NES Core Course on Antimicrobials
Case Study on Urinary Tract Infection
Anna, a 20 year-old student, comes in to your pharmacy and asks to speak
with the pharmacist. She thinks she has an infection in her urine and asks
what you can give her for it.
On her PMR you see a three day course of trimethoprim was dispensed 6
months ago.
Discussion points
1) What questions would you ask Anna to confirm the diagnosis?
 What are her symptoms and how long has she had them?
 Signs and symptoms of UTI include dysuria, urgency, frequency, polyuria,
suprapubic tenderness, fever and flank or back pain. Presence of two or
more signs or symptoms is suggestive of UTI. The presence of fever and
flank or back pain may suggest an upper UTI (pyelonephritis).
 Check for previous episodes and possibility of pregnancy.
 Vaginal itch or discharge may suggest an STI or vulvovaginitis (usually due
to candida).
Urethritis caused by N. gonorrhoeae or C. trachomatis is relatively more
likely if a women has had a new sexual partner in the past few weeks or if
her sexual partner has urethral symptoms; there is a past history of a
sexually transmitted disease (STD); symptoms were of gradual onset over
several weeks and there are accompanying vaginal symptoms such as
vaginal discharge or odour.
Vaginitis is suggested by the presence of vaginal discharge or odour,
pruritus, dyspareunia, external dysuria and no increased frequency or
urgency.
2) What recommendations would you make?
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If she has two or more symptoms of UTI she should be referred to her GP
for antibiotic treatment. If she has only one symptom, she should be
recommended to monitor for worsening of symptoms and encouraged to
drink plenty of fluids, pass urine as soon as she feels the need and
maintain good hand and toilet hygiene (wiping from front to back to avoid
transferring organisms).
Evidence for efficacy of alkalinising agents is lacking so do not suggest
using them. They are contra-indicated in impaired renal function (CrCl <
60ml/min) and interact with nitrofurantoin reducing the effectiveness of the
antibiotic by altering the urinary pH.
If there are any symptoms suggestive of urethritis or vaginitis, refer to the
GP for further investigation which may include a pelvic examination.
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Anna states she has a burning or stinging sensation when passing urine
(dysuria) and is going to the toilet much more frequently so she is referred to
her GP. She returns the next day with a prescription for ciprofloxacin 250mg
twice daily for 7 days.
3) What are the likely infecting organisms in UTI and what is recommended
first line agent?
The spectrum of causative organisms in upper and lower UTI is similar with E.
coli being the main pathogen in 70 to 95 % of cases and Staphylococcus
saprophyticus in about 5 to 10% of cases. Occasionally, other
Enterobacteriaceae, such as Proteus or Klebsiella are isolated. For empiric
treatment of uncomplicated UTI in non-pregnant women, the recommended
first choice is a 3-day course of trimethoprim or nitrofurantoin, which are
narrow spectrum agents. Three days therapy has been shown to be as
effective as 7 days. The use of second line agents such as amoxicillin, coamoxiclav, ciprofloxacin and cefalexin should be restricted to treatment of
proven UTI and based on sensitivity results.
4) Is ciprofloxacin the most appropriate choice for Anna?
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No - she has an uncomplicated UTI which should be treated empirically
with a short course of a narrow spectrum agent such as trimethoprim or
nitrofurantoin. Ciprofloxacin is a broad spectrum antibiotic which should
be reserved for second line treatment of lower UTI based on the results of
urine culture and sensitivity or for upper UTIs. Given the difficulty of
excluding prostatitis in men with symptoms suggestive of UTI, the current
recommendation is to treat bacterial UTI in men empirically with two weeks
of a fluoroquinolone.
Increasing concerns about fluoroquinolone resistance mean that routine
use of these drugs in uncomplicated UTI should be discouraged.
Ciprofloxacin can predispose patients to infection with Clostridium difficile
and MRSA and it can interact with many drugs metabolised by cytochrome
P450 in the liver.
5) What would you discuss with the GP?
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Suggest the use of a narrow spectrum agent such as trimethoprim or
nitrofurantoin for 3 days using the above reasons.
6) What other advice would you offer Anna to avoid future recurrence?
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Clinical Knowledge Summaries website (formerly Prodigy) has a very good
patient information leaflet for the treatment of UTI. It can be accessed via
http://www.cks.library.nhs.uk/patient_information_leaflet/urinary_tract_infe
ction_adults/view_as_a_leaflet
Maintain good toilet hygiene
Pass urine after sexual intercourse
Avoid holding urine in the bladder for a long time – pass urine as soon as
you feel the need
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Treat constipation promptly as this can predispose to UTI.
7) The manufacturers of trimethoprim and nitrofurantoin have applied for
reclassification from POM to P. What advantages and disadvantages can you
see with this? What steps might pharmacists in the community take to avoid
inappropriate use?
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Advantages
- improved patient access to treatment including out of hours,
- education on appropriate use of antibiotics,
- improved pharmacist knowledge on appropriate antimicrobial use.
 Disadvantages
- increased risk of antimicrobial resistance e.g. trimethoprim in MRSA
treatment combinations, nitrofurantoin in ESBLs
- risk of mis-diagnosis of an STI,
- encouragement of other POM to P classifications – cefaclor,
pivmecillinam, ciprofloxacin,
- using trimethoprim & nitrofurantoin in Pharmacies may mean GPs are
more likely to use broader spectrum agents such as ciprofloxacin, coamoxiclav
- gap in overall antimicrobial consumption data.
References
SIGN Guideline 88 Management of Suspected Bacterial Urinary Tract
Infection in Adults. July 2006
Clinical Knowledge Summaries accessed via www.cks.library.nhs.uk
Guidelines on The Management of Urinary and Male Genital Tract Infections.
European Association of Urology March 2008 accessed via
http://www.uroweb.org/nc/professional-resources/guidelines/online/
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