Symptoms of a urinary tract infection may include urinary frequency, urgency, and dysuria. In patients with pyelonephritis, other symptoms include headache, malaise, nausea, and vomiting. A urinary tract infection is diagnosed on the basis of microbiology and is defined as the growth of 105 organisms per milliliter of urine cultured. Most infections are caused by coliform bacteria, with Escherichia coli being the most frequent pathogen. Other pathogens include Klebsiella, Proteus, and Enterobacter species. Staphylococcus organisms are the causative bacteria in fewer than 10% of cases.
Despite the high incidence of urinary tract infections in the postoperative period, few of these infections are serious. Most are confined to the lower urinary tract, and pyelonephritis is a rare complication (88). Catheterization of the urinary tract, either intermittently or continuously with the use of an indwelling catheter, is implicated as a main cause of urinary tract contamination (89). More than 1 million catheter-associated urinary tract infections occur yearly in the United States, and catheter-associated bacteria remains the most common etiology of gram-negative bacteremia in hospitalized patients. Bacteria adhere to the surface of urinary catheters and grow within bile films, which appear to protect embedded bacteria from antibiotics, making treatment less effective. The use of urinary tract catheters should be minimized. An indwelling catheter should be removed or replaced in a patient undergoing treatment for catheter-related infections.
The treatment of urinary tract infection includes hydration and antibiotic therapy. Commonly prescribed and effective antibiotics include penicillin, sulfonamides, cephalosporins, ﬂuoroquinolones, and nitrofurantoin. The choice of antibiotic should be based on knowledge of the susceptibility of organisms cultured at a particular institution. In some institutions, for example, more than 40% of E. coli strains are resistant to ampicillin. For uncomplicated urinary tract infections, an antibiotic that has good activity against E. coli should be given in the interim while awaiting results of the urine culture and sensitivity data.
Patients who have a history of recurrent urinary tract infections, those with chronic indwelling catheters (Foley catheters or ureteral stents), and those who have urinary conduits should be treated with antibiotics that will be effective against the less common urinary pathogens such as Klebsiella and Pseudomonas. Chronic use of ﬂuoroquinolones for prophylaxis is not advised because these agents are notorious for inducing antibiotic-resistant strains of bacteria.
Pulmonary Infections The respiratory tract is an uncommon site for infectious complications in gynecologic surgical patients. In one study only six cases of pneumonia occurred in more than 4,000 women who underwent elective hysterectomy (85). This low incidence is probably a reﬂection of the young age and good health status of gynecologic patients in general. In acute care facilities, pneumonia is a frequent hospital-acquired infection, particularly in elderly patients (90). Risk factors include extensive or prolonged atelectasis, preexistent COPD, severe or debilitating illness, central neurologic disease causing an inability to clear oropharyngeal secretions effectively, nasogastric suction, and a prior history of pneumonia (90,91). In surgical patients, early ambulation and aggressive management of atelectasis are the most important preventive measures. The role of prophylactic antibiotics remains unclear.