Urinary tract infections I can’t wait. Symptoms of UTI: Dysuria, frequency, urgency,...
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Urinary tract infections I cant wait Slide 2 Symptoms of UTI: Dysuria, frequency, urgency, suprapubic tenderness, haematuria, polyuria Slide 3 Women < 65 If severe symptoms or 3+ symptoms of UTI + no vaginal discharge or irritation THEN empirical treatment no need for dipstick or MSU 3 day course trimethoprim or nitrofurantoin. Slide 4 If mild symptoms or 1-2 symptoms (+ cloudy??) THEN urine dipstick Wait 2 minute to interpret Slide 5 Nitrites / leucocytes + blood or nitrites alone = UTI + dont send urine Leucocytes +ve nitrites ve = equal likelihood of infection or not SO consider treatment / delayed prescription depending on severity of symptoms + send urine for MC+S Negative for nitrites / leucocytes / blood or just +ve for blood or protein = UTI unlikely consider other causes Slide 6 Women age > 65 Send if 2+ signs of infection (esp dysuria, fever, new incontinence) If asymptomatic with +ve dipstick = do not send for culture Do not treat asymptomatic bacteriuria (very common) + treating increases resistance + side effects Slide 7 Catheters Do not treat if asymptomatic bacteriuria Send for culture if features of systemic infection after: excluding other causes, checking catheter not blocked, consider if still needs it + if been in place >7 days consider changing it. Do not give prophylactic abx for catheter change unless previous UTIs related to that. Slide 8 When else should I send for culture? Pregnancy if symptoms + at antenatal booking + treat asymptomatic bacteriuria (assoc with pyelonephritis / premature delivery) ? Pyelonephritis Suspected UTI in men (any age) Failed treatment or persistent symptoms Recurrent UTIs, urinary anatomical abnormalities, renal impairment more likely to be resistant Slide 9 Mid stream sample Boric acid tube (red top) Refrigerated Slide 10 Culture interpretation > 10 4 CFU 1 organism > 10 5 CFU mixed growth 1 organism predominant E coli / staph saprophyticus >10 3 White cells - >10 4 = inflammation normal in pregnancy / if no growth + young consider chlamydia Epithelial cells = contamination Red cells = often present in infection if no infection needs follow up / ? Investigation. Lab red cells less accurate than dipstick Slide 11 Follow up MSU Only in asymptomatic bacteriuria of pregnancy Slide 12 Consider chlamydia esp in sexually active young men and women Young men urethritis (NSU) = treat as STI Azithromycin empirically Urine for chlamydia (first pass) / contact tracing (i.e offer GUM clinic if complex!) Gonorrhoea causes urethral discharge so swab if present Sexual hx (who puts what into which orifices) Slide 13 http://www.hpa.org.uk/webc/HPAwebFile/ HPAweb_C/1194947404720 http://www.hpa.org.uk/webc/HPAwebFile/ HPAweb_C/1194947404720 Slide 14 Summary Send in all men Send in > 65 if symptomatic >2 symptoms Send in pyelonephritis, pregnancy, failed treatment, recurrent, anatomical problems In women < 65 only send if leuk +ve nitrites ve + only dip if < 3 symptoms of UTI Slide 15 Haematuria Painless macroscopic haematuria refer urgently urology Symptoms of UTI + macroscopic haematuria = Rx and investigate as UTI + if not confirmed refer urgently Slide 16 Haematuria Age > 40 + recurrent (3+)/ persistent UTI microscopic haematuria refer urgently Unexplained microscopic haematuria (3 dipsticks) - check U+Es / ? Proteinuria Refer urgently >50 / non urgentlySlide 17 UTI in children Slide 18 13 week old baby presents with PUO 1 week post immunisations. Mild diarrhoea but no obvious focus Urinalysis obtained with pad Leukocytes, nitrites, protein, blood. Urine sent for urgent microscopy and culture + empirical trimethoprim Culture not processed by lab 2 weeks later culture confirmed ESBL UTI sensitive to nitrofurantoin Slide 19 UTIs NICE guidelines Under 3 months refer paeds urgent 3 months 3 years consider urgent referral. All below 3 years diagnosis by urgent urine microscopy and culture (if not possible send urine for MC+S + start abx if clinically UTI / dipstick suggestive) Over 3 years dipstick diagnosis Slide 20 Interpreting urgent microscopy Results for bacteriuria + pyuria If +ve for bacteriuria = UTI If just +ve pyuria ve bacteriuria = UTI if clinically If both negative not UTI Slide 21 Dipstick If leuk or nitrites +ve sent for MC+S If both negative dont send unless unwell or hx of recurrent UTI Slide 22 What about imaging? Nice guidelines Below 6 months 6 months 3 years Above 3 years Slide 23 Below 6 months Typical organism (e coli) + responds within 48 hrs. ultrasound within 6 weeks only If atypical or recurrent need urgent US, DMSA and MCUG Slide 24 6 months 3 years Typical organism + responds no scanning Atypical urgent US and DMSA Recurrent 6 week US and DMSA No need of MCUG after 6 months Slide 25 Over 3 years Typical no scans Atypical acute US Recurrent 6 week US and DMSA Slide 26 HOWEVER Trust guidelines completely different. Slide 27