1. Clinical Manifestations and Signs/Symptoms

Early recognition of urinary tract involvement—whether bladder, renal, or catheter-associated—is critical. Typical symptoms may be muted in critically ill or neurologically impaired patients.

1.1 Lower Urinary Tract Symptoms (LUTS)

• Dysuria: Burning or stinging sensation with micturition.
• Frequency and urgency: Desire to void every ≤2 hours or a sudden, compelling urge.
• Suprapubic discomfort or tenderness: Can be assessed on palpation if the patient is responsive.
• Cloudy or malodorous urine: A nonspecific finding that may reflect biofilm, hematuria, or dehydration.
• In sedated/mechanically ventilated patients: Look for unexplained bladder spasms, increased drainage output, or frequent catheter alarms.

Key Point: Classic LUTS have high predictive value in ambulatory adults but may be absent or masked in the ICU. Do not rely on urine appearance alone to diagnose infection.

1.2 Systemic Signs

• Fever (>38°C) or hypothermia (<36°C) without an alternative source.
• Tachycardia (>90 beats/min) and tachypnea (>20 breaths/min) as part of the Systemic Inflammatory Response Syndrome (SIRS).
• New-onset hypotension or acute kidney injury suggesting progression to urosepsis.
• Altered mental status or delirium, which is a common sole indicator in elderly or critically ill patients.

1.3 Neuro-Specific Indicators

• Spasticity or increased muscle tone in patients with spinal cord injuries.
• Autonomic dysreflexia: Paroxysmal hypertension, headache, and flushing in patients with high-level spinal cord injuries (T6 and above).
• Changes in bladder drainage patterns, such as intermittent clots or new outbreaks of leakage around the catheter.

2. Laboratory Diagnostics

Laboratory tests help confirm infection and distinguish colonization from true UTI. Interpretation requires careful clinical correlation, especially in catheterized patients where asymptomatic bacteriuria is common.

2.1 Urinalysis (UA)

• Pyuria: Defined as ≥10 leukocytes per high-power field (HPF). It has a high negative predictive value (absence makes UTI unlikely) but low specificity in catheterized patients, as the catheter itself can cause inflammation.
• Dipstick Tests: Leukocyte esterase (an enzyme from neutrophils) and nitrite (produced by nitrate-reducing bacteria like E. coli) are supportive but prone to false positives from hematuria, concentrated urine, or contamination.

2.2 Quantitative Urine Cultures

• CA-UTI (Symptomatic): ≥10³ colony-forming units (CFU)/mL of a single uropathogen from a properly collected catheter specimen or a midstream voided urine sample within 48 hours of catheter removal.
• CA-ASB (Asymptomatic Bacteriuria): ≥10⁵ CFU/mL without symptoms. This is colonization and should not be treated, except in specific populations like pregnant patients or those undergoing urologic procedures.
• Specimen Technique: To avoid biofilm contamination, obtain a specimen via a freshly placed, sterile catheter or from the sampling port of the existing catheter after cleaning it. Do not culture urine from the drainage bag.

2.3 Blood Cultures and Catheter Tip Cultures

• Blood Cultures: Obtain paired peripheral and catheter-drawn blood cultures when systemic signs (e.g., persistent fever, hypotension) suggest bacteremia. A differential time to positivity (DTP) of ≥2 hours (catheter culture positive before peripheral) strongly favors a catheter-associated bloodstream infection (CABSI).
• Catheter Tip Culture: A semiquantitative roll-plate culture yielding >15 CFU from a removed catheter tip can indicate colonization of the catheter, but its utility in diagnosing UTI is limited.

3. Imaging Modalities

Imaging is not routine for uncomplicated UTIs. It is reserved for complicated, recurrent, or non-responsive infections to identify structural abnormalities like obstruction, abscess, or emphysematous changes.

3.1 Ultrasound

• Indications: Can detect hydronephrosis (kidney swelling due to urine backup), bladder distension, perinephric fluid collections, and abscesses.
• Advantages: It is the first-line imaging modality as it is non-invasive, can be performed at the bedside (POCUS), involves no radiation, and can assess post-void residual volume.

3.2 CT and MRI

• CT Scan: The preferred modality for suspected emphysematous infections (gas in the kidney or bladder wall), urolithiasis (kidney stones), and complex abscesses due to its high sensitivity for gas and calcifications.
• MRI: A useful alternative in transplant recipients and when radiation avoidance is a priority, though less sensitive for stones and gas.

Key Point: Reserve advanced imaging for patients with persistent fever despite 48–72 hours of appropriate antibiotic therapy or when there is a high clinical suspicion for complications.

4. Classification and Severity Scoring

Standardized definitions and scoring tools are crucial for guiding therapy urgency, selecting appropriate antibiotics, avoiding over-treatment, and allocating resources effectively.

4.1 IDSA/CDC Definitions

Using consistent definitions is key to accurate diagnosis and surveillance.

4.2 Severity Scores

• qSOFA (Quick SOFA): A bedside tool to identify patients at higher risk of poor outcomes from infection. A score of ≥2 points (from 1 point each for altered mentation, respiratory rate ≥22/min, and systolic BP ≤100 mmHg) warrants further investigation for organ dysfunction.
• SOFA (Sequential Organ Failure Assessment): A more detailed score used in the ICU to assess organ dysfunction across six systems (respiratory, coagulation, liver, cardiovascular, CNS, renal). An acute increase of ≥2 points from baseline signals sepsis-related organ failure.

4.3 Risk Stratification and Triage Criteria

• High-Risk Features: Immunosuppression, poorly controlled diabetes, known neurogenic bladder, or recent urologic surgery increase the risk for complicated infections.
• Urosepsis Indicators: The presence of hypotension, lactic acidosis (>2 mmol/L), or evidence of organ dysfunction (e.g., acute kidney injury, delirium) signifies severe infection requiring aggressive management.
• Triage to ICU: Admission to the ICU is warranted for patients with septic shock, multiorgan failure, or an insecure airway or deteriorating mental status.

Key Point: Use standardized definitions to avoid overdiagnosis and unnecessary antibiotics. Apply qSOFA at the bedside for rapid risk assessment, and confirm with the full SOFA score when possible to quantify the severity of sepsis.