Download - Urinary tract infections … I can’t wait…. Symptoms of UTI: Dysuria, frequency, urgency, suprapubic tenderness, haematuria, polyuria.

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Urinary tract infections

… I can’t wait…

Symptoms of UTI:

Dysuria, frequency, urgency, suprapubic tenderness, haematuria, polyuria

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.

If mild symptoms or 1-2 symptoms (+ cloudy??)

THEN urine dipstick Wait 2 minute to interpret

Nitrites / leucocytes + blood or nitrites alone = UTI + don’t 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

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

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.

When else should I send for culture?

Pregnancy – if symptoms + at antenatal booking + treat asymptomatic bacteriuria (assoc with pyelonephritis / premature delivery)

? PyelonephritisSuspected UTI in men (any age)Failed treatment or persistent symptomsRecurrent UTIs, urinary anatomical

abnormalities, renal impairment – more likely to be resistant

Mid stream sampleBoric acid tube (red top)Refrigerated

Culture interpretation

> 104 CFU – 1 organism > 105 CFU – mixed growth 1 organism

predominant E coli / staph saprophyticus >103

White cells - >104 = 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

Follow up MSU

Only in asymptomatic bacteriuria of pregnancy

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)

http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947404720

Summary

Send in all menSend in > 65 if symptomatic >2 symptomsSend in pyelonephritis, pregnancy, failed

treatment, recurrent, anatomical problemsIn women < 65 only send if leuk +ve

nitrites –ve + only dip if < 3 symptoms of UTI

Haematuria

Painless macroscopic haematuria refer urgently urology

Symptoms of UTI + macroscopic haematuria = Rx and investigate as UTI + if not confirmed refer urgently

Haematuria

Age > 40 + recurrent (3+)/ persistent UTI microscopic haematuria refer urgently

Unexplained microscopic haematuria (3 dipsticks) - check U+Es / ? Proteinuria

Refer urgently >50 / non urgently <50Renal or urology depending on ?

Proteinuria / renal function

UTI in children

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

UTIs – NICE guidelines

Under 3 months – refer paeds urgent3 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

Interpreting urgent microscopy

Results for bacteriuria + pyuria

If +ve for bacteriuria = UTIIf just +ve pyuria –ve bacteriuria = UTI if

clinically If both negative not UTI

Dipstick

If leuk or nitrites +ve sent for MC+S

If both negative don’t send unless unwell or hx of recurrent UTI

What about imaging?

Nice guidelines

Below 6 months6 months – 3 yearsAbove 3 years

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

6 months – 3 yearsTypical organism + responds – no

scanningAtypical – urgent US and DMSARecurrent – 6 week US and DMSA

No need of MCUG after 6 months

Over 3 years

Typical – no scansAtypical – acute USRecurrent – 6 week US and DMSA

HOWEVER

Trust guidelines completely different….

Blood Tests (routine)

ACE Inhibitors U&E pre medication, 2 weeks after start or dose change,

then annually. 6m BP Amiodarone 6 monthly Tft Bendroflumethiazide U&E 4 weeks after start then annually Coeliac Fbc U&E Lft Tft Se Fer B12 & Folates lipids Hba1c & weight CKD Annual Fbc U&E Bp & urine for ACR CVD including Annual U&E Chol. & 6m Bp for QOF Stroke IHD & H F Dementia Screen Fbc PV U&E BS Calcium + phosphate Tft Lft B12 + Folate

VDRL Hba1c. Urine for MC+S. Xray as appropriate Diabetes Annual U&E Lft Tft lipids eGFR Hba1c & Urine for

microalbumin + albumin/creatinine ratio. 6 monthly Hba1c.

Epilepsy Fbc U&E Lft at 4/52 then at 6 months, then annually unless on sodium valproate then 6 monthly

Finasteride & PSA annually Tamsulosin Furosemide U&E 1 week after any dose change then annually Gout If on Allopurinol Se Urates annually Glitazones Lft at 2 months then annually Hyperlipidaemia LFT & lipids 3 months after starting medication. Annual lipids & LFT. Hydroxocobalamin Annual FBC Hypertensive (new)Fbc U&E eGFR Lft Tft Fasting lipids + Hba1c. Urine for ACR

Then annual U&E eGFR urine for ACR. & 6m BP (QOF) Lithium When first started or dose change Lithium levels every 4-5

days until dose stable for 4 weeks. U&E Tft 6 monthly Menopause FSH/LH day 2-6 of cycle if still appropriate. Repeat test 3

months. Mental Health Annual Fbc U&E Lft lipids & Hba1c. NSAID’s Annual U&E eGFR if > 65 Theophyllin Pre med U&E Lft. Theophyllin levels 3 days after dose

adjustment. Then theophyllin levels annually 2-4 hours post dose or trough.

Thyroid Annual Thyroid monitoring EF/MB 8/2012