e-Learning | Lower urinary tract infection (UTI)

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:

  • Dysuria
  • 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.

Self-care advice:

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.

2 Responses

  1. David Church
    Your comment*I have a slight problem with the instruction to not treat over -65s with bacteriuria on dipstix as 'over half of over 65s have asymtomatic bacteriuria on dipstick'. I see symptomatic patients, some of whom are over 65 (there are not enough appointments to see asymptomatic patients!). I use dipstix to support a clinical diagnosis; or occasionally exclude one. If I have 90% decided to treat due to symptoms and examination, should I reverse that clinical decision just because the dipstix detects bacteriuria in confirmation of my diagnosis? How can a dipstix detect that a patient who reports symptoms actually has so-called 'asymptomatic bacteriuria'? does a strip carry a tab for patients lying about symptoms? who invented that one? I think your articles are excellent Louise, but there is a fundamental scientific problem with the evidence base the 'experts' are interpreting to us. If there are symptoms, then whatever the RCGP and NICE says, the patient does NOT have 'asymptomatic bacteriuria' . If the patient is indeed asymptomatic, then they do not come to see me complaining of symptoms.
    • Louise Hudman
      Hello David. Thankyou for your kind comments about my blogs. Hopefully I can clarify things for you. The advice in the over 65s is not to do the dipstick at all. If you do do a dipstick, there is a 50% chance it will be positive, regardless of whether the patient has a UTI or not. So it isn't helpful in diagnosing a UTI in the over 65s. If you see a patient who has enough symptoms to make it likely that they have a UTI (see the list of symptoms in my blog), then don't bother with a dipstick as it just isn't helpful. Either treat immediately, or use a back-up script whilst awaiting an MSU result. You can save the 120s that the dipstick takes! If you do decide to do the dipstick and it is positive - they are not advising you to ignore that. They are just pointing out that there was always a 50% chance it would be positive anyway - UTI or no UTI. If you are assessing a patient who doesn't really have enough symptoms (ie doesn't have new dysuria and doesn't have 2 or more of the listed symptoms), then think of other causes for their presentation, or consider an MSU I guess. In this scenario, there is less chance of the patient having a UTI. If you do a dipstick 'just to check' and it is positive, then it doesn't help you as they may well have something else going on and 'asymptomatic bacteruria'. So in the very common scenario where the nursing home rings up saying 'this patient is more confused than normal and they have a positive dipstick', then that positive dipstick adds nothing to your ability to know whether this patient has a UTI or not. If the only symptom is increasing confusion, then there may well be an alternative cause for that patient's confusion. At the moment I suspect a lot of us (ahem me too!) would just do a script in this case. PHE is trying to say - don't do that - they may well not have a UTI and it may well be an unecessary antibiotic script.

Leave your comments