UTI's

Question 1

What is a UTI?

Answer 1

An infection of the urinary tract classed as either uncomplicated or complicated (Structural GU tract problems like stones, obstruction, catheter, male, treatment resistant). Common causative organisms include E. Coli and Staphylococcus Saprophyticus. UTI’s are much more common in women due to their shorter urethra, especially following sexual intercourse

If the infection tracks up to the kidneys it produces a more systemic response (Pyelonephritis), this is more severe and requires longer antibiotic treatment or hospital admission

Question 2

What will you find in a history taking of a UTI?

Answer 2

Symptoms:
Dysuria
Frequency/Urgency
Haematuria
Foul Smelling Urine
Suprapubic Pain
Confusion – More common in elderly patients 
Symptoms of pyelonephritis - Back/Flank pain, Fever/Rigors, Vomiting, Sepsis  

Risk Factors: 
Older Patients 
Sexually active
Females 
History of UTI’s
Pregnancy
Impaired Bladder Emptying - Neurogenic bladder, Renal Stones, Diabetes, Structural Defect, Urinary Catheter 

Specific Questions:
Look for signs of pyelonephritis - Supra-pubic pain, fever which indicate more severe Upper UTI infection
Ask about vaginal discharge - Could indicate pelvic inflammatory disease or an STD
History of UTI or STD – Increases risk of either
Family history of UTI’s
Use of immunosuppressants e.g. Steroids

Differentials:
Prostate Cancer – Elderly Male, Hesitancy, Incomplete emptying, Frequency, Urgency, Incontinence, Terminal Dribbling, Weak Stream, Trouble initiating
Urethral Syndrome - Effectively UTI with no infective agent involved. Based off UTI history with negative urine cultures
Atrophic Vaginitis – Post menopausal change in the vagina (epithelial thinning, drying out, fragility) cause it to become more easily inflamed giving the symptoms of ta UTI.,
STD – Associated with discharge and abnormal bleeding in female, but can also present with UTI symptoms

Question 3

What will you find on examination of a patient with a UTI?

Answer 3

Examination findings:
End of the bed:
Systemic signs of infection like fever

Abdomen:
Abdominal/Loin Pain
Distended bladder

Question 4

What investigations will you find in a UTI?

Answer 4

Bedside:
Urine dipstick - nitrite and leukocyte esterase positive with haematuria, can still have a UTI and be dipstick negative
Urine microscopy, culture and sensitivity - Looking for causative organism if resistant or complicated case.
Pregnancy test

Bloods: - Only required if systemic signs of infection
FBC - Raised WCC
Une - Looking for dehydration/sepsis
ESR/CRP – will be raised in systemic infection
Blood Cultures - Looking for bacteraemia/sepsis

Imaging: Indications (resistant to medical treatment, severe infection, UTI in a child or male, recurrent infection)
Renal US - looking for kidney stone; hydronephrosis; renal abscess; renal scarring or any structural deformity

Question 5

What is the treatment of a UTI?

Answer 5

Medical:
Paracetamol to help pain
Uncomplicated cases – nitrofurantoin/ trimethoprim for 3 days.
Complicated cases - nitrofurantoin/ trimethoprim for 7 days
Treatment resistant cases – Culture urine and treat based off sensitivity
Recurrent UTI – 6 months of low dose nitrofurantoin/ trimethoprim
Pregnancy – Get help as can be associated with birth problems, start antibiotic treatment based off local guidelines. Cannot use trimethoprim first trimester or nitrofurantoin 3rd trimester
Pyelonephritis - Order urine cultures. Empirical antibiotics e.g. Co-amoxiclav for 2 weeks/Ciprofalxin for 1 week, paracetamol to control fever and lots of fluids. Treat in community unless pregnant, elderly, septic, dehydrated.