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Managing the symptoms of urinary tract infection in women Chetan Shah, Stephen Goundrey-Smith
Continence Urinary tract infection Antibiotic therapy
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This article will focus on the signs, symptoms, diagnosis and management of uncomplicated UTIs in women.
SIGNS AND SYMPTOMS
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Common signs and symptoms of UTIs include (Health Protection Agency (now known as Public Health England) [HPA], 2010): Dysuria Urinary frequency Urinary urgency Suprapubic pain or tenderness Haematuria Polyuria.
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rinary tract infections (UTIs) are commonly seen in general practice, accounting for 1–3% of all GP consultations each year (National Prescribing Centre [NPC], 2009) and are the second most common clinical indication for antibiotic treatment in primary and secondary care (Scottish Intercollegiate Guidelines Network [SIGN, 2012]).
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UTIs affect women more commonly than men — around 50% of women will suffer from a symptomatic UTI during their lifetime, with the incidence increasing with advancing age (NPC, 2009) from approximately 7–8% for those aged 60 to 80 years of age to around 20% for those aged 80 years and above (Mahaffey, 2006).
Apart from being female and increasing in age, other risk factors for developing UTIs include institutionalisation, being sexually active, co-morbid diabetes and the presence of a catheter (SIGN, 2012).
Chetan Shah, Senior Lecturer in Pharmacy Practice/Public Health, University of Hertfordshire; Stephen Goundrey-Smith, Consultant Pharmacist, PDC Healthcare Ltd, Leicestershire
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Near-patient testing may include observing the urine sample to see if it is ‘cloudy’, or the use of urine dipsticks. In the absence ofinfection, a urine sample should be odourfree and clear. Any sample that is malodorous and cloudy is likely to be indicative of an UTI (SIGN, 2012). However, visual inspection of a urine sample is prone to observer error and, therefore, may not be a useful discriminator when attempting to diagnose a UTI (SIGN, 2012).
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KEYWORDS:
Near-patient testing
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Urinary tract infections are often seen in community settings and can be debilitating for patients, involving dysuria (painful urination), increased urinary frequency and urgency, suprapubic pain, haematuria (blood in the urine), and polyuria (excessive urine production). This article takes an in-depth look at these symptoms, as well as the diagnosis and management of this common problem, which mostly affects female patients.
regarding any previous UTIs and their treatment. Aids to diagnosis include (Mahaffey, 2006): Near-patient testing Microbiology.
Other symptoms that may also present are malodorous and cloudy urine, rigors, pyrexia (fever), nausea and an acute confusional state (Mahaffey, 2006). The presence of bacteria in the urine, also referred to as bacteriuria, can often lead to inappropriate antibiotic treatment — bacteriuria alone is rarely an indication for antibiotic treatment (SIGN, 2012). The diagnosis of UTI should be primarily based on the signs and symptoms described above (SIGN, 2012).
DIAGNOSIS AND TESTING A full history should be taken, which encompasses information
Urine dipsticks, or testing strips, are placed into a sample of urine for a short period of time — the urine will react with the stick, changing colour to indicate the presence of biochemicals and blood cells. Although the quality of evidence for urine dipsticks strips is weak (SIGN, 2012), they may have a useful role to play in allowing treatment to commence while awaiting confirmation of the infection (it may take the laboratory a while to confirm a diagnosis, so treatment might need to be commenced in the meantime). The SIGN (2012) guidance advises the use of dipstick tests to guide treatment decisions in otherwise healthy women aged under 65 years whose UTI symptoms are mild, or those who present with less than two symptoms. Urine dipsticks test for four factors: Nitrites Leucocytes
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Microbiology testing
Give empirical antibiotic treatment
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Patient presents with UTI symptoms
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Severe or ≥ 3 symptoms of UTI
At the current time, Escherichia coli species are the most common cause of UTI (in 70–95% of uncomplicated cases). Other causative pathogens in uncomplicated UTIs include Enterobacteriae such as Proteus mirabilis and Klebsiella species,
Mild or ≤ 2 symptoms of UTI
Obtain urine sample
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Microscopy can be used to detect haematuria, pyuria (white cells in the urine) or bacteriuria (Balakrishnan and Hill, 2011), or to confirm the organism type and guide antibiotic selection in complicated UTI or pyelonephritis (kidney infection) (BMJ Best Practice, 2013). A UTI might be considered complicated if there are risk factors that predispose the patient to infection (e.g. urinary obstruction or vesico-ureteric reflux).
With mid-stream urine samples, it may not always be possible
CAUSATIVE ORGANISMS
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Urine dipstick testing for nitrites and leucocytes is most effective when the bacterial count is high, however, diagnosis is more accurate if used in combination with other tests (BMJ Best Practice, 2013). If the dipstick result is negative, but the symptoms suggest a UTI, the probability of a UTI is still relatively high (BMJ Best Practice, 2013).
Therefore, urine dipstick testing is of little use in these patient groups.
to eradicate all contamination. Specimens need to be either processed promptly or refrigerated after collection in order to minimise bacterial multiplication (Balakrishnan and Hill, 2011). Figure 1 illustrates a protocol for diagnosis of UTI.
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Testing for nitrites and leucocytes works on the rationale that bacteria present in the urine cause urinary nitrates to breakdown into nitrites. Similarly, a higher concentration of the leucocyte esterase enzyme will be present in the urine as a result of the increased neutrophils present during infection (Balakrishnan and Hill, 2011).
Similarly, urine dipstick testing in general has been found to be unreliable in the following groups (Balakrishnan and Hill, 2011): Pregnant women Children under three years of age Patients whose urinary tracts have structural anomalies Patients with diabetes mellitus Patients who are immunocompromised.
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Blood (erythrocytes) Protein.
Consider other diagnosis
Urine cloudy – dipstick test
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Urine culture and sensitivity testing is the most specific and sensitive test for confirmation of a UTI. A midstream urine sample can be sent for cultures and sensitivity analysis to confirm the diagnosis and to ensure that an appropriate antibiotic can be prescribed (SIGN, 2012). A mid-stream urine sample should be taken for culture to ensure that contamination of the sample is kept to a minimum (Mahaffey, 2006).
There are limitations to both near-patient testing and laboratory microbiology. The detection of protein and blood in the urine by dipstick testing is unreliable, with a high rate of false positives and false negatives, and is, therefore, of comparatively little diagnostic value (Balakrishnan and Hill, 2011). 90 JCN
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Urine not cloudy
Positive nitrite, leucocytes and blood or positive nitrites alone
Probable UTI Treat with first-line agents (follow HPA guidance)
Negative nitrite and positive leucocyte
Negative nitrite, leucocytes and blood or negative nitrite and leucocyte and positive blood or protein
Could equally be UTI or other diagnosis. Treat if severe symptoms or consider delayed antibiotic treatment and urine culture
Consider other diagnosis
Figure 1. Protocol for diagnosis of UTI (adapted from Health Protection Agency [2010a]).
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4 – Name some of the causes of a UTI. 5 – Can you outline some of the main treatments for UTI?
Enterococci, group B Streptococci, Pseudomonas aeruginosa, and Citrobacter species.
‘The diagnosis of UTI is particularly difficult in elderly patients, who are more likely to have asymptomatic bacteriuria as they get older’
If a patient presents with mild symptoms, or at least two of the common signs and symptoms described earlier, a urine specimen should be sought. If the specimen is not cloudy, then a diagnosis other than UTI should be considered. If the urine is cloudy, the clinician should perform a urine dipstick test (in those under the age of 65 years). Possible results and treatment recommendations are as follows (HPA, 2010): A positive nitrite test, with or without a positive leucocyte result, indicates a probable UTI. Based on this result the HPA recommends antibiotic treatment with either trimethoprim 200mg twice-daily or nitrofurantoin 100mg modified release twicedaily (HPA and British Infection Association, 2010) A negative nitrite but positive leucocyte result indicates that UTI or other diagnoses, such as diabetes mellitus, glomerulonephritis, or coagulation disorders, are equally likely. In such situations the clinician should:
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In recent years, the development of E. coli strains with antibiotic resistance mediated by extended spectrum beta lactamase (ESBL) production has been observed (SIGN, 2012). ESBL is an enzyme produced by some pathogens, which breaks down beta-lactam antibiotics (penicillins and cephalosporins), meaning they are no longer effective.
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MANAGEMENT AND ANTIBIOTIC THERAPY
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The HPA produced a useful guidance document for the diagnosis of UTIs in primary care (HPA, 2010). The guidance advises that if a patient presents with severe symptoms — or with at least three or more of the common signs and symptoms described above — there is a 90% probability that a urine culture would be positive for a UTI. Broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) should be avoided as first-line agents as they increase the risk of Clostridium difficile infection, methicillin-resistant Staphylococcus aureus (MRSA)
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The diagnosis of UTI is particularly difficult in elderly patients, who are more likely to have asymptomatic bacteriuria as they get older. This may be due to changes in the structure of the urinary tract or the existence of co-morbidities, such as type 2 diabetes.
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3 – What are some of the diagnostic testing techniques for a UTI?
Management of UTI in elderly patients
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2 – Name some of the main symptoms of a UTI.
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1 – What is a urinary tract infection (UTI)?
Previous studies have shown that trimethoprim and nitrofurantoin are broadly equivalent in efficacy for the treatment of uncomplicated UTI where there are no resistant pathogens. However, there is now some evidence to suggest that resistance to trimethoprim is rising, whereas resistance to nitrofurantoin remains relatively low (McKinnell et al, 2011; National Institute for Health and Care Excellence [NICE], 2012).
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Answer the following questions about this, either to test the new knowledge you have gained or to form part of your ongoing practice development portfolio.
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(i): review time of specimen collection (morning is most reliable) (ii): treat if symptoms are severe or consider delayed antibiotic prescription, and (iii): send for urine culture A negative nitrite, leucocyte and blood result, or negative nitrite and leucocyte test but positive blood or protein result, indicates that an alternative diagnosis should be considered.
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and resistant UTIs. The HPA and British Infection Association (2010) guidance suggests considering narrow spectrum antibiotics such as trimethoprim or nitrofurantoin as first-line treatments when there are three or more symptoms of UTI.
The prevalence of bacteriuria may be so high that urine culture ceases to be a diagnostic test — this is particularly true for elderly institutionalised patients because of the close proximity of other patients/ residents and the possibility of crossinfection (SIGN, 2012). There is no evidence that treatment of asymptomatic bacteriuria in the elderly reduces the risk of symptomatic episodes or mortality — in fact, the evidence actually shows that antibiotic treatment significantly increases the risk of adverse events, such as rashes and gastrointestinal symptoms (SIGN, 2012). In elderly patients, the use of urine dipstick testing is not routinely recommended. However, if patients exhibit two or more of the common signs and symptoms of UTI, diagnosis should be guided using urine dipstick testing, as described above (HPA, 2010). For elderly patients with swallowing difficulties, or patients of any age with dysphagia due to comorbidities such as recent stroke, both nitrofurantoin and trimethoprim are available in liquid formulations. Furthermore, there may be high levels of antibiotic resistance
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When performing urine cultures in elderly patients, community nurses should consider the following: Do not send urine for culture in asymptomatic elderly people with positive dipstick tests Only send urine for culture if there are two or more signs of infection (especially dysuria), fever over 38o or new episodes of incontinence Do not treat asymptomatic bacteriuria in the elderly as it is very common (SIGN, 2012).
CONCLUSION UTIs are commonly encountered in women in the community, with prevalence increasing with age. Other risk factors include sexual activity, institutionalisation, comorbid disease and catheterisation (SIGN, 2012). 92 JCN
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UTIs are common in the community and are more prevalent in women, the prevalence increasing with age.
Other risk factors include sexual activity, institutionalisation, co-morbid disease and catheterisation. diagnosis of UTIs should be based on the signs and symptoms, although microbiological testing may have a role in confirming the diagnosis.
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Guidance from the HPA (2010) suggests considering narrow spectrum antibiotics such as trimethoprim or nitrofurantoin as first-line treatments in uncomplicated UTIs.
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uncomplicated UTIs. Both trimethoprim and nitrofurantoin are available in liquid formulations to enable treatment in a range of patient groups, such as those with swallowing difficulties. Of all healthcare professionals, community nurses are ideally placed to advise clinicians about patients with UTI symptoms, and the most appropriate form of treatment for a particular patient, as they regularly see patients at home or in nursing/ residential homes. JCN
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However, as nitrofurantoin is contraindicated in the presence of significant renal impairment, particular care should be taken when prescribing to elderly patients at increased risk of toxicity (SIGN, 2012).
KEY POINTS
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‘There may be high levels of antibiotic resistance in residential facilities due to elderly and vulnerable individuals living in close proximity.’
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A recent European survey of the treatment of UTIs in residential facilities suggests that the volume of nitrofurantoin prescribing is indeed increasing in the institutionalised elderly patient population (McClean et al, 2011).
Guidance from the HPA (2010) suggests considering narrow spectrum antibiotics such as trimethoprim or nitrofurantoin as first-line treatments in
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The administration of nitrofurantoin, formulated as a liquid, may ensure effective treatment of uncomplicated UTIs in these vulnerable patient populations, as well as ensuring the appropriate use of antibiotics to minimise future resistance problems (commonly known as ‘antibiotic stewardship’).
The diagnosis of UTIs should always be based on the signs and symptoms, although microbiological testing may have a role in confirming the diagnosis.
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in residential facilities due to elderly and vulnerable individuals living in close proximity as well as indiscriminate antibiotic prescribing (McClean et al, 2011). UTIs in these patients may, therefore, be harder to treat. Nitrofurantoin may have an advantage over trimethoprim in these patients in terms of its continued low incidence of resistance.
This paper has been funded and reviewed by the Amdipharm Mercury Company Ltd
REFERENCES Balakrishnan I, Hill V (2011) Dealing with urinary tract infections. Pharmaceutical J 287: 687–90 British Medical Journal Best Practice (2013) Urinary tract infections in women. Available at: http://bestpractice.bmj. com/best-practice/monograph/77.html (accessed 22 August, 2013) HPA (2010) Diagnosis of UTI Quick Reference Guide for Primary Care. HPA, London HPA/British Infection Association (2010) Management of Infection Guidance for Primary Care for Consultation and Local Adaptation. HPA, London Mahaffey W (2006) Diagnosis, treatment and management of urinary tract infections in primary care. Nurse Prescribing 4(7): 282–87 McClean P, Hughes C, Tunney M, Goossens H, Jans B (2011) Antimicrobial prescribing
Both trimethoprim and nitrofurantoin are available in liquid formulations to enable treatment in a range of patient groups, such as those with swallowing difficulties.
in European nursing homes. J Antimicrob Chemother 66: 1609–16 McKinnell JA, Stollenwerk NS, Jung CW, Miller LG (2011) Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc 86(6): 480–88 NICE (2012) Urinary Tract Infection (lower) — women: evidence. Available at: http://www.cks.nhs.uk/urinary_tract_ infection_lower_women/evidence/ supporting_evidence/antibiotic_ treatment_for_non_pregnant_women/ trimethoprim_compared_with_ nitrofurantoin (accessed 22 August 2013) NPC (2009) Common Infections: Urinary Tract Infection. Available at: http://www. npc.nhs.uk/therapeutics/common_ infections/uti/resources/dfc_common_ infect_uti.pdf (accessed 22 August, 2013) SIGN (2012) Management of suspected bacterial urinary tract infection in adults: a national clinical guideline. Available at: http://www.sign.ac.uk/pdf/ sign88.pdf (accessed 22 August, 2013)
