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Nurse Practitioner Clinical Protocol MANAGING URINARY TRACT INFECTIONS Advisory panel Name Tonia Zeeman Position Sydney Aquino General Manager, Clinical Service Development General Practitioner Pharmacist Dr Steven Ward Pathologist Robyn Knuckey Program Manager, Interim Care Dr Peter Foley Professional qualification RN, RMHN, B Sc (Nursing) MBBS BPharm AACP MB CL FRCP FRCPA FRACP BAppSc(Physio) Organisation Signature Brightwater Care Group Subiaco Station Medical Group Epsom Pharmacy Belmont Western Diagnostic Pathology Brightwater Care Group INTRODUCTION Urinary tract infections (UTIs) are a common problem. Although affecting men, women and children of all ages, they are most common in sexually active women.1 Factors that may cause UTI are congenital abnormalities of the renal tract (rare - usually detected during childhood), neurological impairment affecting bladder function, diabetes and renal calculi. EPIDEMIOLOGY OF URINARY TRACT INFECTIONS Epidemiologically, UTIs be subdivided into catheter associated and non-catheter associated infections. Whether acquired in hospital (nosocomial) or in the community, infections the can be asymptomatic or non-symptomatic.2 A sudden deterioration of mental state in the elderly may be an indication of the presence of an infective process.3 Escherichia Coli (E-coli) is the most commonly isolated pathogen in residents without catheters, urological abnormalities or calculi, but its susceptibility to specific antibiotics is becoming less predictable.2 In Females4 UTI is the most common cause of all bacterial infections in adult women, particularly in young women who are sexually active. Almost half of all women will experience one UTI in their lifetime.5 There is a double peak in the prevalence of UTI in women: 20 – 40 age group: predisposed by intercourse 55 – 60 age group: related to declining oestrogen levels Older women may be at higher risk for UTI due to a combination of factors, including atrophic changes, impaired urethral function, insufficient fluid intake, constipation, and increased residual urine volume. The presence of back pain/fever increases the probability of upper urinary tract infection (UUTI). Page 1 of 7 Adapted from Fremantle Hospital Nurse Practitioner – Continence Service, Clinical practice Guideline& protocol. Acknowledged with thanks. Brightwater Care Group Clinical Protocols 17 Dec 2007 Norfloxacin added July 2011 In Men4 Urinary tract symptoms in young men are a rare occurrence. The incidence increases with age and particularly after the age of 50 years. Symptoms in young men are frequently the result of sexually transmitted infection (STI) rather than a UTI. After the age of 50 years the increasing incidence of urinary tract symptoms is usually related to increase in prostate size. Bladder outflow obstruction may cause post-void residual urine, which becomes a medium for bacterial colonisation. The incidence of UTI continues to increase with age (and generally prostate size). In Residents With Catheters4 Between 2-7% of residents with indwelling catheters (IDC) acquire bacteriuria each day even with the application of best practice for insertion and care of the catheter. All residents with long term catheters are bacteriuric – with urine samples often positive for two or more organisms. ASSESSMENT AND MANAGEMENT DEFINITIONS6 Urinary Tract Infection (UTI) – Detection of more than 10⁵ organisms per mL of suitably collected urine. UUTI = upper urinary tract infection. Recurrent UTI – Repeated (three or more/year) episodes of infection.. Relapse – Repeat UTI with the same strain of organism. Suggests treatment failure if infection re-occurs within two weeks. Asymptomatic bacteriuria is the presence of bacteria with no symptoms. Diagnostic factors – older people may present with atypical symptoms such as confusion, delirium, falls or adverse behaviours. Scope of Practice PRACTITIONER SCOPE OUTCOMES Nurse Practitioner (NP) Symptoms suggestive of uncomplicated UTI Appropriate residents are identified and treated by NPUC Medical Practitioner + NP Previously treated UTI not responsive to antibiotics UUTI with nausea, vomiting, tachycardia, pronounced tenderness Residents outside the NPC scope are referred to Medical Practitioners Resident Assessment PRESENTATION Irritative voiding symptoms In residents with catheters SYMPTOMS OUTCOMES Dysuria Frequency Urgency Urinary incontinence Suprapubic discomfort Haematuria may be present in women 7 New suprapubic or loin tenderness Rigors New onset of delirium Fever > 37.98 UTI will be recognised and diagnosed promptly Antibiotic therapy is considered in the presence of at least one of these symptoms.8 Page 2 of 7 Adapted from Fremantle Hospital Nurse Practitioner – Continence Service, Clinical practice Guideline& protocol. Acknowledged with thanks. Brightwater Care Group Clinical Protocols 17 Dec 2007 Norfloxacin added July 2011 Vital signs T°, P Fever Pain assessment Burning on micturition Flank pain Back pain Suprapubic discomfort on abdominal palpation Reports of a sudden deterioration in the mental state of an elderly person Vaginal discharge Constipation may contribute to residual urine Cognitive state Other symptoms PRESENTATION Resident history Females Males UUTI will be considered in the presence of fever The need for analgesia will be considered if pain is reported. UUTI will be considered in the presence of flank pain. A diagnosis of UTI will be considered in an elderly confused resident. 3 Alternative diagnoses will be explored. SYMPTOMS OUTCOMES Onset and duration of symptoms History of previous UTIs Recent or present instrumentation – catheter, cystoscopy, urodynamics Co-morbidities Medications/known allergies Sexual history Visual examination of external genitalia and vaginal examination if there is vaginal itch or discharge Visual examination of external genitalia. Digital rectal examination (DRE) if an enlarged prostate is suspected Predisposing and associated conditions will be detected and considered when determining a diagnosis STD and other infections will be eliminated as a possible cause of presenting symptoms. Prostatic hypertrophy will be eliminated as a cause of presenting symptoms in males at risk Residents with BPH will be referred to the GP. Investigations Urinalysis The need for MSU will be determined 9 Pathology Mid Stream Urine Urine which is positive for nitrites, leucocytes will be sent for MC&S. Imaging Bladder scan Residual urine and retention of urine will be detected Resident Education/Follow up Follow up Resident/care worker education Referrals Review in 2 days then in 2 weeks Hygiene and prevention strategies Unresolved UTI Other problems outside NP scope of practice The need for referral to the GP will be determined on the basis of the MSU The resident or CW will demonstrate an understanding of the risk factors for UTI Residents with problems outside the NP’s scope of practice are referred to appropriate health care providers Page 3 of 7 Adapted from Fremantle Hospital Nurse Practitioner – Continence Service, Clinical practice Guideline& protocol. Acknowledged with thanks. Brightwater Care Group Clinical Protocols 17 Dec 2007 Norfloxacin added July 2011 Algorithms to Interpret Findings MEDICALLY STABLE NON PREGNANT FEMALE Goals of Treatment10 Relief of symptoms Eradication of infection Prevention of recurrence Prevention of complications Patient history Physical assessment Vaginal itch reported Multiple symptoms including fever and back pain Two or less symptoms Explore alternative Dx Consider UUTI Dipstick urine Commence Trimethoprim or Amoxycillin/Clavulanic acid Dipstick positive Dipstick negative Nausea, vomiting Tachycardia Pronounced tenderness Commence Trimethoprim or Amoxycillin/Clavulanic acid Offer antibiotics Discuss risks/benefits Yes No Symptoms unresolved after 1st course Symptoms unresolved after 1st course renal tract ultrasound Urology referral Commence Trimethoprim or Amoxycillin/Clavulanic acid Refer for investigation of other causes for symptoms Refer for investigation of other causes for symptoms Symptoms unresolved after 1st course Investigate other causes for symptoms Page 4 of 7 Adapted from Fremantle Hospital Nurse Practitioner – Continence Service, Clinical practice Guideline& protocol. Acknowledged with thanks. Brightwater Care Group Clinical Protocols 17 Dec 2007 Norfloxacin added July 2011 SUSPECTED URINARY TRACT INFECTION – MALE Goals of Treatment10 Relief of symptoms Eradication of infection Prevention of recurrence Prevention of complications Patient history Physical assessment Consider differential diagnosis Prostitis, epididymitis Chlamydial infection MSU for MC & S History of fever and flank pain Consider UUTI Renal tract ultrasound Urology review Colonisation >100,000/mL or >1000 cfu/mL if 80% growth is a single organism Commence Trimethoprim or Amoxycillin/Clavulanic acid Commence Trimethoprim or Amoxycillin/Clavulanic acid Review in 2 days Check MSU result cc results to GP Review in 2 days Check MSU result cc results to GP Recurrent UTI Further investigations Renal tract ultrasound, Cystoscopy Urology referral FORMULARY TRIMETHOPRIM Indications Treatment of uncomplicated lower UTIs in non-pregnant women/men Relative contraindications Moderate renal impairment, may increase serum creatinine concentration. Reduce the dose Dosage Women Men 300 mg orally for 5 days Or 300 mg orally at night for 10 – 14 days for relapsing UTI 300 mg orally for 14 days Prophylaxis for UTI 150 mg orally at night Special considerations Elderly persons prone to nutritional folate deficiency may be more susceptible to side effects Avoid if pregnant Advise resident to take dose at bedtime Page 5 of 7 Adapted from Fremantle Hospital Nurse Practitioner – Continence Service, Clinical practice Guideline& protocol. Acknowledged with thanks. Brightwater Care Group Clinical Protocols 17 Dec 2007 Norfloxacin added July 2011 Drug interactions Warfarin - Trimethoprim may potentiate the anticoagulation effect of warfarin Adverse effects Fever, itch rash, nausea, vomiting most common Other adverse effects concern gastrointestinal tract and haematopoietic systems CEPHALEXIN Indications Treatment of UTI Dosage 500mg orally QID for 5 days (women) or 14 days (men) for uncomplicated UTI (AMH, 2007; NPS, 2005) or 500 mg orally BD in severe renal impairment. Prophylaxis for UTI 250 mg orally at night as alternative to Trimethoprim if there are “breakthrough” infections while the resident is receiving prophylactic Trimethoprim. Specific considerations Reduce dose in severe renal impairment Adverse effects Cholestatic hepatitis (rare) AMOXYCILLIN WITH CLAVULANIC ACID Indications 3rd line treatment of UTI when organism is resistant to Trimethoprim and Cephalexin Dosage Based on Amoxycillin component Adult - 500/125 mg orally BD for 5 days (women), 14 days (men) (AMH, 2007; NPS, 2005). Adverse effects Transient increase in liver enzymes and bilirubin Potential interaction with warfarin – INR monitoring required Special considerations Reduce dose for mod to severe renal impairment, Cholestatic hepatitis - increased risk of hepatitis in people >55 Norfloxacin Indication Complicated UTI due to susceptible organisms (E Coli, Pseudomonas & Klebsiella resistant to other antibiotics). Dosage 400mg on empty stomach (1 hr before or 2 hr after meals) BD 7-10 days. Adverse effects GI upset; pseudomembranous colitis; tendon inflammation, rupture (discontinue); photosensitivity; convulsion; dizziness; headache; depression; somnolence; insomnia; raised LFTs; blood dyscrasia; hypersensitivity; Page 6 of 7 Adapted from Fremantle Hospital Nurse Practitioner – Continence Service, Clinical practice Guideline& protocol. Acknowledged with thanks. Brightwater Care Group Clinical Protocols 17 Dec 2007 Norfloxacin added July 2011 References Australian Medicines Handbook (AMH). (2006). Drug choice companion: aged care. 2nd Ed., Adelaide: AMH AMH. (2007). Australian medicines handbook. Adelaide: AMH Pty Ltd Australian Medicines Handbook. National Prescribing Service. (2005). Antibiotics in primary care: Treatment of urinary tract infection. PPR 30, NPS. Therapeutic Guidelines – Antibiotic (2006). MiniTG March 2007, Therapeutic Guidelines Limited. (Following citations from source document) 1. Nicolle L, Epidemiology of Urinary Tract Infection. Infections in Medicine, 2001. 18(3): p. 153-162. 2. Stamm W., Urinary Tract Infections and Pylonephritis, in Harrison’s Principles of Internal Medicine (16th ed). 2005, McGraw-Hill New York. 3. Midthun SJ, Criteria for urinary tract infection in the elderly: Variables that challenge nursing assessment Urol Nurse, 2004. 24(3): p. 57-162 & 166-170. 4. Hornsby Kuringai Health Service. Nurse Practitioner clinical guideline for assessment and treatment of urinary tract symptoms. 2005 [cited 27th March 2007]; Available from: http://www.health.nsw.gov.au/nursing/pdf/joc_np_crg_uti_2005.pdf. 5. Foxman B, Epidemiology of urinary tract infections: incidence, morbidity and economic costs, . Am J Med, 2002. 113(Jul 8): p. Suppl 1A:5S-13S. 6. National Health Service. Urinary tract infection (lower) - Men. Clinical Knowledge Summaries 2004 [cited 25th March 2007]; Available from: Prodigy Guidence http://www.prodigy.nhs.uk/uti_lower_men/view_whole_guidance. 7. Hooten TM. Scholes D. Hughes JP. Winter C. Roberts PL. Stapleton AE. Stergachis A. & Stamm, W., A prospective study of risk factors for symptomatic urinary tract infection in young women,. N Engl J Med, 1996. 335(7 Aug 15): p. 468-74. 8. Scottish Intercollegiate Guideline Network. Management of suspected bacterial urinary tract infection in adults; A national clinical guideline. 2006 [cited 21st March 2007]; Available from: http://www.sign.ac.uk/pdf/sign88.pdf. 9. American College of Physicians. Urinary tract infection. The Physicians’s information and education resource 2007 [cited 7th March 2007]; Available from: http://online.statref.com.fhlibresources.health.wa.gov.au/Document/Document.aspx?FxId=92&StartDoc= 3161&EndDoc=3204&Level=2&Offset=0&State=False&SessionId=8FF30BSZMXIUSGMO. 10. National Health Service. Urinary tract infection (lower) - Women Clinical Knowledge Summaries 2007 [cited 27th March, 2007]; Available from: Prodigy Guidence http://www.cks.library.nhs.uk/uti_lower_women. Page 7 of 7 Adapted from Fremantle Hospital Nurse Practitioner – Continence Service, Clinical practice Guideline& protocol. Acknowledged with thanks. Brightwater Care Group Clinical Protocols 17 Dec 2007 Norfloxacin added July 2011