Urinary Tract Infection

UTI

Urinary tract infection is one of the most commonly reported primary care conditions in Canada. It is important that primary care practitioners are aware of the clinical guidelines to assess, diagnose, and manage urinary tract conditions because unnecessary treatments have been causing escalating rate of antibiotic resistance and collateral damage in many communities. Similarly, delaying treatments in high risk patients can lead to complications including urosepsis and death.

In this module you will review the following:

UTI screening in adults, children, and pregnant woman

signs and symptoms of lower urinary tract infection Vs upper urinary tract infection

Management of asymptomatic bacteriuria

High risk factors and UTI complications

Early detection of complications associated with UTI

Choosing antimicrobial wisely

Managing UTI recurrence, prophylaxis

Step-1

Abstract Conceptualization

Pathophysiology of UTI and Risk Factors

Most cases of UTI are caused by ascending infections that travel up urethra in to bladder. Almost 80-90% of UTI are caused by E-coli. Although ascending infection are the most common route of infection, hematogenous and lymphatic source of urinary tract infections can also occur. UTI rate increases with advancing age. Previous history of UTI, diabetes mellitus, sexual intercourse, intrauterine contraceptives, parity, anatomical variations, calculi formation, obesity, family history of UTI, and catheterization are the common risk factor for UTI in premenopausal women (1,3). Vaginal atrophy, hypoestrogenic stage, poor personal hygiene, catheterization etc. are the other high-risk factors in elderly (5). In children with recurring UTI, renal abnormalities or pre-existing medical problems, should be suspected (4).

Stage 2

Active Experimentation

Screening and diagnosing of UTI

Lower urinary tract infection is often referred as cystitis. Associated symptoms may include, dysuria, increased frequency, suprapubic pressure, and rarely hematuria. Malodourous urine or concentrated urine are not definite signs of UTI. Fever, back pain, chills may be associated with pyelonephritis. (complicated UTI) (6). In seniors, UTI may present with behavioural symptoms, lethargy, frequent falls etc. Fever or other typical signs of UTI alone are not reliable indicators of UTI in seniors(5).It is recommended to perform a urinalysis and urine culture for children <3 years of age with a fever (>39.0°C rectal) with no apparent source of infection. Similarly, children with other typical signs of UTI should be screened with urinalysis and urine culture. For Infants under 2 months of age with febrile illness, bacterial sepsis must be ruled out (4). Ordering urinalysis/ culture in asymptomatic patients including seniors will cause collateral damage such as antibiotic resistance, side effects from antibiotic use, increased health care cost etc. Avoid routine urine culture in asymptomatic patients.

Asymptomatic bacteriuria (Pt has bacteria in urine in the absence of any symptoms) does not require treatment unless patient is pregnant or planning to undergo genitourinary surgery with mucosal breach (1,2,5). It is also important to identify whether the presenting signs and symptoms are suggestive of a complicated or uncomplicated UTI. UTI associated with structural, functional, metabolic impairments are considered as complicated UTI (1). In case of a complicated UTI or pyelonephritis, urine culture to be sent. Likewise, blood culture should be considered if patient is hemodynamically unstable, has pyelonephritis, or pyrexia. High risk factors that lead to complicated UTI include: male sex, chronic obstruction, nephrolithiasis, poorly controlled diabetes, indwelling urinary catheter, indwelling urinary stent or nephrostomy tube, chronic renal insufficiency, pregnancy, immunosuppression etc (1).

Clinical Management of UTI (1,2,6)

UTI_Clinical_Management_1 UTI_Clinical_Management_2

Pediatric UTI Management

Pharmacotherapy

Amoxicillin50 mg/kg/day (divided in three doses)
Amoxicillin/clavulanate(7:1 formulation) 40 mg/kg/day (divided in three doses)
Co-trimoxazole8 mg/kg/day of the trimethoprim component divided in two doses (0.5 mL/kg/dose)
Cefixime8 mg/kg/day (given as a single dose)
Cefprozil30 mg/kg/day (divided in two doses)
Cephalexin50 mg/kg/day (divided in four doses)
Ciprofloxacin*30 mg/g/day (divided in two doses)
To learn more about pediatric UTI management read Canadian Pediatric Society Guidelines at
https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children

Clinical Pearl

  • Ask relevant questions to r/o STD, PID, prostatitis, epididymitis, vaginitis for patients presenting with UTI symptoms.
  • know the antibiotic resistance prevalent in your community and choose antibiotics accordingly
  • Avoid use of fluoroquinolones as the first line (due to resistance, reserved for severe situations) (6).
  • If TMP/ SMX resistance is more than 20% in the community, avoid the use (6).
  • Amoxicillin is not a first choice.
  • In case of recurrent cystitis (2 or more episodes in 6 months, 3 or more in a year), low dose antimicrobials can be prescribed for post coital use. E.g. Macrobid 100mg po qhs or post coital. Choose antimicrobial based on culture result.
  • . Post menopausal women with recurrent cystitis should be prescribed vaginal estrogen (2)
  • Avoid nitrofurantoin use at 36-42 weeks of pregnancy, TMP/SMX and trimethoprim during the first trimester and TMP/SMX during the last 6 weeks. Trimethoprim reduces fetal availability of folic acid. Follow up culture should be done after completion of treatment (6). Canadian Task force recommendation on screening for asymptomatic bacteriuria in pregnant woman is available at https://canadiantaskforce.ca/tools-resources/asymptomatic-bacteriuria-2/asymptomatic-bacteriuria-clinician-faq/
  • Children < 2 years of age should be investigated after their first febrile UTI with a renal and bladder ultrasound (RBUS) (4).
  • To learn more about management of UTI in nursing home and renal dosing of antimicrobials in UTI management, follow the link: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pad-service/utis-in-primary-and-long-term-care
  • There is some evidence that cranberry juice and derivatives may reduce the number of symptomatic UTI; however, more evidence required (3).
  • Evidence from two small RCTs shows that in postmenopausal women with recurrent UTI, vaginal estrogens reduce the number of UTIs; 0.5 mg of estriol cream vaginally every night for 2-weeks and then twice a week for 8-months compared with those using a placebo were compared in both the studies (2).

Stage -3

SOAP note (Example)

Pt felt unwell for •1 day

dysuria+, - hematuria,+ve, foul smelling urine, +very cloudy urine

+ fever, +urgency

No nausea, no vomiting

No back pain, chills

Past h/o UTI-+

No associated comorbidities

O:

Urine dip test- Nitrites +, leukocytes++, Hb- nil

+vesuprapubic tenderness, CVA tenderness-nil

Abdo: soft, non-distended, non-tender, no CVA tenderness, no guarding/rebound, no peritoneal signs, no mass/HSM

A:

Cystitis

P:

Macrobid as directed

advised to stay well hydrated

If any fever, chills, no improvement in symptoms within 24 hrs, should rtc as soon as possible

Stage 4

Reflective Observation

Learning activity

Write a reflection on your learning experience with UTI management? What are your new ideas or learning outcome that you would like to experiment in your future practice.

Reference Page

1. Beahm, N. P., Nicolle, L. E., Bursey, A., Smyth, D. J., &Tsuyuki, R. T. (2017). The assessment and management of urinary tract infections in adults: Guidelines for pharmacists. Canadian pharmacists journal: CPJ = Revue des pharmaciens du Canada: RPC, 150(5), 298-305. doi:10.1177/1715163517723036

2. Epp, A., &Larochelle, A., (October 2017). Recurrent urinary tract infection. Journal of Obstetrics and GynecologyCanada, Volume 39 (10), Retrieved from https://www.jogc.com/article/S1701-2163(17)30826-5/abstract

3. The American College of Gynecology and Obstetricians (2016). Treatment of urinary tract infections in non-pregnant woman. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Treatment-of-Urinary-Tract-Infections-in-Nonpregnant-Women?IsMobileSet=false

4. Robinson, J., Finlay, J., Lang, M., Bortolussi, R., (January 30, 2017)Urinary tract infection in infants and children: Diagnosis and management.Pediatric Child Health19(6): Page No: 315-19. Retrieved from https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children

5. Government of BC (2019). UTI in primary and long tern care. Retrieved from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pad-service/utis-in-primary-and-long-term-care

6. Ani infective Review Panel. Anti Infective Guidelines for community acquired infections. Toronto: MUMS Guideline Clearing House:2013.

7. Canadian Task Force on Preventive Health Care (2018). Asymptomatic bacteriuria in pregnancy. Retrieved from https://canadiantaskforce.ca/tools-resources/asymptomatic-bacteriuria-2/asymptomatic-bacteriuria-clinician-faq/