Comprehensive Guide to Urinary Tract Infections: Symptoms, Treatment, and Prevention

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Dr Paul Treon

Dr Paul Treon

Clinical Director – East Dunbartonshire HSCP

Clinical Director – East Dunbartonshire HSCP

GP Partner – Kersland House Surgery, Milngavie

GP Partner – Kersland House Surgery, Milngavie

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Bacteriuria

Bacteriuria

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Lower Urinary Tract Infection

Lower Urinary Tract Infection

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Women

Women

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Pregnant Women

Pregnant Women

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Men

Men

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Upper Urinary Tract Infection

Upper Urinary Tract Infection

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Sepsis

Sepsis

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Catheters

Catheters

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Urine Testing

Urine Testing

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FAQs

FAQs

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Risk of false positive cultures – gold standard is needle aspiration of

Risk of false positive cultures – gold standard is needle aspiration of

urine from bladder!

urine from bladder!

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first void v MSSU v catheter specimen

first void v MSSU v catheter specimen

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Not a disease

Not a disease

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Common in >65’s, institutionalised women, long term indwelling

Common in >65’s, institutionalised women, long term indwelling

catheters, sexually active & diabetes

catheters, sexually active & diabetes

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6-7% of men and 16-17% of women >65 in Scotland

6-7% of men and 16-17% of women >65 in Scotland

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Only treat if benefit out ways harm (e.g. pregnancy v elderly)

Only treat if benefit out ways harm (e.g. pregnancy v elderly)

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70-73% of non-pregnant women <50 with acute UTI sx have

70-73% of non-pregnant women <50 with acute UTI sx have

bacteriuria

bacteriuria

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Symptoms of LUTI

Symptoms of LUTI

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FREQUENCY, DYSURIA, urgency, polyuria, suprapubic tenderness, frank

FREQUENCY, DYSURIA, urgency, polyuria, suprapubic tenderness, frank

haematuria, nocturia

haematuria, nocturia

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~90% of healthy <65 with frequency and dysuria will have UTI

~90% of healthy <65 with frequency and dysuria will have UTI

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Vaginal discharge/itch 

Vaginal discharge/itch 





 ?STI 

 ?STI 





 ?GP assessment

 ?GP assessment

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? NSAIDs/fluids

? NSAIDs/fluids

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Empirical (3d) treatment for healthy women with ??? (SIGN 88v160)

Empirical (3d) treatment for healthy women with ??? (SIGN 88v160)

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Trimethoprim 200mg BD

Trimethoprim 200mg BD

OR

OR

    Nitrofurantoin 50mg QDS / 100mg BD (not if eGFR >30, caution 30-45)

    Nitrofurantoin 50mg QDS / 100mg BD (not if eGFR >30, caution 30-45)

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DO NOT treat asymptomatic non-pregnant women

DO NOT treat asymptomatic non-pregnant women

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3+ in 12months or 2+ in 6mths

3+ in 12months or 2+ in 6mths

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Self care/advice re: hygiene

Self care/advice re: hygiene

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hydration/voiding

hydration/voiding

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cranberry products

cranberry products

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note warfarin

note warfarin

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High strength capsules most effective (not men/catheterised)

High strength capsules most effective (not men/catheterised)

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Post-menopausal women ?vaginal oestogen 

Post-menopausal women ?vaginal oestogen 

(not routinely)

(not routinely)

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?Post coital (trimethoprim / nitrofurantoin 100mg stat)

?Post coital (trimethoprim / nitrofurantoin 100mg stat)

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Stand by Abx (3d course)

Stand by Abx (3d course)

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Consider 3-6mths prophylactic Abx (trimethoprim 50mg nocte/

Consider 3-6mths prophylactic Abx (trimethoprim 50mg nocte/

nitrofurantoin 100mg nocte)

nitrofurantoin 100mg nocte)

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MSSU for C&S before treatment starts and 7 days after completion

MSSU for C&S before treatment starts and 7 days after completion

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Treat all symptomatic UTI & asymptomatic bacteriuria for 7days

Treat all symptomatic UTI & asymptomatic bacteriuria for 7days

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Abx of choice in GGC

Abx of choice in GGC

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 Line 

Nitrofurantoin 50mg QDS / 100mg BD (1

Nitrofurantoin 50mg QDS / 100mg BD (1

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/2

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 trimester only)

 trimester only)

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nd

 Line 

 Line 

Amoxicillin 500mg TDS (if susceptible)

Amoxicillin 500mg TDS (if susceptible)

OR

OR

Cefelexin 500mg TDS

Cefelexin 500mg TDS

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MSSU for C&S before treatment starts

MSSU for C&S before treatment starts

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Treat all symptomatic UTI

Treat all symptomatic UTI

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Empirical (7d) treatment

Empirical (7d) treatment

Trimethoprim 200mg BD

Trimethoprim 200mg BD

OR

OR

 Nitrofurantoin 50mg QDS / 100mg BD (not if eGFR >30, caution 30-45)

 Nitrofurantoin 50mg QDS / 100mg BD (not if eGFR >30, caution 30-45)

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Consider prostatitis, epididymitis, chlamydia

Consider prostatitis, epididymitis, chlamydia

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Recurrent / no response - ?prostatitis +/- refer urology

Recurrent / no response - ?prostatitis +/- refer urology

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Symptoms of UUTI

Symptoms of UUTI

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LUTI & low back/loin pain, fever, rigors, nausea/vomiting

LUTI & low back/loin pain, fever, rigors, nausea/vomiting

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Empirical (7d) treatment

Empirical (7d) treatment

Trimethoprim 200mg BD (if susceptible) [not in pregnancy]

Trimethoprim 200mg BD (if susceptible) [not in pregnancy]

OR

OR

 Co-amoxiclav 625mg TDS

 Co-amoxiclav 625mg TDS

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OR

Ciprofloxacin 500mg BD (if true penicillin allergy)

Ciprofloxacin 500mg BD (if true penicillin allergy)

[Cefelexin 500mg BD in pregnancy]

[Cefelexin 500mg BD in pregnancy]

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DO NOT forget sepsis – severe life threatening systemic infection

DO NOT forget sepsis – severe life threatening systemic infection

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May need immediate GP review / admission or

May need immediate GP review / admission or

review and admit after 24hours

review and admit after 24hours

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Age >75, impaired immunity, recent trauma/surgery, indwelling lines

Age >75, impaired immunity, recent trauma/surgery, indwelling lines

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Likely infection source

Likely infection source

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New altered mental state (delirium)

New altered mental state (delirium)

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Systolic BP <90mmHg

Systolic BP <90mmHg

(<100 then GP assessment)

(<100 then GP assessment)

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HR >130/min

HR >130/min

(>90 then GP assessment)

(>90 then GP assessment)

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RR >25/min

RR >25/min

(>21 then GP assessment)

(>21 then GP assessment)

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SpO

SpO

2

2

 >92% (88% in COPD)

 >92% (88% in COPD)

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Skin changes (non-blanching rash, mottled, ashen, cyanotic

Skin changes (non-blanching rash, mottled, ashen, cyanotic

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Not passing urine (last 18hours)

Not passing urine (last 18hours)

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Only treat if symptomatic, and send CSU for C&S pre-treatment

Only treat if symptomatic, and send CSU for C&S pre-treatment

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DO NOT dip or routinely culture asymptomatic patients (false +ve)

DO NOT dip or routinely culture asymptomatic patients (false +ve)

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If catheter in situ for >7days then require catheter change

If catheter in situ for >7days then require catheter change

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No need for prophylactic Abx at routine catheter change unless

No need for prophylactic Abx at routine catheter change unless

history of catheter associated UTI / trauma

history of catheter associated UTI / trauma

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Empirical (7d) treatment

Empirical (7d) treatment

 Nitrofurantoin 50mg QDS or 100mg BD

 Nitrofurantoin 50mg QDS or 100mg BD

OR

OR

Trimethoprim 200mg BD

Trimethoprim 200mg BD

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Pharmacy Urine Collection tips: (Tayside)

Pharmacy Urine Collection tips: (Tayside)

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?use of public toilets

?use of public toilets

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Double wrap (?stock of nappy bags)

Double wrap (?stock of nappy bags)

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Test away from patient area (in case chatty patients) to read accurately

Test away from patient area (in case chatty patients) to read accurately

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Double bag and return to patients for disposal

Double bag and return to patients for disposal

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Appearance

Appearance

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Turbidity (against bright background)

Turbidity (against bright background)

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Microscopy

Microscopy

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Wide variation and issues of health and safety at work

Wide variation and issues of health and safety at work

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Urinalysis / dipstick 

Urinalysis / dipstick 

(no benefit >65yrs of age)

(no benefit >65yrs of age)

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+ve if Leucocyte or Nitrites present (urine in bladder >4hrs)

+ve if Leucocyte or Nitrites present (urine in bladder >4hrs)

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Sign 88 - indicated for women with minimal signs/symptoms of UTI (+ve

Sign 88 - indicated for women with minimal signs/symptoms of UTI (+ve

dipstick & 1 symptom/sign = 80% likelihood of UTI)

dipstick & 1 symptom/sign = 80% likelihood of UTI)

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Sign 160 - ?Parallel to hx v following hx of 2+ sx 

Sign 160 - ?Parallel to hx v following hx of 2+ sx 





 increases likelihood ratio

 increases likelihood ratio

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Urine Culture 

Urine Culture 

(?diagnostic role in >65s)

(?diagnostic role in >65s)

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suprapubic aspirate or operatively obtained v clean catch, MSSU & CSU

suprapubic aspirate or operatively obtained v clean catch, MSSU & CSU

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Testing for conventional aerobic bacteria >10

Testing for conventional aerobic bacteria >10

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cfu/ml (less for men)

cfu/ml (less for men)

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Single MSU reliable in 80% (2 +ve MSUs 95% reliable)

Single MSU reliable in 80% (2 +ve MSUs 95% reliable)

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Too many organisms suggests contamination

Too many organisms suggests contamination

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C&S if failure to respond to 1

C&S if failure to respond to 1

st

st

 line or if indicated as previously

 line or if indicated as previously

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The only test that can accurately guide ABx choice

The only test that can accurately guide ABx choice

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Children

Children

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Need C&S as may need referral if atypical organism or recurrent

Need C&S as may need referral if atypical organism or recurrent

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>65s

>65s

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Can present with atypical symptoms

Can present with atypical symptoms

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Urinary sepsis may be more subtle (hypoactive delirium)

Urinary sepsis may be more subtle (hypoactive delirium)

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But usually treat empirically (caution re: CKD/AKI)

But usually treat empirically (caution re: CKD/AKI)

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UUTI

UUTI

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Higher risk of sepsis – so should be clinically examined to rule out

Higher risk of sepsis – so should be clinically examined to rule out

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May need immediate admission for IV fluids/ABx.

May need immediate admission for IV fluids/ABx.

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Strong worsening statement – review +/- admission if not better at 24hrs

Strong worsening statement – review +/- admission if not better at 24hrs

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Diabetes

Diabetes

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High risk for sepsis & recurrence

High risk for sepsis & recurrence

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Check blood glucose control (acutely and in general)

Check blood glucose control (acutely and in general)

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Sick day rules

Sick day rules

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Risk of treatment failure

Risk of treatment failure

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May opt for MSSU for C&S to guide treatment

May opt for MSSU for C&S to guide treatment

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May discuss risk factors or alternative diagnosis (STI, prostatitis)

May discuss risk factors or alternative diagnosis (STI, prostatitis)

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May discuss prophylactic treatments

May discuss prophylactic treatments

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Pregnancy / Breastfeeding

Pregnancy / Breastfeeding

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Choice of antibiotic

Choice of antibiotic

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Treatment of asymptomatic bacteriuria

Treatment of asymptomatic bacteriuria

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Vaginal discharge / itch

Vaginal discharge / itch

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These are negatively predictive symptoms

These are negatively predictive symptoms

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?alternative treatments e.g. thrush / STI

?alternative treatments e.g. thrush / STI

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Testing is not always the answer – ?just treat

Testing is not always the answer – ?just treat

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Remember atypical symptoms and alternative diagnosis

Remember atypical symptoms and alternative diagnosis

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Remember women of child bearing age may be pregnant

Remember women of child bearing age may be pregnant

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If in doubt refer to the GP Team

If in doubt refer to the GP Team

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Ask patient to bring a urine specimen to an appointment (just in case)

Ask patient to bring a urine specimen to an appointment (just in case)

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Sign Guideline 88

Sign Guideline 88

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Management of Suspected Bacterial Urinary Tract Infection in Adults

Management of Suspected Bacterial Urinary Tract Infection in Adults

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Sign Guideline 160

Sign Guideline 160

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Management of Suspected Bacterial Lower Urinary Tract Infection in Adult

Management of Suspected Bacterial Lower Urinary Tract Infection in Adult

Women

Women

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NHS GG&C Clinical Guideline

NHS GG&C Clinical Guideline

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Infection Management in Adults, Primary Care

Infection Management in Adults, Primary Care

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Sepsis Trust

Sepsis Trust

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Sepsis Screening Tool Community Nursing

Sepsis Screening Tool Community Nursing

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