Urinary Tract Infection & Pyelonephritis — Viva

How to run this viva

Reveal one block at a time. The candidate must update localisation, risk factors, testing, empirical therapy and source control after each release. A safe repeated answer is:^[11]

“For nonseptic lower-tract infection I use the current syndrome-specific regional policy. For septic complicated UTI, the IDSA 2025 framework adds previous susceptibility results and a recent relevant local antibiogram. I culture when indicated, narrow to susceptibility and verify exposure and dose against the current label or local renal policy.”^[10][11]

Branch 1 — Is this cystitis, systemic UTI or a mimic?

Opening prompt

“A 24-year-old woman reports dysuria and frequency for one day. How do you localise the syndrome?”^[7]

Expected response^[7]

Ask about urgency, suprapubic pain, haematuria, fever or hypothermia, rigors, flank pain, vomiting and systemic illness. Ask about vaginal discharge or irritation, urethral exposure, pregnancy, stones, retention, recent antibiotics and prior cultures. Under current EAU terminology, localized cystitis has bladder symptoms without systemic features; systemic UTI/pyelonephritis may cause fever, rigors, flank pain, vomiting, hypotension or organ dysfunction, but no rigid temperature threshold is required.^[7]

Data release A

“She is afebrile and stable but has vulval itch and thick discharge.”^[7]

Branch answer: Reconsider vaginitis rather than labelling every dysuria as UTI. Examine appropriately and test for vaginal or sexually transmitted infection according to history; do not prescribe a universal off-scope antimicrobial regimen.^[7]

Data release B

“Instead, she has rigors, right costovertebral-angle tenderness and cannot keep fluids down.”^[7]

Branch answer: This is systemic UTI/pyelonephritis until proved otherwise. Obtain urine culture before treatment when feasible, assess sepsis and obstruction, renal function, pregnancy and need for admission under the EAU Urological Infections guideline. Use an agent with renal-parenchymal exposure; nitrofurantoin and oral fosfomycin are not pyelonephritis drugs.^[10]

Branch 2 — What do dipstick, microscopy and culture mean?

Prompt

“Her nitrite and leucocyte-esterase dipstick is negative. Is UTI excluded?”^[7]

Expected response^[7]

No. Dipstick modifies probability and must be interpreted with syndrome and pretest risk. Negative nitrite can reflect short bladder dwell time or organism biology. Pyuria supports inflammation but does not by itself diagnose UTI or separate infection from ASB/CAUTI.^[1][3]

Data release

“She now says she is 10 weeks pregnant.”^[7]

Branch answer: Obtain a urine culture even if symptoms are mild. For a midstream specimen follow local collection instructions and collect before antibiotics when feasible. In a catheterised patient sample from the port, never the bag; after indicated replacement, culture the new catheter.^[2][3]

Counts below 10^5 CFU/mL can matter in symptomatic disease. The IDSA ASB guideline uses at least 10^5 CFU/mL for ASB in voided urine and formally uses two consecutive specimens for women, while obstetric practice uses one early-pregnancy screening culture. Compatible CAUTI uses at least 10^3 CFU/mL from an appropriate catheter specimen under the IDSA CAUTI guideline.^[1][2][3]

Branch 3 — Asymptomatic bacteriuria

Prompt

“A 78-year-old long-term-care resident has bacteriuria and pyuria after a fall but no urinary symptoms, fever, instability or other systemic sign. Treat?”^[1]

Expected response^[1]

Do not treat or keep screening reflexively. ASB is bacteriuria without attributable UTI symptoms, irrespective of pyuria. Assess dehydration, medicines, neurological, metabolic, traumatic and other causes; observe for developing local or systemic features.^[1]

Data release A

“The patient is pregnant.”^[1]

Branch answer: Pregnancy is an exception: the ACOG 2023 Clinical Consensus recommends screening once early and treating culture-confirmed ASB with a 5- to 7-day targeted course, with single-dose fosfomycin an exception when susceptibility and context support it. Choose from susceptibility, gestation, renal function, allergy, current label and local obstetric guidance. The historical 30% to 40% progression figure is not a current universal absolute. Evidence is insufficient to mandate routine repeat culture after treated ASB.^[2]

Data release B

“The patient is about to undergo an endoscopic urological procedure with mucosal trauma.”^[1]

Branch answer: Screen and treat with targeted therapy; the IDSA ASB guideline recommends one or two doses beginning 30 to 60 minutes before the procedure rather than a prolonged course.^[1]

Do not screen or treat ASB routinely in healthy nonpregnant adults, older adults, diabetes, spinal-cord injury, indwelling catheters or elective nonurological surgery. IDSA identifies knowledge gaps in the first month after renal transplantation, high-risk neutropenia and catheter removal.^[1]

Branch 4 — Pregnancy safety and pyelonephritis

Prompt

“At 12 weeks, culture shows a susceptible lower-tract isolate. What is your prescribing framework?”^[2]

Expected response^[2]

Use the culture, gestation, allergy, renal function, G6PD status when relevant, interactions, current product label and local obstetric formulary. Under ACOG 2023, a susceptibility-supported lower-tract agent is given for 5 to 7 days, with single-dose fosfomycin an exception when appropriate. Nitrofurantoin and fosfomycin are lower-tract agents and are not suitable for pyelonephritis. Avoid unsupported phenotype-independent class rules.^[2][10]

Data release

“She develops fever, flank pain, vomiting and hypotension.”^[2]

Branch answer: Admit for pyelonephritis/systemic UTI, culture without delaying urgent care, start locally appropriate parenteral therapy, monitor maternal and fetal status, and assess organ dysfunction and obstruction. Under ACOG 2023, complete 14 days total, step down only when clinically improving, able to absorb oral treatment and an active oral option exists, and obtain a urine culture after treatment.^[2]

Branch 5 — Men and the prostate

Prompt

“A 58-year-old man has fever, dysuria, pelvic pain and weak stream. What changes?”^[7]

Expected response^[7]

Consider acute bacterial prostatitis, retention, systemic UTI and obstruction. Examine gently if needed, but do not massage the prostate. Obtain culture, renal function and a bladder residual; admit or seek urgent urology for sepsis, retention or suspected abscess.^[7]

Data release

“He is stable and the isolate is susceptible to a prostate-penetrating oral agent.”^[7]

Branch answer: Check contraindications, interactions, renal dosing and current fluoroquinolone safety advice. The UK NICE acute-prostatitis guideline NG110 reviews therapy after 14 days and either stops or continues for another 14 days according to symptoms, examination and tests. Do not recite an unconditional “2 to 4 weeks for everyone.”^[10]

Branch 6 — Recurrent UTI

Prompt

“A woman has had four culture-compatible cystitis episodes in 12 months. Define recurrence and plan prevention.”^[7]

Expected response^[7]

Under NICE recurrent-UTI guideline NG112, recurrent UTI is at least two episodes in 6 months or three in 12 months. Confirm episode quality and cultures, address retention, stones and exposures, and do not routinely image otherwise uncomplicated recurrent lower UTI. Refer recurrent upper UTI, unknown cause, men, haematuria or features suggesting obstruction or malignancy.^[7]

Data release A

“She is postmenopausal with genitourinary symptoms.”^[12]

Branch answer: The NICE NG112 vaginal-oestrogen recommendation supports vaginal oestrogen after shared decision-making if appropriate and advises against systemic hormone replacement solely for UTI prevention.^[12]

Cranberry can be discussed with uncertainty about formulation, dose and population-specific effect.^[5]

Data release B

“She is nonpregnant; current infection is treated, and simpler measures, vaginal oestrogen or single-dose prophylaxis have been inadequate.”^[13]

Branch answer: The NICE NG112 methenamine-eligibility recommendation allows methenamine hippurate as an alternative to daily antibiotics after those conditions are met.^[13]

The NICE NG112 interaction advice says to seek specialist advice for pregnancy, recurrent upper UTI or complicated disease and to avoid alkalinising citrate sachets while taking methenamine.^[13]

The NICE NG112 methenamine-review recommendation is review at 6 months, then annually.^[13]

If antibiotic prophylaxis is chosen, the NICE NG112 review recommendation is to use prior cultures and local resistance and review at least every 6 months.^[13]

Branch 7 — Catheter-associated infection

Prompt

“A catheterised patient has cloudy urine, pyuria and bacteriuria but no attributable symptoms or systemic signs. Treat?”^[3]

Expected response^[3]

No. Cloudiness, odour, pyuria and bacteriuria do not diagnose CAUTI. Remove an unnecessary catheter and assess for other causes.^[1][3]

Data release

“The patient develops rigors, suprapubic pain and no other source; the catheter is still required.”^[3]

Branch answer: Obtain culture before antibiotics, select treatment from severity, prior isolates/exposure, renal function and local resistance, then narrow. Replacement thresholds must be labelled: the IDSA CAUTI guideline replaces a still-needed catheter after more than 2 weeks and cultures the new catheter; NICE CAUTI guideline NG113 considers removal/change after more than 7 days without delaying antibiotics.^[3]

IDSA uses 7 days for prompt response and 10 to 14 days for delayed response, with shorter regimens only for defined patients. Do not teach one fixed duration for every CAUTI.^[3]

Branch 8 — Urosepsis and an obstructed kidney

Prompt

“A patient with flank pain is hypotensive, confused and oliguric. CT shows an obstructing ureteric stone with hydronephrosis. Prior urine grew an ESBL-producing organism. Priorities?”^[4]

Expected response^[4]

Recognise septic shock/high-likelihood sepsis from an infected obstructed system. Take blood and urine cultures if this does not delay care. The IDSA 2025 septic-cUTI framework uses prior susceptibility and a recent relevant severe-sepsis antibiogram; choose an empirical regimen active against the prior isolate, adjust maintenance for renal function, and narrow when susceptibilities return.^[9][10][11]

Under SSC 2021, shock or high-likelihood sepsis needs antimicrobials immediately, ideally within 1 hour; possible sepsis without shock needs rapid evaluation and treatment within 3 hours if concern persists. SSC suggests at least 30 mL/kg crystalloid in the first 3 hours for hypoperfusion or shock, but this is weak, low-quality evidence: individualize and reassess, especially in kidney or heart disease; add vasopressor support as indicated.^[4]

Under the EAU Urological Infections guideline, urgent decompression by ureteric stent or percutaneous nephrostomy proceeds in parallel with resuscitation and antibiotics. Antibiotics alone do not control an infected obstructed collecting system.^[4]

Branch 9 — No improvement and emphysematous disease

Prompt

“After 48 hours of apparently active therapy, fever and flank pain persist. What do you reconsider?”^[7]

Expected response^[7]

Recheck diagnosis, specimen and susceptibility; dose and tissue exposure; adherence/absorption; obstruction, stone, abscess, papillary necrosis or emphysematous infection; and a non-urinary source. Imaging strategy is jurisdiction- and risk-dependent: the EAU Urological Infections guideline supports early imaging in systemic UTI, while NICE acute-pyelonephritis guideline NG111 does not require universal imaging in every improving low-risk case. Image early when sepsis, acute kidney injury, solitary kidney, transplant, immunocompromise or suspected obstruction can change care, and by 48 to 72 hours if the course is not improving.^[7]

Data release

“CT shows renal gas in a patient with diabetes.”^[7]

Branch answer: Emphysematous pyelonephritis. State the Huang-Tseng extent: class 1, collecting-system gas only; class 2, renal-parenchymal gas without extrarenal extension; class 3A, perinephric extension; class 3B, pararenal extension; class 4, bilateral disease or a solitary functioning kidney. Resuscitate, give effective antibiotics, control glucose and involve urology urgently. Drain obstruction or a collection; nephrectomy is selected for failed conservative/source-control management, a non-salvageable kidney or selected unstable cases, not dictated automatically by radiological class.^[8]

Closing examiner checklist

A complete candidate has:^[7]

1. distinguished localized cystitis, systemic UTI/pyelonephritis, ASB and mimics;^[7]
2. collected urine correctly and interpreted dipstick, pyuria and counts in context;^[7]
3. used current syndrome-specific regional policy for nonseptic lower-tract infection, and the prior-susceptibility plus local-antibiogram branch for septic complicated UTI;^[11]
4. narrowed treatment and checked renal exposure/dosing;^[7]
5. handled pregnancy, prostate, recurrence and catheter branches without false absolutes;^[7]
6. recognized sepsis and urgent source control; and^[7]
7. replaced fixed syndrome-wide durations with the source-bounded response and exclusion branches above.^[7]

References13ShowHide

1. [1]Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America Clin Infect Dis, 2019.PMID 30895288
2. [2]American College of Obstetricians and Gynecologists. Urinary Tract Infections in Pregnant Individuals Obstet Gynecol, 2023.PMID 37473414
3. [3]Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Clin Infect Dis, 2010.PMID 20175247
4. [4]Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 Crit Care Med, 2021.PMID 34605781
5. [5]Williams G, Hahn D, Stephens JH, et al. Cranberries for preventing urinary tract infections Cochrane Database Syst Rev, 2023.PMID 37068952
6. [6]Gupta K, Hooton TM, Naber KG, et al. 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 Clin Infect Dis, 2011.PMID 21292654
7. [7]Foxman B. Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden Infect Dis Clin North Am, 2014.PMID 24484571
8. [8]Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis Arch Intern Med, 2000.PMID 10737279
9. [9]Lea-Henry TN, Carland JE, Stocker SL, et al. Clinical Pharmacokinetics in Kidney Disease: Fundamental Principles Clin J Am Soc Nephrol, 2018.PMID 29934432
10. [10]Eyler RF, Shvets K. Clinical Pharmacology of Antibiotics Clin J Am Soc Nephrol, 2019.PMID 30862698
11. [11]Zahavi I, Kunwar D, Olchowski J, et al. Short vs. long antibiotic treatment for pyelonephritis and complicated urinary tract infections: a living systematic review and meta-analysis of randomized controlled trials Clin Microbiol Infect, 2025.PMID 40228579
12. [12]Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections N Engl J Med, 1993.PMID 8350884
13. [13]Harding C, Chadwick T, Homer T, et al. Methenamine hippurate compared with antibiotic prophylaxis to prevent recurrent urinary tract infections in women: the ALTAR non-inferiority RCT Health Technol Assess, 2022.PMID 35535708