics of North America. 29 (3): 539–52. doi:10.1016/j.emc.2011.04.001. PMID 21782073.
- Woodford, HJ; George, J (February 2011). "Diagnosis and management of urinary infections in older people". Clinical Medicine. 11 (1): 80–3. doi:10.7861/clinmedicine.11-1-80. PMC 5873814. PMID 21404794.
- Study Guide for Pathophysiology (5 ed.). Elsevier Health Sciences. 2013. p. 272. ISBN 9780323293181. Archived from the original on 16 February 2016.
- Introduction to Medical-Surgical Nursing. Elsevier Health Sciences. 2015. p. 909. ISBN 9781455776412.
- Jarvis, William R. (2007). Bennett & Brachman's hospital infections (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 474. ISBN 9780781763837. Archived from the original on 16 February 2016.
- Ferroni, M; Taylor, AK (November 2015). "Asymptomatic Bacteriuria in Noncatheterized Adults". The Urologic Clinics of North America. 42 (4): 537–45. doi:10.1016/j.ucl.2015.07.003. PMID 26475950.
- Glaser, AP; Schaeffer, AJ (November 2015). "Urinary Tract Infection and Bacteriuria in Pregnancy". The Urologic Clinics of North America. 42 (4): 547–60. doi:10.1016/j.ucl.2015.05.004. PMID 26475951.
- "Recurrent uncomplicated cystitis in women: allowing patients to self-initiate antibiotic therapy". Rev Prescire. 23 (146): 47–9. November 2013. PMID 24669389.
- Colgan, R; Williams, M (1 October 2011). "Diagnosis and treatment of acute uncomplicated cystitis". American Family Physician. 84 (7): 771–6. PMID 22010614.
- Al-Achi, Antoine (2008). An introduction to botanical medicines : history, science, uses, and dangers. Westport, Conn.: Praeger Publishers. p. 126. ISBN 978-0-313-35009-2. Archived from the original on 28 May 2016.
- Arellano, Ronald S. (19 January 2011). Non-vascular interventional radiology of the abdomen. New York: Springer. p. 67. ISBN 978-1-4419-7731-1. Archived from the original on 10 June 2016.
- Bhat RG, Katy TA, Place FC (August 2011). "Pediatric urinary tract infections". Emergency Medicine Clinics of North America. 29 (3): 637–53. doi:10.1016/j.emc.2011.04.004. PMID 21782079.
- Nugent, J; Childers, M; Singh-Miller, N; Howard, R; Allard, R; Eberly, M (September 2019). "Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis". The Journal of Pediatrics. 212: 102–110.e5. doi:10.1016/j.jpeds.2019.04.053. PMID 31230888.
- AMDA – The Society for Post-Acute and Long-Term Care Medicine (February 2014), "Ten Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, AMDA – The Society for Post-Acute and Long-Term Care Medicine, archived from the original on 13 September 2014, retrieved 20 April 2015
- Abraham, Soman N.; Miao, Yuxuan (October 2015). "The nature of immune responses to urinary tract infections". Nature Reviews. Immunology. 15 (10): 655–663. doi:10.1038/nri3887. ISSN 1474-1733. PMC 4926313. PMID 26388331.
- Amdekar S, Singh V, Singh DD (November 2011). "Probiotic therapy: immunomodulating approach toward urinary tract infection". Current Microbiology. 63 (5): 484–90. doi:10.1007/s00284-011-0006-2. PMID 21901556.
- Sievert DM, Ricks P, Edwards JR, et al. (January 2013). "Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009–2010". Infect Control Hosp Epidemiol. 34 (1): 1–14. doi:10.1086/668770. PMID 23221186.
- Bagshaw, SM; Laupland, KB (February 2006). "Epidemiology of intensive care unit-acquired urinary tract infections". Current Opinion in Infectious Diseases. 19 (1): 67–71. doi:10.1097/01.qco.0000200292.37909.e0. PMID 16374221.
- "Urinary Tract Infections in Adults". Archived from the original on 9 January 2015. Retrieved 1 January 2015.
- Brill, JR (1 April 2010). "Diagnosis and treatment of urethritis in men". American Family Physician. 81 (7): 873–8. PMID 20353145.
- Franco, AV (December 2005). "Recurrent urinary tract infections". Best Practice & Research. Clinical Obstetrics & Gynaecology. 19 (6): 861–73. doi:10.1016/j.bpobgyn.2005.08.003. PMID 16298166.
- Engleberg, N C; DiRita, V; Dermody, T S (2007). Schaechter's Mechanism of Microbial Disease. Baltimore: Lippincott Williams & Wilkins. ISBN 978-0-7817-5342-5.
- Dielubanza, EJ; Schaeffer, AJ (January 2011). "Urinary tract infections in women". The Medical Clinics of North America. 95 (1): 27–41. doi:10.1016/j.mcna.2010.08.023. PMID 21095409.
- Goldstein, I; Dicks, B; Kim, NN; Hartzell, R (December 2013). "Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women". Sexual Medicine. 1 (2): 44–53. doi:10.1002/sm2.17. PMC 4184497. PMID 25356287.
- Holt, JD; Garrett, WA; McCurry, TK; Teichman, JM (15 February 2016). "Common Questions About Chronic Prostatitis". American Family Physician. 93 (4): 290–6. PMID 26926816.
- Nicolle LE (2001). "The chronic indwelling catheter and urinary infection in long-term-care facility residents". Infect Control Hosp Epidemiol. 22 (5): 316–21. doi:10.1086/501908. PMID 11428445.
- Phipps, S.; Lim, Y.N.; McClinton, S.; Barry, C.; Rane, A.; N'Dow, J. (2006). Phipps, Simon (ed.). "Short term urinary catheter policies following urogenital surgery in adults". Cochrane Database of Systematic Reviews (2): CD004374. doi:10.1002/14651858.CD004374.pub2. PMID 16625600.
- Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA (2010). "Guideline for prevention of catheter-associated urinary tract infections 2009". Infect Control Hosp Epidemiol. 31 (4): 319–26. doi:10.1086/651091. PMID 20156062.
- Harris, Richard (December 2009). "Genitourinary infection and barotrauma as complications of 'P-valve' use in drysuit divers". Diving and Hyperbaric Medicine. 39 (4): 210–2. PMID 22752741. Retrieved 4 April 2013.
- Jagannath VA, Fedorowicz Z, Sud V, Verma AK, Hajebrahimi S (14 November 2012). "Routine neonatal circumcision for the prevention of urinary tract infections in infancy". The Cochrane Database of Systematic Reviews. 11: CD009129. doi:10.1002/14651858.CD009129.pub2. PMID 23152269.
The incidence of urinary tract infection (UTI) is greater in uncircumcised babies
- Morris, BJ; Wiswell, TE (June 2013). "Circumcision and lifetime risk of urinary tract infection: a systematic review and meta-analysis". The Journal of Urology. 189 (6): 2118–24. doi:10.1016/j.juro.2012.11.114. PMID 23201382.
- Eves, FJ; Rivera, N (April 2010). "Prevention of urinary tract infections in persons with spinal cord injury in home health care". Home Healthcare Nurse. 28 (4): 230–41. doi:10.1097/NHH.0b013e3181dc1bcb. PMID 20520263.
- Opperman, EA (June 2010). "Cranberry is not effective for the prevention or treatment of urinary tract infections in individuals with spinal cord injury". Spinal Cord. 48 (6): 451–6. doi:10.1038/sc.2009.159. PMID 19935757.
- Jorge Gutierrez-Aceves, "Preoperative Antibiotics and Prevention of Sepsis in Genitourinary Surgery" in Smith's Textbook of Endourology, 3rd Edition (2012), p. 39 edited by Arthur D. Smith et al.
- Detweiler K, Mayers D, Fletcher SG (November 2015). "Bacteruria and Urinary Tract Infections in the Elderly". The Urologic Clinics of North America (Review). 42 (4): 561–8. doi:10.1016/j.ucl.2015.07.002. PMID 26475952.
- Raynor, MC; Carson CC, 3rd (January 2011). "Urinary infections in men". The Medical Clinics of North America. 95 (1): 43–54. doi:10.1016/j.mcna.2010.08.015. PMID 21095410.
- Leung, David Hui; edited by Alexander; Padwal, Raj (15 January 2011). Approach to internal medicine : a resource book for clinical practice (3rd ed.). New York: Springer. p. 244. ISBN 978-1-4419-6504-2. Archived from the original on 20 May 2016.
- Kursh, edited by Elroy D.; Ulchaker, James C. (2000). Office urology. Totowa, N.J.: Humana Press. p. 131. ISBN 978-0-89603-789-2. Archived from the original on 4 May 2016.CS1 maint: extra text: authors list (link)
- Walls, authors, Nathan W. Mick, Jessica Radin Peters, Daniel Egan; editor, Eric S. Nadel; advisor, Ron (2006). Blueprints emergency medicine (2nd ed.). Baltimore, Md.: Lippincott Williams & Wilkins. p. 152. ISBN 978-1-4051-0461-6. Archived from the original on 27 May 2016.
- Keane, edited by Sam D. Graham, Thomas E. (2009). Glenn's urologic surgery (7th ed.). Philadelphia, Pa.: Lippincott Williams & Wilkins. p. 148. ISBN 9780781791410. Archived from the original on 24 April 2016.CS1 maint: extra text: authors list (link)
- Kramer, ed. by A. Barry Belman; Lowell R. King; Stephen A. (2002). Clinical pediatric urology (4. ed.). London: Dunitz. p. 338. ISBN 9781901865639. Archived from the original on 15 May 2016.CS1 maint: extra text: authors list (link)
- Popescu OE, Landas SK, Haas GP (February 2009). "The spectrum of eosinophilic cystitis in males: case series and literature review". Archives of Pathology & Laboratory Medicine. 133 (2): 289–94. doi:10.1043/1543-2165-133.2.289 (inactive 18 March 2020). PMID 19195972.
- de Jong, Y; Pinckaers, JH; Ten Brinck, RM; Lycklama À Nijeholt, AA; Dekkers, OM (2014). "Urinating Standing versus Sitting: Position Is of Influence in Men with Prostate Enlargement. A Systematic Review and Meta-Analysis". PLOS ONE. 9 (7): e101320. Bibcode:2014PLoSO...9j1320D. doi:10.1371/journal.pone.0101320. PMC 4106761. PMID 25051345.
- Lam, TB; Omar, MI; Fisher, E; Gillies, K; MacLennan, S (23 September 2014). "Types of indwelling urethral catheters for short-term catheterisation in hospitalised adults". The Cochrane Database of Systematic Reviews. 9 (9): CD004013. doi:10.1002/14651858.CD004013.pub4. PMID 25248140.
- Cubeddu, Richard Finkel, Michelle A. Clark, Luigi X. (2009). Pharmacology (4th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 397. ISBN 9780781771559. Archived from the original on 9 June 2016.
- Beerepoot M, Geerlings S (April 2016). "Non-Antibiotic Prophylaxis for Urinary Tract Infections". Pathogens (Basel, Switzerland) (Review). 5 (2): 36. doi:10.3390/pathogens5020036. PMC 4931387. PMID 27092529.
- Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (16 April 2008). "Oestrogens for preventing recurrent urinary tract infection in postmenopausal women". Cochrane Database of Systematic Reviews (2): CD005131. doi:10.1002/14651858.CD005131.pub2. PMID 18425910.
- Marschall J, Carpenter CR, Fowler S, Trautner BW (2013). "Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis". BMJ. 346: f3147. doi:10.1136/bmj.f3147. PMC 3678514. PMID 23757735.
- Magistro, G; Stief, CG (6 August 2018). "Vaccine Development for Urinary Tract Infections: Where Do We Stand?". European Urology Focus. 5 (1): 39–41. doi:10.1016/j.euf.2018.07.034. PMID 30093359.
- Huttner, A; Gambillara, V (24 May 2018). "The development and early clinical testing of the ExPEC4V conjugate vaccine against uropathogenic Escherichia coli". Clinical Microbiology and Infection. 24 (10): 1046–1050. doi:10.1016/j.cmi.2018.05.009. PMID 29803843.
- Dai, B; Liu, Y; Jia, J; Mei, C (2010). "Long-term antibiotics for the prevention of recurrent urinary tract infection in children: a systematic review and meta-analysis". Archives of Disease in Childhood. 95 (7): 499–508. doi:10.1136/adc.2009.173112. PMID 20457696.
- Salo J, Ikäheimo R, Tapiainen T, Uhari M (November 2011). "Childhood urinary tract infections as a cause of chronic kidney disease". Pediatrics. 128 (5): 840–7. doi:10.1542/peds.2010-3520. PMID 21987701.
- Wang CH, Fang CC, Chen NC, Liu SS, Yu PH, Wu TY, Chen WT, Lee CC, Chen SC (9 July 2012). "Cranberry-containing products for prevention of urinary tract infections in susceptible populations: a systematic review and meta-analysis of randomized controlled trials". Archives of Internal Medicine. 172 (13): 988–96. doi:10.1001/archinternmed.2012.3004. PMID 22777630.
- Jepson RG, Williams G, Craig JC (17 October 2012). "Cranberries for preventing urinary tract infections". Cochrane Database of Systematic Reviews (Submitted manuscript). 10: CD001321. doi:10.1002/14651858.CD001321.pub5. PMC 7027998. PMID 23076891.
- Rossi R, Porta S, Canovi B (September 2010). "Overview on cranberry and urinary tract infections in females". Journal of Clinical Gastroenterology. 44 Suppl 1: S61–2. doi:10.1097/MCG.0b013e3181d2dc8e. PMID 20495471.
- Schwenger, EM; Tejani, AM; Loewen, PS (23 December 2015). "Probiotics for preventing urinary tract infections in adults and children". The Cochrane Database of Systematic Reviews. 12 (12): CD008772. doi:10.1002/14651858.CD008772.pub2. PMID 26695595.
- Whiteside SA, Razvi H, Dave S, Reid G, Burton JP (February 2015). "The microbiome of the urinary tract – a role beyond infection". Nature Reviews. Urology (Review). 12 (2): 81–90. doi:10.1038/nrurol.2014.361. PMID 25600098.
- Schneeweiss J, Koch M, Umek W (September 2016). "The human urinary microbiome and how it relates to urogynecology". International Urogynecology Journal (Review). 27 (9): 1307–12. doi:10.1007/s00192-016-2944-5. PMID 26811114.
- Bao Y, Al KF, Chanyi RM, Whiteside S, Dewar M, Razvi H, Reid G, Burton JP (January 2017). "Questions and challenges associated with studying the microbiome of the urinary tract". Annals of Translational Medicine (Review). 5 (2): 33. doi:10.21037/atm.2016.12.14. PMC 5300849. PMID 28217698.
- Gaines, KK (June 2004). "Phenazopyridine hydrochloride: the use and abuse of an old standby for UTI". Urologic Nursing. 24 (3): 207–9. PMID 15311491.
- Aronson, edited by Jeffrey K. (2008). Meyler's side effects of analgesics and anti-inflammatory drugs. Amsterdam: Elsevier Science. p. 219. ISBN 978-0-444-53273-2. Archived from the original on 7 May 2016.CS1 maint: extra text: authors list (link)
- Glass, [edited by] Jill C. Cash, Cheryl A. (2010). Family practice guidelines (2nd ed.). New York: Springer. p. 271. ISBN 978-0-8261-1812-7. Archived from the original on 11 June 2016.CS1 maint: extra text: authors list (link)
- Santillo, VM; Lowe, FC (January 2007). "Cranberry juice for the prevention and treatment of urinary tract infections". Drugs of Today. 43 (1): 47–54. doi:10.1358/dot.2007.43.1.1032055. PMID 17315052.
- Guay, DR (2009). "Cranberry and urinary tract infections". Drugs. 69 (7): 775–807. doi:10.2165/00003495-200969070-00002. PMID 19441868.
- Ariathianto, Y (October 2011). "Asymptomatic bacteriuria – prevalence in the elderly population". Australian Family Physician. 40 (10): 805–9. PMID 22003486.
- Colgan, R; Nicolle, LE; McGlone, A; Hooton, TM (15 September 2006). "Asymptomatic bacteriuria in adults". American Family Physician. 74 (6): 985–90. PMID 17002033.
- American Geriatrics Society, "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Geriatrics Society, archived from the original on 1 September 2013, retrieved 1 August 2013
- Widmer, M.; Gülmezoglu, AM.; Mignini, L.; Roganti, A. (2011). Widmer, Mariana (ed.). "Duration of treatment for asymptomatic bacteriuria during pregnancy". Cochrane Database Syst Rev (12): CD000491. doi:10.1002/14651858.CD000491.pub2. PMID 22161364.
- Guinto VT, De Guia B, Festin MR, Dowswell T (8 September 2010). "Different antibiotic regimens for treating asymptomatic bacteriuria in pregnancy". Cochrane Database Syst Rev (9): CD007855. doi:10.1002/14651858.CD007855.pub2. PMC 4033758. PMID 20824868.
- Smaill, F.; Vazquez, JC. (2007). Smaill, Fiona M (ed.). "Antibiotics for asymptomatic bacteriuria in pregnancy". Cochrane Database Syst Rev (2): CD000490. doi:10.1002/14651858.CD000490.pub2. PMID 17443502.
- Julka, S (October 2013). "Genitourinary infection in diabetes". Indian Journal of Endocrinology and Metabolism. 17 (Suppl1): S83–S87. doi:10.4103/2230-8210.119512. PMC 3830375. PMID 24251228.
- Grigoryan, L; Trautner, BW; Gupta, K (22 October 2014). "Diagnosis and management of urinary tract infections in the outpatient setting: a review". JAMA. 312 (16): 1677–84. doi:10.1001/jama.2014.12842. PMID 25335150.
- Zalmanovici Trestioreanu, A.; Green, H.; Paul, M.; Yaphe, J.; Leibovici, L. (2010). Zalmanovici Trestioreanu, Anca (ed.). "Antimicrobial agents for treating uncomplicated urinary tract infection in women". Cochrane Database of Systematic Reviews. 10 (10): CD007182. doi:10.1002/14651858.CD007182.pub2. PMID 20927755.
- "FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects". Food and Drug Administration (FDA). 8 March 2018. Archived from the original on 18 July 2019. Retrieved 17 July 2019.
- Jarvis, TR; Chan, L; Gottlieb, T (February 2014). "Assessment and management of lower urinary tract infection in adults" (PDF). Australian Prescriber. 37 (1): 7–9. doi:10.18773/austprescr.2014.002. Archived from the original (PDF) on 8 February 2014. Retrieved 13 March 2014.
- Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE (1 March 2011). "International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases". Clinical Infectious Diseases. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654.
- American Urogynecologic Society (5 May 2015), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Urogynecologic Society, archived from the original on 2 June 2015, retrieved 1 June 2015
- Knottnerus BJ, Grigoryan L, Geerlings SE, Moll van Charante EP, Verheij TJ, Kessels AG, ter Riet G (December 2012). "Comparative effectiveness of antibiotics for uncomplicated urinary tract infections: network meta-analysis of randomized trials". Family Practice. 29 (6): 659–70. doi:10.1093/fampra/cms029. PMID 22516128.
- Shadi Afzalnia (15 December 2006). "BestBets: Is a short course of antibiotics better than a long course in the treatment of UTI in children". www.bestbets.org. Archived from the original on 14 August 2009.
- Bryan, Charles S. (2002). Infectious diseases in primary care. Philadelphia: W.B. Saunders. p. 319. ISBN 978-0-7216-9056-8. Archived from the original on 13 February 2012.
- Wagenlehner, FM.; Vahlensieck, W.; Bauer, HW.; Weidner, W.; Piechota, HJ.; Naber, KG. (March 2013). "Prevention of recurrent urinary tract infections". Minerva Urol Nefrol. 65 (1): 9–20. PMID 23538307.
- Pallett, A.; Hand, K. (November 2010). "Complicated urinary tract infections: practical solutions for the treatment of multiresistant Gram-negative bacteria". J Antimicrob Chemother. 65 Suppl 3: iii25–33. doi:10.1093/jac/dkq298. PMID 20876625.
- Shepherd, AK.; Pottinger, PS. (July 2013). "Management of urinary tract infections in the era of increasing antimicrobial resistance". Med Clin North Am. 97 (4): 737–57, xii. doi:10.1016/j.mcna.2013.03.006. PMID 23809723.
- The Sanford Guide to Antimicrobial Therapy 2011 (Guide to Antimicrobial Therapy (Sanford)). Antimicrobial Therapy. 2011. pp. 30. ISBN 978-1-930808-65-2.
- Brunner & Suddarth's textbook of medical-surgical nursing (12th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2010. p. 1359. ISBN 978-0-7817-8589-1. Archived from the original on 28 April 2016.
- Wilson...], [general ed.: Graham (1990). Topley and Wilson's Principles of bacteriology, virology and immunity : in 4 volumes (8. ed.). London: Arnold. p. 198. ISBN 978-0-7131-4591-5.
- Schneeberger, C; Geerlings, SE; Middleton, P; Crowther, CA (26 July 2015). "Interventions for preventing recurrent urinary tract infection during pregnancy". The Cochrane Database of Systematic Reviews (7): CD009279. doi:10.1002/14651858.CD009279.pub3. PMC 6457953. PMID 26221993.