Types of UTI

Types of UTI • „Simple‟ or „uncomplicated‟ – – – – Female First presentation No signs of pyelonephritis Not pregnant • „Complicated‟ – – – – – – 1 Pregnant Male Children Recurrent Pyelonephritis Elderly So what could it be? Prodigy Urinary Tract Infection (cystitis) • Typical features include: – Dysuria, frequency, urgency, nocturia, haematuria, suprapubic pain, cloudy or smelly urine – Caused by bacteriuria, defined as >105 organisms/ml (102-104 if under sterile conditions) – „Simple‟ UTIs are rarely associated with renal failure or sepsis (HummersPradier. Br J Gen Pract 2002; 52: 752-761) Acute pyelonephritis • As above plus: – fever (>38.5oC), loin/flank pain/tenderness, rigors, nausea, vomiting and malaise – Can be life-threatening so requires urgent treatment As cystitis but no bacteriuria „Urethral syndrome‟ • Sexually transmitted disease e.g. chlamydia, gonorrhoea, herpes simplex, Candida Other causes can include drugs (e.g. cyclophosphamide, NSAIDs), parasitic infection, female menopause 2 So what are the management options here? A 25 year old lady presents with a 48 hour history of needing to “go the toilet a lot to pee” and it hurts when she does. She also thinks she may have seen blood in her urine. If we diagnose a „simple‟ UTI (assuming she is not pregnant and she has no history of UTI): • Prognosis is good: – Unlikely to cause serious complications – But symptoms are unpleasant (to say the least) • • Up to 50% have no significant bacteriuria. Up to 50% will self-resolve in a few days, even without treatment. – Giving antibiotics may cause more harm than good – May disturb natural gut/vaginal flora and encourage Candida growth. • 3 Can we predict who is more likely to have a bacterial cause for their UTI? Signs and symptoms to help predict a bacteriuria Bent S, et al. JAMA 2002; 287: 2701-2710 • The prevalence of a bacterial UTI in a young woman is around 12% • If she has certain signs and symptoms, this likelihood increases: – Dysuria (by about 1-2 times) – Frequency (by about 1-2 times) – Blood in urine (by about 2 times) – No vaginal discharge (by about 3 times) – No vaginal irritation (by about 3 times) • So if more than 3 of these are present, it is reasonable to assume a bacterial cause for the symptoms – >70 out of 100 women will have a bacterial cause 4 What do the guidelines recommend wrt dipstick testing? Prodigy • • If the woman has several clinical features typical of lower UTI – Treat empirically without testing as urine dipstick test not helpful If the woman has few clinical features typical of lower UTI – Dipstick test the urine: • Dipstick test positive (nitrite and LE both positive), diagnose UTI • Dipstick test equivocal or negative (either or both negative), consider other causes Our thinking: • If „barndoor‟ symptoms (>3), don‟t bother with the dipsticks – a negative test may mislead you • If diagnosis is unsure (1-2 symptoms) use them • But don‟t expect them to tell you the „right‟ answer each time 5 What agent and for how long? Prodigy, SIGN: • • • • • A 3 day course of trimethoprim is effective for „simple‟ UTI Nitrofurantoin is an option, but may be less convenient for patients Compared the success of 3 day regimens with 5 days or more For symptomatic failure rates, no differences were seen For bacteriological failure rates, 3 days was slightly less effective Cochrane Review – Milo G, et al. Date of last amendment 22 Feb 2005 • • Adverse effects were more common with longer courses Bottom line:- 3 days is fine for simple UTI, but not for those in whom bacteriological cure is important, such as pregnancy 6 Trends in Prescribing of Trimethoprim Tabs 200mg (% of 6/10/14 Tabs) in General Practice in England 45 40 35 30 25 % 20 15 10 5 0 Jan-Mar 97 Jan-Mar 98 Jan-Mar 99 Jan-Mar 00 Jan-Mar 01 Jan-Mar 02 Jan-Mar 03 Jan-Mar 04 Jan-Mar 05 7 6 10 14 © Copyright NHSBSA 2006 Simple UTIs - conclusion • Look for ALARMS (temp>38.5oC, rigors, vomiting etc) • Simple UTIs are generally self-limiting, non-serious infections but can be very unpleasant • Use decision rules to help with diagnosis: – >3 symptoms (and self-reported) very likely to be bacterial cause – 1-2 symptoms only - test with dipsticks (but they can mislead) • Management options: – Empirical antibiotics • 3 days trimethoprim or nitrofurantoin – Delayed prescription – Symptomatic treatment ± delayed prescription 8