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INTRODUCTION

Urinary tract infections (UTIs) account for 1–3% of all general practice consultations every year, and are the second most common clinical indication for empirical antimicrobial treatment. In a bid to overcome antimicrobial resistance, current advice is that in patients with only one or two mild symptoms, issuing self care advice, analgesia and a delayed antibiotic prescription may be appropriate.

This module examines the diagnosis and management of both men and women with UTI. Key learning points include interpretation of urine dipsticks in patients with UTI, differential diagnoses and management – including use of antibiotics, and special considerations for patients with UTI who are pregnant.

LEARNING OBJECTIVES

After completing this module, you should be better able to:

  • Understand the interpretation of urine dipsticks in patients with UTI
  • Consider the differential diagnosis of UTI
  • Understand the management of pregnant patients with UTI

AUTHORS

Dr Sally Hope, Former GP, Clinical assistant in osteoporosis, Oxford, Dr Raj Thakkar, GP, Wooburn Green, Buckinghamshire and Dr Jessica Garner, GP, London

This resource is provided at an intermediate level by MIMS Learning. Read the article and reflect on what you have learned, then answer the test questions at the end.

Complete the resource to obtain a certificate of completion to include in your revalidation portfolio. You should record the time spent on this resource in your CPD log.

Managing urinary tract infections

Consultations for UTIs can be the easiest or the most difficult, depending on the circumstances.

A straightforward uncomplicated lower UTI in a healthy woman who is not pregnant requires a three-day course of antibiotics.1,2

However, an upper UTI in a pregnant, immunosuppressed woman with diabetes may require the patient to be hospitalised. How do you decide in three minutes?

LOWER UTIs IN ADULT WOMEN

Fifteen per cent of women experience a lower UTI or cystitis. In young, sexually active women, the odds of acute cystitis are increased by a factor of 60 in the first 48 hours after sex.

In these consultations, a holistic GP will also discuss contraception and safe sex, and will consider the possibility of STIs (either mimicking the urgency and frequency of a UTI, or both infections coexisting).

If this type of patient presents with more than three sex-related UTIs in a year, you can consider giving her antibiotics to take as a one-off postcoital dose.

DIAGNOSING UTI

The diagnosis is essentially clinical: dysuria, frequency, suprapubic tenderness and possibly haematuria.

Patients often feel systemically unwell, with myalgia and chills. For patients with two or more acute symptoms who are otherwise fit and well, there is more than a 90% chance of the diagnosis being a UTI.2 Turbidity of urine has a sensitivity of 90%.2

Dipstick tests can be used if there are mild or only one or two symptoms: nitrite, or both leucocytes and blood, is moderately sensitive (77%) and specific (70%), with a positive predictive value of 81% and a negative predictive value of 65%.3

An MSU should be exactly what it says: midstream. Yet how many of us really explain to women how to proceed in order to collect a bit of the middle of the urine stream? Contact with perineal skin, or leaving the pot in the treatment room laboratory fridge overnight, hopelessly contaminates most MSUs. Fortunately, they are only required in relapse or reinfection.

ANTIBIOTIC RESISTANCE

UTIs are the second most common clinical indication for empirical antimicrobial treatment in primary and secondary care,4 accounting for 1-3% of all GP consultations in a year.5

Female patients under the age of 65 with mild symptoms of a UTI may not require antibiotic treatment at all as symptoms can resolve spontaneously. Current recommendations suggest that in patients with only one or two mild symptoms, issuing self care advice, analgesia and a delayed antibiotic prescription may be appropriate.

In 2017, Public Health England has changed its guidance on antibiotic treatment of UTIs.1 This is due to increased antibiotic resistance and a rising presence of [italics] E coli in the community. Groups with a particular risk of resistance include care-home residents, patients who have been hospitalised for more than a week in the preceding six months, a history of previous antibiotic resistance or patients with unresolving symptoms.

The guidance suggests a three-day course of nitrofurantoin as a first-line treatment in patients with a UTI. Exceptions to this are patients with a GFR less than 45, and younger women without any high risk markers, who can be treated with a three-day course of trimethoprim.

In patients unsuitable for nitrofurantoin, pivmecillinam can be used, or alternatively amoxicillin. In patients at very high risk of resistance, fosfomycin may be used.

Particular care should be taken when prescribing nitrofurantoin to elderly patients, who may be at increased risk of toxicity. Do not treat non-pregnant women (of any age) with asymptomatic bacteriuria with an antibiotic.

UTIS IN OTHER PATIENTS

Men

NICE has developed guidelines for UTIs in men.6 If they have symptoms of an upper UTI, fail to respond to appropriate antibiotics or have recurrent UTIs, they should have a urological referral. In men whose symptoms suggest prostatitis, UTIs should be treated empirically with a quinolone, unlike other bacterial UTIs.

Pregnant women

Only in pregnancy is asymptomatic bacteriuria treated, for seven days and with an MSU before and after treatment.

Trimethoprim should not be given if pregnancy is certain or a possibility, because it is contraindicated in the first trimester due to the teratogenic risk.2

Nitrofurantoin is the treatment of choice in all pregnant or potentially pregnant women, except those at term, when there is a possibility of neonatal haemolysis.2 Nitrofurantoin should be prescribed only when the benefit outweighs the risk.

Postmenopausal women

Local vaginal estrogens may offer a useful treatment option for postmenopausal women who experience recurrent UTIs.7

Follow-up

Only follow up women who are still symptomatic two days into treatment. Consider:2,4,8

  • Relapse or reinfection
  • Wrong diagnosis
  • Bacterial vaginosis
  • STI
  • Overactive bladder
  • Urethral syndrome
  • Chronic pelvic pain or dysmenorrhoea

Further reading

Scottish Antimicrobial Prescribing Group. Good practice recommendations for hospital antimicrobial stewardship in NHS Scotland https://www.scottishmedicines.org.uk/files/sapg/Good_practice_recommendations_for_hospital_antimicrobial_stewardship_December_2016.pdf

Bean DC, Krahe D, Wareham DW. Antimicrobial resistance in community and nosocomial Escherichia coli urinary tract isolates, London 2005-2006. Ann Clin Microbiol Antimicrob 2008; 7: 13 https://www.ncbi.nlm.nih.gov/pubmed/18564430

Healthcare Protection Agency. Trends in antimicrobial resistance in England and Wales: 2004-2005 http://webarchive.nationalarchives.gov.uk/20140714084352/http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1196942166920

McNulty CA, Richards J, Livermore DM et al. Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care. J Antimicrob Chemother 2006; 58: 1000-8 https://www.ncbi.nlm.nih.gov/pubmed/16998209

Curtis L. Unit costs of health and social care http://www.pssru.ac.uk/archive/pdf/uc/uc2011/uc2011.pdf

References

1. Public Health England. Management and treatment of common infections https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/643046/Management_and_treatment_of_common_infections.pdf

2. SIGN. Management of suspected bacterial urinary tract infection in adults http://www.sign.ac.uk/sign-88-management-of-suspected-bacterial-urinary-tract-infection-in-adults.html.

3. Little P, Turner S, Rumsby K. Developing clinical rules to predict urinary tract infection in primary care settings: sensitivity and specificity of near patient tests (dipsticks) and clinical scores. Br J Gen Pract 2006; 56(529): 606-12 https://www.ncbi.nlm.nih.gov/pubmed/16882379

4. Car J. Urinary tract infections in women: diagnosis and management in primary care. BMJ 2006; 332: 94-7 http://www.bmj.com/content/332/7533/94

5. NICE. Clinical Knowledge Summaries. Urinary tract infection (lower) – women. https://cks.nice.org.uk/urinary-tract-infection-lower-women.

6. NICE CG97. The management of lower urinary tract symptoms in men, 2010. https://www.nice.org.uk/guidance/cg97/chapter/1-recommendations.

7. Perrotta C, Aznar M, Mejia R et al. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008, Issue 2. Art No: CD005131 https://www.ncbi.nlm.nih.gov/pubmed/18425910

8. NICE CG171. The management of urinary incontinence in women https://www.nice.org.uk/guidance/CG171/chapter/recommendations,