NICE released new guidelines in Oct 18 on antimicrobial prescribing in lower urinary tract infection (UTI). Public Health England (PHE) has guidelines on the diagnosis and management of UTI, which were update shortly afterwards. There is separate advice on antibiotic prescribing in pyelonephritis, but this doesn't change practice.
The PHE guideline especially is really useful. It gives a very clear, evidenced based way of deciding who needs investigating (ie dipstix or culture) and who needs treating. I suspect I have been overtreating.
For me, the single biggest learning point was that we shouldn't be dipping urine in the over 65s. Half of the over 65s will have asymptomatic bacteruria which will show up on a dipstix as a false positive.
Both these guidelines cover children, but as there is separate NICE guidance on this, I will not summarise these bits (it doesn't change any of our management).
I am also not going to cover which antibiotics to use as we will probably need to be led by our local prescribing guidelines on this because of resistance patterns.
Managing non-pregnant women under 65 years of age with symptoms of UTI.
PHE outlines 3 key symptoms:
- Nocturia (new)
- Urine is cloudy
Proportion of women who have these key criteria who have a positive culture:
- 0 key symptoms - uncertain proportion
- 1 key symptom - 68%
- 2 key symptoms - 74%
- 3 key symptoms - 82%
NB - if a woman has vaginal discharge, 80% of them will not have a UTI.
Women with 0 key symptoms:
If a woman has 0 key symptoms but has any of the following:
- Severe urgency
- Severe visible haematuria
- Severe frequency
- Severe suprapubic tenderness
Do a dipstix test.
Women with 1 key symptom:
If a woman has 1 key symptom, then do a dipstix test.
Women with 2 or 3 key symptoms:
Consider immediate antibiotics.
If symptoms are mild, you can consider watching and waiting with a back-up prescription.
How to act on dipstix results.
- Nil positive - consider other diagnoses.
- Positive leukocytes, negative nitrites. A UTI is as likely as other diagnoses. Consider repeating on a morning sample or sending a culture. Consider either back-up or immediate antibiotics, depending on symptom severity.
- Either leukocytes or nitrites positive AND positive red blood cells - UTI is likely.
NICE advice on deciding when to prescribe antibiotics
Consider either an immediate prescription, or a back-up prescription to use if symptoms don't improve within 48 hrs, or if they worsen at any time.
Take into account:
- Severity of symptoms.
- Chance of complications (eg structural abnormalities or immunosupression).
- Preferences of the woman.
There is good evidence for the use of back-up antibiotics:
- in women aged 18 -70 years old WITH
- uncomplicated lower UTI WHEN
- immediate prescription was not thought to be necessary.
In this group of women, back-up antibiotics are as effective as immediate prescriptions in the severity and duration of symptoms and in the time to reconsultation. Back-up scripts (especially if forward dated by 48 hrs) reduce antibiotic use.
Managing men under 65 yrs old with symptoms of UTI
Always send an MSU.
Dipstix are poor at ruling out infection (though they do go on to say that if both leukocytes and nitrites are negative, that a UTI is less likely) .
A positive nitrite makes a UTI more likely (there is a positive predictive value of 96%).
An immediate prescription should be given if UTI is suspected.
Managing pregnant women with symptoms of UTI.
Send an MSU.
Give an immediate antibiotic prescription if a UTI is suspected.
Managing men and women over the age of 65 with symptoms of UTI
Do not do a dipstix. About half of older people without a catheter (and nearly all those with one) will have asymptomatic bacteruria. This will give a false positive dipstix.
Check for any NEW signs and symptoms. If there is:
-New onset dysuria OR
- 2 or more of the following
- Temperature (over 1.5 deg over the person's normal twice in 12 hrs).
- New frequency or urgency.
- New incontinence.
- New or worsening delirium / disability.
- New suprapubic pain.
- Visible haematuria.
Then UTI is likely. Send an MSU.
If symptoms are mild and they don't have a catheter and they are at low risk of complications then consider a back-up script. An immediate script can also be used.
If the patient has a catheter, consider changing it as soon as possible and taking the MSU from the new catheter.
If there is only fever and delirium or disability alone, then consider other causes before treating the patient for a UTI.
Safety netting advice to give all patients with a UTI.
- Seek advice if symptoms worsen significantly or rapidly at any time.
- Seek advice if symptoms don't improve within 48 hrs of taking antibiotics.
- Seek advice if they become systemically very unwell.
Use paracetamol or ibuprofen for pain relief.
Drink enough fluids to avoid dehydration.
There is no evidence that cranberry juice or alkalinising agents are effective (there just aren't the studies done either way really).
There are excellent leaflets on the RCGP site that we can give out. These have a handy tick-box list, which makes it really clear to the patient whether antibiotics are likely to be useful.
What length course of antibiotics should we be advising?
3 days of antibiotics is as effective as longer courses for most non-pregnant women, even the over 65s. There are fewer side-effects than with longer courses.
Consider a 7 day course for women with recurrent infections. There is no clear evidence for this being more effective, but there is evidence that a 7 day course gives a greater chance of a clear culture, which may be more important in women with recurrent UTI.
Men and pregnant ladies should have a 7 day course.
Should we be treating asymptomatic bacteruria?
Pregnant women - yes.
Men, children and non-pregnant women - no.