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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