Urinary tract infections

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Urinary tract infections

• I cant wait

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• Symptoms of UTI
• Dysuria, frequency, urgency, suprapubic
  tenderness, haematuria, polyuria

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Women lt 65

• If severe symptoms or 3 symptoms of UTI no
  vaginal discharge or irritation
• THEN empirical treatment no need for dipstick or
  MSU
• 3 day course trimethoprim or nitrofurantoin.

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• If mild symptoms or 1-2 symptoms ( cloudy??)
• THEN urine dipstick
• Wait 2 minute to interpret

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• Nitrites / leucocytes blood or nitrites alone
  UTI dont send urine
• Leucocytes ve nitrites ve equal likelihood of
  infection or not
• SO consider treatment / delayed prescription
  depending on severity of symptoms send urine
  for MCS
• Negative for nitrites / leucocytes / blood or
  just ve for blood or protein UTI unlikely
  consider other causes

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Women age gt 65

• Send if 2 signs of infection (esp dysuria,
  fever, new incontinence)
• If asymptomatic with ve dipstick do not send
  for culture
• Do not treat asymptomatic bacteriuria (very
  common) treating increases resistance side
  effects

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Catheters

• Do not treat if asymptomatic bacteriuria
• Send for culture if features of systemic
  infection
• after excluding other causes, checking catheter
  not blocked, consider if still needs it if been
  in place gt7 days consider changing it.
• Do not give prophylactic abx for catheter change
  unless previous UTIs related to that.

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When else should I send for culture?

• Pregnancy if symptoms at antenatal booking
  treat asymptomatic bacteriuria (assoc with
  pyelonephritis / premature delivery)
• ? Pyelonephritis
• Suspected UTI in men (any age)
• Failed treatment or persistent symptoms
• Recurrent UTIs, urinary anatomical abnormalities,
  renal impairment more likely to be resistant

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• Mid stream sample
• Boric acid tube (red top)
• Refrigerated

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Culture interpretation

• gt 104 CFU 1 organism
• gt 105 CFU mixed growth 1 organism predominant
• E coli / staph saprophyticus gt103
• White cells - gt104 inflammation normal in
  pregnancy / if no growth young consider
  chlamydia
• Epithelial cells contamination
• Red cells often present in infection if no
  infection needs follow up / ? Investigation. Lab
  red cells less accurate than dipstick

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Follow up MSU

• Only in asymptomatic bacteriuria of pregnancy

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• Consider chlamydia esp in sexually active young
  men and women
• Young men urethritis (NSU) treat as STI
• Azithromycin empirically
• Urine for chlamydia (first pass) / contact
  tracing (i.e offer GUM clinic if complex!)
• Gonorrhoea causes urethral discharge so swab if
  present
• Sexual hx (who puts what into which orifices)

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• http//www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/119
  4947404720

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Summary

• Send in all men
• Send in gt 65 if symptomatic gt2 symptoms
• Send in pyelonephritis, pregnancy, failed
  treatment, recurrent, anatomical problems
• In women lt 65 only send if leuk ve nitrites ve
  only dip if lt 3 symptoms of UTI

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Haematuria

• Painless macroscopic haematuria refer urgently
  urology
• Symptoms of UTI macroscopic haematuria Rx and
  investigate as UTI if not confirmed refer
  urgently

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Haematuria

• Age gt 40 recurrent (3)/ persistent UTI
  microscopic haematuria refer urgently
• Unexplained microscopic haematuria (3 dipsticks)
  - check UEs / ? Proteinuria
• Refer urgently gt50 / non urgently lt50
• Renal or urology depending on ? Proteinuria /
  renal function

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UTI in children
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• 13 week old baby presents with PUO
• 1 week post immunisations.
• Mild diarrhoea but no obvious focus
• Urinalysis obtained with pad
• Leukocytes, nitrites, protein, blood.
• Urine sent for urgent microscopy and culture
  empirical trimethoprim
• Culture not processed by lab
• 2 weeks later culture confirmed ESBL UTI
  sensitive to nitrofurantoin

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UTIs NICE guidelines

• Under 3 months refer paeds urgent
• 3 months 3 years consider urgent referral.
• All below 3 years diagnosis by urgent urine
  microscopy and culture (if not possible send
  urine for MCS start abx if clinically UTI /
  dipstick suggestive)
• Over 3 years dipstick diagnosis

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Interpreting urgent microscopy

• Results for bacteriuria pyuria
• If ve for bacteriuria UTI
• If just ve pyuria ve bacteriuria UTI if
  clinically
• If both negative not UTI

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Dipstick

• If leuk or nitrites ve sent for MCS
• If both negative dont send unless unwell or hx
  of recurrent UTI

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What about imaging?

• Nice guidelines
• Below 6 months
• 6 months 3 years
• Above 3 years

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Below 6 months

• Typical organism (e coli) responds within 48
  hrs. ultrasound within 6 weeks only
• If atypical or recurrent need urgent US, DMSA and
  MCUG

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• 6 months 3 years
• Typical organism responds no scanning
• Atypical urgent US and DMSA
• Recurrent 6 week US and DMSA
• No need of MCUG after 6 months

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• Over 3 years
• Typical no scans
• Atypical acute US
• Recurrent 6 week US and DMSA

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HOWEVER

• Trust guidelines completely different.

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