Primary care Recurrent UTI pathway
RJP 2009
Recurrent UTI Management Pathway – adult females
Patient with:
3 or more UTI in 6 months
4 or more UTI in 12 months
Initial
assessment
questionnaire
bladder scan
dipstick of urine
NB. does not include
asymptomatic bacteruria
(bacteruria in the absence of
UTI symptoms)
pregnancy
neurological disease
long-term catheters
renal stones
pneumaturia
No a.w UTI
haematuria not
pyelonephritis
palpable bladder
urea-splitting organisms on MSU
Yes
Referral to Urology
or Obstetrics
No
Advice sheet
Lifestyle management
Post-menopausal
UTI a/w intercourse
Vaginal oestrogens
Post-coital antibiotics
Follow-up assessment
at 6/12
Improved
No better
Follow-up assessment
at 12/12
Improved
Referral to Urology
No better
Discharge
1
Primary care Recurrent UTI pathway
RJP 2009
Definitions:
UTI:
symptomatic episode (eg frequency, dysuria, malaise)
attributed to bacterial infection of bladder.
Recurrent UTI:
3 or more UTI episodes over 6 month period or
4 or more UTI episodes over 12 month period
Asymptomatic bacteruria: presence of bacteria in urine on urine culture or
microscopy in the absence of symptoms of UTI
Pyelonephritis:
severe loin pain, fever, rigors attributable to bacterial
infection of upper urinary tract
2
Primary care Recurrent UTI pathway
RJP 2009
First visit:
 Rule out “red-flag” factors requiring specialist referral (questionnaire):
o pregnancy
o neurological disease (esp spina bifida, spinal cord injury)
o long-term catheters
o other significant urological problems (eg renal stones)
o pneumaturia (air in urine)
o history of frank haematuria not associated with proven UTI
 Post-micturition bladder scan (PMBS)
o If PMBS > 150cc, consider the following
 confirm result using ISC catheter
 examine for significant prolapse or vaginal atrophy
 look at micturition dynamics and voiding technique
 check medications (eg antidepressants, opioid analgesia)
 teach double voiding
 Queen Square bladder stimulator
o If PMBS still >150,
 consider ISC three times daily
 alternatively, consider urethral dilatation
 Dipstick of urine
 Introital swab for STI screen where appropriate
MSU samples
 MSUs can be useful in the diagnosis of RUTI:
o to establish a firm diagnosis of RUTI, esp if symptoms are equivocal
o in order to establish the causative organism and sensitivities if UTIs
are resistant to conservative treatment
o where the above questions have been answered, further MSUs may
not be required
MSUs sent in the absence of symptoms are unlikely to be helpful and may be
counterproductive. The presence of bacteruria in the absence of symptoms of UTI
(ie “asymptomatic bacteruria”) does not need treatment except in certain key
groups (eg pregnant women). Antibiotic treatment of asymptomatic bacteruria is
more likely to be harmful than beneficial 1,2,3.
MSU only to be sent if
dipstick positive for nitrites or leukocytes
patient has symptoms of UTI
Symptoms of lower urinary tract infection include frequency, dysuria and
malaise. In the elderly, confusion may be the only symptom.
3
Primary care Recurrent UTI pathway
RJP 2009
Initial management
 Antibiotics 4 may be given if clinical evidence of UTI
o Trimethoprim 200mg bd 3 days
o Nitrofurantoin 100mg bd 7 days
o 2nd line: dependent on sensitivities
o amoxicillin 500mg tds; cefalexin 500mg bd; coamoxyclav 375mg tds
Prevention
 Advice sheet given to patient (see appendix)
 Vaginal oestrogens if post-menopausal 5,6,7,8 (even if on HRT)
o eg vagifem pessaries, oestriol cream
 Option of antibiotics to be taken prior to sexual intercourse
o suitable for women with UTI precipitated by intercourse 9
o trimethoprim 100mg po
Treatment of UTI episodes
 UTI diary (see appendix) provided for patient to record symptomatic
episodes
 Sample pots provided for MSUs if patient develops symptoms of UTI at
home
 Antibiotics may be given if clinical evidence of UTI
o Trimethoprim 200mg bd 3 days
o MSU to be sent prior to starting antibiotics during initial assessment
period in order to confirm diagnosis of recurrent UTI and establish
antibiotic sensitivities.
 Option of home supply of antibiotics to enable self-initiation of treatment if
patient becomes symptomatic
o eg Trimethoprim 200mg bd 3 days
If adequate conservative measures have already been properly
instigated and the patient is still symptomatic, then referral to the
urology clinic can be made at the doctor’s / nurse’s discretion.
Follow-up:
 Follow-up at no less than 6 months allows accurate assessment of
response to initial management.
 Record: number of UTIs reported by patient over last 6 months (diary)
number of positive MSUs on hospital records
 Refer to urology clinic if 3 or more symptomatic episodes needing
antibiotics over last 6 months.
 Discharge at 12 months if no referral indicated
4
Primary care Recurrent UTI pathway
RJP 2009
Recurrent Urinary Tract Infections Questionnaire:
1
How long ago did you first start getting water infections?
< 6 months
6-12 months
< 2 years
< 5 years
> 5 years
2
How many infections have you had in the last
6 months? …….…….
12 months? ……..……
3
Are your water infections usually brought on by sexual intercourse?
Yes / No
4
What symptoms do you get with a water infection?
(tick all that apply, or none)
burning or stinging
passing urine frequently
rushing to the toilet
pains in the abdomen or flank
fever
5
How soon after antibiotics finish does the infection come back?
< 1 week
> 1 week
5
Primary care Recurrent UTI pathway
6
RJP 2009
What urinary symptoms do you have when you don’t have an infection?
(tick all that apply, or none)
burning or stinging
passing urine frequently
rushing to the toilet
abdominal pain
fever
straining to pass water
poor flow of urine or slow urine stream
feeling of incomplete bladder emptying
7
Have you ever passed air in the urine?
Yes / No
8
Have you ever had blood in your urine?
during an infection
Yes / No
at other times
Yes / No
9
Have you had problems with constipation?
Yes / No
10
Do you still have menstrual periods?
Yes / No
when did they stop? ……………………………………………..
do you use hormone replacement therapy (HRT)?
11
Yes / No
Do you have, or have you had any of the following…
diabetes
Yes / No
kidney stones
Yes / No
operations of your kidneys or bladder
Yes / No
MS or other neurological disease
Yes / No
do you use a catheter ?
Yes / No
are you on steroid tablets ?
Yes / No
are you pregnant ?
Yes / No
Thankyou for completing this questionnaire. Please return it to the nurse.
6
Primary care Recurrent UTI pathway
RJP 2009
Advice sheet:
Recurrent Urinary Tract Infections
Urinary tract infections (UTIs) are a common problem for women. Bacteria
often travel from the urethra to the bladder, causing a bladder infection (see
Illustration A). Occasionally, the infection may also affect the kidneys.
Patients with urinary tract infections may complain of some or all of the
following symptoms

Lower abdominal pain or pressure

Frequent and urgent urination

Burning or stinging during urination

Back pain

Fever

Blood in the urine

Dark, foul-smelling urine
Urinary tract infections usually get better on their own within a few days, and
drinking plenty of fluids can help. Sometimes, a short course of antibiotics for
2 or 3 days is required. It is helpful to provide a urine specimen that can be
sent for testing when the symptoms start, and this must always be done prior
to starting antibiotics.
7
Primary care Recurrent UTI pathway
RJP 2009
There are a number of things you can do to prevent urinary tract infections:

Avoid long intervals between urination.

Have at least eight to ten drinks (mug-size) daily. These could be
water, cranberry juice, squash or other fluids. Caffeinated drinks are
best avoided.

Shower instead of taking a bath. Avoid using bubble bath or other
cosmetic bath products.

Avoid using any feminine hygiene sprays and scented douches.

Avoid using a vaginal diaphragm for birth control.

Empty your bladder after sexual intercourse, as sexual relations can
often trigger UTIs.

After urination, wipe from front to back.

After a bowel movement, clean the area around the anus gently, wiping
from front to back and never repeating with the same tissue. Soft,
white, non-scented tissue is recommended.

Some patients find that drinking cranberry juice regularly can reduce
the numbers of infections they get. Drink a large glass of juice taken
twice a day. Cranberry juice should be taken with caution if you are on
Warfarin tablets. If you don’t like cranberry juice, then cranberry
capsules are also available.
8
Primary care Recurrent UTI pathway
RJP 2009
Urinary Infections Diary
Name ………………………………………………………………………..
Date of start of
symptoms
Date urine
sample
provided
Date of start of
antibiotics
(if given)
Date symptoms
settled
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
9
Primary care Recurrent UTI pathway
RJP 2009
References
1
Harding NEJM 2002;347(20):1576
Abrutyn J Am Geriatr Soc 1996;44(3):293
3 Nicolle Am J Med 1987;83(1):27
4 NUH Trust antimicrobial guidelines
5 Rozenberg Int J Fertil Womens Med. 2004 Mar-Apr;49(2):71-4
6 Cardozo, Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(1):15-20
7 Perrotta C. Cochrane Database of Systematic Reviews 2008
8 Raz NEJM 1993; 329:753-6
9 Melekos J Urol. 1997;157(3):935-9.
2
10