UTI in practice Flashcards
what parts of the urniary system make up the lower urinary tract?
Bladder
– Urethra
what parts make up the upper urinary tract- i.e more serious?
– Kidneys
– Ureters
how do bacteria enter the urinary tract? what is the usual bacteria found?
hrough urethra
• Typically Escherichia Coli (Gram negative),
commonly found in GI tract
what are the bladder symptoms of lower UTI?
– Polyuria
– Dysuria
– Lower abdominal discomfort
what are the urethra symptoms of a lower UTI?
– Burning on passing urine
– Discharge
why are stis included in differeential diagnosis of UTI?
Note that sexually transmitted infections can cause
urethritis due to proximity of uretha to vagina-
therefore differential diagnosis includes STIs such as
chlamydia, gonorrhoea etc
why are UTIs more common in females?
- Shorter urethra
* Urethra proximity to anus
what are the risk factors for UTIs?
Post menopausal women
• decline in circulating oestrogen
– Indwelling catheters
• provide an ascending route for bacteria
– Recent antibiotic use
• disrupts normal bacterial flora
– Spermicides can cause irritation & attachment sites for E.Coli
– Sexual intercourse – may introduce bacteria to urinary tract
– Pregnancy
when would you refer UTI?
Pregnant woman
– risks include pyelonephritis, premature birth, rupture of membranes
and other complications
• Men
– always “complicated”
• <16 years
• Symptoms of pyelonephritis
– Fever, loin pain, rigors, flu-like illness, nausea/vomiting – symptoms of
upper UTI
• Signs of Sepsis
– See risk stratification tool NICE- high risk signs include altered mental
state/behaviour, increased RR/HR, low BP, anuria, mottled/ashen skin,
cyanosis, non-blanching rash
• Non-response to first antibiotics
– MSU for culture
when would you not use a urine dipstick?
Not recommended in the elderly (>65yrs) as
asymptomatic bateriuria is common in this
group and could result in unnecessary
antibiotics
how do you give a urine culture?
midstream
what would be suggest a UTI on a urine dipstick?
positive nitrate or leukocyte and RBC positive
when do you treat asymptomatic UTI?
if pregnant
when considering diagnosis what sort of vaginal and urethral causes of urinary symptoms would you exclude?
- 80% of women with vaginal discharge do not have a UTI
- Urethritis- inflammation post sexual intercourse, irritants
- Check sexual history to exclude STI
- Genitourinary syndrome of menopause (vulvovaginal atrophy)
what are the signs and symptoms of pyelonephritis?
– Kidney pain/tenderness in back under ribs – New/different myalgia, flu like illness – Rigors or pyrexia – Nausea/vomiting
what are the signs of sepsis?
– High risk signs include: • Altered mental state/behaviour • Increased RR/HR • Low BP • Anuria • Mottled/ashen skin • Cyanosis • Non-blanching rash
when diagnosing UTI what are the 3 key diagnostic fectures?
Dysuria, new nocturia, cloudy urine
– If 2 or 3 present UTI likely and dipstick not needed
– If 1 present perform urine dipstick
– If 0 check if other symptoms are present (urgency,
visible haematuria, frequency, suprapubic
tenderness)
what does the urine dipstick tell us?
• Negative for nitrites, leukocytes & RBC: UTI
less likely
• Negative nitrite but positive leukocyte
• Could be UTI – send urine culture and consider
treatment depending on symptom severity
• Positive RBC with positive nitrite or leukocyte
• Likely UTI – treat or watch/wait with backup
antibiotic depending on symptom severity
how does the guidance for over 65’s differ?
• No urine dipsticks • New onset dysuria or 2+ new symptoms UTI likely • Always send urine culture • Delirium considerations/ other diagnostics
what extra precautions need to be done for pregnant women?
• Regular MSU screening as part of antenatal care
• Antibiotics given if bacteriuria confirmed even if
asymptomatic (2 x culture)
if suspected UTI in a pregnant women what should be done?
– Symptomatic relief with paracetamol
– Prescribe antibiotic 7d (check suitable- often
nitrofurantoin but not recommended at term)
– Send MSU for culture
– Amend prescription if needed
– If a group B streptococcus is isolated, prophylactic
antibiotics will be offered during labour and delivery.
what should you take into account when prescribing antibiotics?
how severe are symptoms risks of complications previous urine culture results previous antibiotic use culture results
what do you consider when giving an antibiotic?
– Immediate
– Back up (to use if no improvement at 48hr or
symptoms worsen at any time)
who have low risk of resistance?
• younger women with acute UTI and no resistance risks
what are the risk factors for increased resistance?
• care home resident,
• recurrent UTI (2 in 6 months; >3 in 12 months),
• unresolving urinary symptoms,
• hospitalisation for >7d in the last 6 months,
• recent travel to a country with increased resistance,
• previous UTI resistant to trimethoprim, cephalosporins, or
quinolones.,
if there is a risk of resistance what should you do?
always safety net.
send urine for culture & susceptibilities
what do antibiotics increase the risk of?
Clostridium difficile
how do you reduce c. difficle?
Reduce use of • Ciprofloxacin • Cephalosporins • Co-amoxiclav Increase use of ● Nitrofurantoin ● Trimethoprim ● Pivmecillinam
when is trimethoprim good?
still good for UTI in younger patients, or if known results
when is co-amoxiclav only recommended?
- Pyelonephritis in pregnancy
- Facial cellulitis or prophylaxis post dog or human bites
- Diverticulitis
- Persistent sinusitis second line
what do you consider when choosing an antibiotic?
Trimethoprim is narrow spectrum but resistance is
common
• Nitrofurantoin is more broad spectrum but is
concentrated in the area of need & resistance rates
much lower
what is the recommended duration of treatment with antibiotics for a UTI?
3 day course of empirical antibiotics is recommended for
most women with uncomplicated UTI
what is the dose of nitrofuratoin and trimethoprim?
100mg modified release twice a day for 3 days
200mg twice a day for 3 days
what is the MOA for nitrofurantoin?
concentrated in urine- bactericidal- reduced by
bacterial flavoproteins to reactive intermediates
which inactivate/alter bacterial ribosomal proteins
when do you avoid nitrofurantoin?
Renal impairment: avoid if eGFR
<45ml/min/1.73m2
– not effective in renal impairment as antibacterial
efficacy depends on renal secretion of drug into
urinary tract
– can use 30-44ml/min in exceptional circumstances if
benefits outweigh risks
what counselling points should be given with nitrofurantoin?
• Take with food to increase bioavailability
• Standard release 50mg QDS
• Modified release 100mg BD
• Can darken urine colour (yellow/brown)
• Contraindications: eGFR low (see previous
slide) G6PD deficiency, acute porphyria,
infants <3months
• Cautions: liver toxicity, pregnancy, diabetes,
pulmonary disease, anaemia, low B12, folate
deficiency
what are the adverse effects of nitrofurantoin?
GI (nausea, vomiting, loss of appetite, diarrhoea) –
minimised by taking with food or milk
– Dizzy/tired
– Itchy rash/allergic reaction/ swollen salivary glands -
discontinue
– Peripheral neuropathy (therefore caution in pts who
may be susceptible e.g. diabetes)- discontinue if signs
– Pulmonary reactions- stop at first sign of respiratory
problems e.g. breathing difficulties/chest pain
– Discontinue treatment with nitrofurantoin if otherwise
unexplained pulmonary, hepatotoxic, haematological or
neurological syndromes occur.
what is the MOA of trimetoprim?
nhibits DHFR therefore
blocks the reduction of dihydrofolate to
tetrahydrofolate, the active form of folic acid,
by susceptible organisms
• Inhibitory activity for most gram-positive
aerobic cocci and some gram-negative aerobic
bacilli
what does trimethoprim interact with?
methotrexate, warfarin
– can cause hyperkalaemia so caution with other
drugs that can increase K+ e.g. ACEI
what are the contraindications of trimethoprim?
blood dyscrasias, first
trimester pregnancy
what are the side effects of trimethoprim?
Mild gastrointestinal disturbances e.g.
nausea/vomiting
– Pruritis and skin rash (3-7% patients)
– Blood disorders (long term)
what is the role of the pharmacist in UTI?
• Consider diagnosis • Recognise when mild symptoms could respond to self-care and • Advise on appropriate self-care • Recognise when referral is required • PHE leaflet may support consultation on this • Ensure prescriptions are appropriate and any longer term antibiotics are reviewed
what self care should be done with UTIs?
• Adequate fluid intake
– Help to flush bacteria from urinary tract
– Avoid dehydration
• Paracetamol for pain (or ibuprofen, if appropriate
and lower UTI)
• Cranberry juice or tablets, alkalinising agents (not
likely to be harmful, may help) – no good evidence
• Hygiene- wipe from front to back
• Empty bladder soon after sexual intercourse
• Birth control
• Avoid potentially irritating female products as these
can irritate the urethra
when is a PGD used to supply trimethoprim?
• Strict inclusion/exclusion criteria
• Safety netting
• Pharmacists must have completed specified training
before administering this PGD
• Record of supply made on patients PMR and GP
notified of supply
