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Urinary symptoms
dysuria, urgency, frequency, polyuria, incontinence,
flank or suprapubic pain, frank haematuria
Systemic symptoms
flank tenderness, shaking chills (rigors), new onset
delirium, fever, hypothermia
Non-specific symptoms
alteration of behaviour (elderly), loss of diabetes
control
Signs and symptoms
Main diagnostic criteria
Dysuria + frequency → probability of UTI >90%
Urine appearance
Urine turbidity (66% sensitivity, 90% specificity) but
prone to observer error
Microscopy not recommended
Urine dipsticks
Limited value and evidence to support use is poor
Positive nitrite alone or with positive leucocytes
and blood 92% → probability of UTI
Only advised for non-pregnant and noncatheterised women under 65 years with limited
(≤2) symptoms
•Bacteriuria is not a disease and alone is rarely an indication
for an antimicrobial
•CSU will usually be positive so limited use in UTI diagnosis
•Contaminated MSSU samples can yield false positives
•Required only in pregnancy, men, suspected upper UTI,
recurrence/treatment failure
•Sample before initiating antimicrobial therapy
•Do not take urine samples for post-antibiotic checks or
clearance of infection checks
Most common bacteria - Escherichia coli Staphylococcus
saprophyticus
Less common bacteria - Proteus mirabilis, Klebsiella
species, Enterococci, Pseudomonas aeruginosa
Contamination – heavy mixed growth may indicate
contamination. Repeat sampling advised.
Susceptability results – many labs only report policy
antibiotics to promote local compliance
Local resistance rates - sampling bias means that typical
resistance rate for trimethoprim is 20%
National surveillance of urinary isolates - starting in 2012
led by Health Protection Scotland
Treat with an antibiotic if severe or ≥3 symptoms
Dipstick if few/limited symptoms
Explore other diagnoses if vaginal itch/discharge
No antibiotic for asymptomatic bacteriuria
Empiric treatment: trimethoprim or nitrofurantoin
Treatment duration: 3 days (as good as longer
courses with fewer ADRs and better adherence)
• Culture urine if failure to respond
• Second line choice of antibiotic guided by urine
culture results
• Role of delayed prescriptions?
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• Always culture urine if UTI suspected
• Treat if asymptomatic bacteriuria detected on routine
screening
• Empiric treatment: trimethoprim or nitrofurantoin for 7
days then re-culture 7 days later
• Nitrofurantoin: theoretical risk of neonatal haemolysis at
term but short-term use unlikely to cause problems
• Trimethoprim: theoretical risk in 1st trimester in those with
poor diet or folate deficient (folate antagonist)
• Second line: amoxicillin (if organism sensitive) or cefalexin
• Ciprofloxacin contraindicated (foetal arthropathy in animal
studies)
•UTI in men often associated with urinary tract abnormality
•Consider the possibility of prostatitis, chlamydial infection
and epididymitis
•Prostatic involvement in 50% of men with recurrent UTI
and 90% of men with febrile UTI
•Urine culture for all patients
•Evidence on antibiotic choice and duration in men is weak
•Empiric treatment with 7 day course trimethoprim or
nitrofurantoin while culture results awaited
•Consider 14 day course of ciprofloxacin if prostatitis
suspected
•Refer for urological investigation if recurrent UTI or
treatment failure
All patients will develop bacteriuria over time
No investigation or treatment unless symptomatic
UTI prophylaxis not recommended
Antibiotic treatment indicated if systemic symptoms
Culture urine and change catheter before starting
antibiotics
• Empirical treatment with nitrofurantoin or trimethoprim
• Consider ciprofloxacin or co-amoxiclav if upper UTI
suspected (systemic symptoms of infection)
• Lack of evidence on course length – HPA guidance
suggests same as non-catheterised patients (3 days
women and 7 days men) but if upper UTI suspected 7 days
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• Can be accompanied by bacteraemia which is
potentially life-threatening
• Hospital admission if pregnant, sepsis, vomiting or
no response to empiric therapy within 24 hours
• Urine culture for all patients (increased clinical risk
associated with treatment failure)
• Empirical treatment while results awaited:
ciprofloxacin for 7 days or co-amoxiclav for 14 days
• Trimethoprim (14 days, only if susceptible organism)
can also be used but not nitrofurantoin (ineffective
due to inadequate blood concentration)
• Consider for women with ≥3 episodes/year
• Cranberry reduces recurrence
• Repeated/prolonged antibiotic use contributes to patient
level and population resistance – antibiotic cycling may
help but evidence is lacking
• Post-coital or nightly prophylaxis with nitrofurantoin or
trimethoprim equally effective
• But adverse effects occur, 30% of women don’t adhere to
treatment and should be reviewed after 6–12 months.
• Standby antibiotic (+ MSSU pack) an alternative: self
diagnosis of recurrence generally accurate
• Methenamine hippurate may be effective in the absence
of upper renal tract abnormalities
Extended spectrum beta-lactamase producing organisms
are increasing.
These organisms are resistant to most antibiotics
commonly used to treat lower and upper UTI.
Some ESBL-producing E. coli are sensitive to
nitrofurantoin.
Alternatives are pivmecillinam, fosfomycin and
carbapenems (IV)
Fosfomycin unlicensed in UK but some boards have
protocols for use in primary care.
Concentration of fosfomycin maintained in urine for 2
days so single dose sufficient in uncomplicated UTI in
women but a second dose is required at 3 days in men.
1.
What are challenges in diagnosis?
2.
What are issues with treatment choice and
duration?
3.
What are patient expectations?
4.
Any particular issues with care homes residents?
5.
Are there education needs for staff /patients?