EMed

Urinary Tract Infection

Background

UTI is the second most common clinical indication for antimicrobial treatment in primary and secondary care. The common local (Cork Kerry region) pathogens are Coliform (80%), Enterococcus (6%), Proteus (4%) and Staph. (3%). Others include Pseudomonas, Strep. and MRSA.

Diagnosis

Lab testing for Culture & Sensitivity indicated in

  • Pregnancy
  • Suspected UTI in children
  • Suspected pyelonephritis
  • Suspected UTI in men
  • Recurrent UTI in women
  • Failed antibiotic treatment
  • Patients with known abnormalities of the GU tract
  • Patients with renal impairment

Catheterised Patients

  • Avoid unnecessary samples as bacteruria is usual
  • Send sample if features of systemic infection
  • If catheterised, antibiotics will not eradicate bacteruria
  • Only treat is systemically unwell or pyelonephritis likely

The Elderly

  • Asymptomatic bacteruria in the elderly is very common
  • It is not related to morbidity or mortality
  • Ix & Rx will ↑ side effects and medicalise the condition
  • Only sample if two signs of infection e.g. dysuria, >38° or new incontinence

Dipstick urinalysis

AMRIC position 2021.

  1. Dipstick urinalysis may be useful in assessing for UTI in non-pregnant ♀ patients < 65 years old when there is a low clinical index of suspicion of a UTI based on the presenting signs of symptoms on the panel across (list A)
  2. In the presence of signs and symptoms of a UTI, the use of dipstick urinalysis for all persons aged 65 years and older is not a useful guide to Mx and is not recommended
  3. In the presence of signs and symptoms of a UTI, the use of dipstick urinalysis in persons at any age with an indwelling catheter is not a useful guide to management and is not recommended
  4. In the absence of signs and symptoms of a UTI, the use of dipstick urinalysis to assess for evidence of a UTI is not useful and should be avoided in people of all ages. This includes those instances which are commonly reported to trigger dipstick urinalysis such as:
    • Foul smelling, dark, concentrated and/or cloudy urine: In the absence of signs &anp; symptoms of a UTI (Box A), this is suggestive of dehydration rather than of infection
    • Altered mental status and behavioural changes (confusion, decreased appetite, decreased balance, falls, disorientation, wandering, and verbal aggression (delirium)): In the absence of signs and symptoms of a UTI, these should not be readily attributed to a UTI. Consider other common causes (PINCHME)
  5. Dipstick urinalysis has no role in assessing response to treatment of a UTI

Box A

Signs and Symptoms of UTI:
  • Acute dysuria
  • New/worsening frequency
  • New/worsening urgency
  • New onset incontinence
  • Fever
  • Suprapubic or costovertebral angle pain or tenderness
  • Haematuria

Box C

Meds to consider reviewing
  • Hypnotics including benzodiazepines
  • Gabapentinoids
  • Opioids incl. tramadol & patches
  • Anticholinergics such as Amitriptyline, Chlorphenamine, Tolterodine, Oxybutynin, Paroxetine, Procyclidine, Promethazine, Chlorpromazine

Treatment

Management suspected UTI in men

  • DDx includes prostatitis, chlamydial & epididymitis
  • Take urine sample for C&S
  • UTI in men should be treated for 14 days (cannot exclude prostatitis)
  • Men should be referred to urology if:
    • recurrent UTI (2 or more episodes in 3/12)
    • symptoms of upper UTI
    • fail to respond to appropriate antibiotics

Recommended length of treatment

  • Uncomplicated UTI in women - treat for 3/7
  • UTI in pregnant women and children treated for 7 days
  • UTI in men should be treated for 14 days (cannot exclude prostatitis)
  • Upper UTI should:
    • Treat for 14 days (or 7 days if using quinolone)
    • Admit to hosp. if upper UTI not responding in 24 hrs
    • UroSEPSIS has different antibiotic guidelines. Please also treat with Septic 6 bundle

UTI - simple

Please see NCHD.ie.

UTI - pyelonephritis

Please see NCHD.ie.

UTI - SEPTIC patient

Please see NCHD.ie.

Catheter Related Bacteruria

Please see NCHD.ie.

?UTI older people

Patient Hx Symptoms Signs Urine dip
Clear and unambiguous New onset of frequency, dysuria Abdominal pain, Haematuria, Offensive smelling urine, Fever Negative – seek other cause. Do not send MSU
Positive for leucocytes and nitrites – likely UTI, send MSU and treat
No urinary symptoms   Do not dip urine, do not send MSU
Lacking because of communication barrier ↑confusion, apathy, irritability, (delirium), ↓mobility, off food Abdominal pain, Haematuria, Offensive smelling urine, Fever Negative – seek other cause. Do not send MSU
Positive for
leucocytes and
nitrites – likely UTI,
send MSU and treat
Leucocyte positive only – seek alternative diagnosis
Nitrite positive only – send MSU and start treatment

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 12/04/23.