Uncomplicated Symptomatic Urinary Tract Infection
Urinary Tract Infections –
Urinary tract infections (UTI – also known as cystitis) are a bacterial infection of the lower urinary tract or bladder. Infections in the elderly can range
from being asymptomatic to bactereamia. The most common organism isolated is gram-negative bacilli with E. coli infection in up to 20-50% of
presentations. Other common organisms include Klebsiella, Enterococci, group B Streptococcus and Proteus mirabilis. UTIs are a common
infection in the elderly and women have a higher prevalence. The expected outcome of use of this clinical guideline is rapid and effective relief from
symptoms and eradication of bacteria from urinary tract, prevention of reoccurrence of infection, reduction in hospitalisation rates, improved
morbidity and reduce the risk and rate of mortality. The diagnosis of UTI in the elderly can be difficult, treatment of a resident with cloudy or
malodorous urine without symptoms does not require treatment. There is a worldwide emergence of multi-resistant E. Coli associated with UTIs.
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Uncomplicated Symptomatic Urinary Tract Infection
SCOPE OF PRACTICE
PRACTITIONER
Nurse Practitioner –
Aged Care
Medical Practitioner ± Nurse
Practitioner
Uncomplicated Symptomatic Urinary tract Infection.doc
SCOPE
OUTOMES
Resident showing signs and symptoms of
uncomplicated UTI
The NP will refer all Hall & Prior residents outside
their scope of practice, to a medical practitioner.
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•
The expected outcome of use of this clinical
guideline is rapid and effective relief from
symptoms and eradication of bacteria from the
urinary tract, prevention of reoccurrence of
infection, reduction in hospitalisation rates,
improved morbidity and reduce the risk and
rate of mortality.
• Upon failure of treatment, complications of
infection or recurrence of infection, referral to
an urologist is required.6 Nurse practitioners
should consider referral to continence advisor
if incontinence is a contributing factor.
Referral to occupational therapist and/or
physiotherapist should be considered if lack of
mobility or hygiene aids are contributing
factors.
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Uncomplicated Symptomatic Urinary Tract Infection
RESIDENT’S ASSESSMENT
RESIDENT’S
HISTORY
SCOPE
Presenting symptoms
Signs and symptoms of uncomplicated UTI in the
elderly: dysuria, frequent urination with small volume,
nocturia, urgency, haematuria,loin pain suprapubic
discomfort, confusion, delirium, falls, immobility or
anorexia, temperature may be elevated .
•
Relevant medical, surgical and obstetric history
•
Constructing and ruling out related differential
diagnoses to specific pathophysiology
identified.
•
Identify residents not suitable for treatment by
NP with CPG and direct to GP .
Previous medical history
Medications
Other relevant information
PHYSICAL Ax
Usual physical examination
Indications for specific
examinations
Uncomplicated Symptomatic Urinary tract Infection.doc
OUTCOMES
•
Current Medications
Allergies, previous UTI history, continence, nutrition &
hydration, skin integrity, mobility, cognition, behaviour
SCOPE
Gaining comprehensive and holistic data in
order to prescribe appropriate diagnostics and
interventions related to indicators identified in
assessment.
Identify resident suitable for treatment by NP
with clinical practice guidelines (CPG)
OUTCOMES
Record findings: vital signs, genitourinary
assessment, pain assessment, other symptoms may
be present vaginal discharge or haematuria.
Visual assessment of external genitalia, digital rectal
examination (DRE) at NPs discretion
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•
•
•
•
Correct diagnosis, provision of effective
disease and symptomatic eradication/relief.
Consideration of previous history of UTIs.
Recent or present instrumentation.
Pre-disposing and associated conditions
detected and considered to determine UTI
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Uncomplicated Symptomatic Urinary Tract Infection
SCOPE
INDICATIONS
INVESTIGATIONS
Routine investigations
Laboratory/diagnostics used for diagnosis and
identification of organism: urinalysis (positive
blood/protein/nitrites/leucocytes), clean or sterile mid
stream urine specimen for microculture and sensitivity
testing, FBC (if indicative of bacteraemia).
Pathology
To determine underlying
organism, severity and
sensitivity of organism.
OUTCOMES
•
Results from all investigations will be used
when determining future management of the
resident’s urine which is positive for nitrates
and leucocytes will be sent for MC and S.
•
Accurate diagnosis will be made in the
presence of signs and symptoms.
•
Correct diagnosis will be determined
•
Correct pharmacotherapy will be prescribed
based on sensitivity of organism.
•
A diagnosis of UTI will be considered in an
elderly confused resident .
•
Treatment will be made with correct antibiotics
Urine MCS
Imaging
Bladder Scan for detection of residual urine +/retention of urine .
Haematology / Biochemistry
If suspected pyelonephritis
only.
FBC, U&E
Other Investigations
nil
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Uncomplicated Symptomatic Urinary Tract Infection
FOLLOW UP AND EDUCATION
INTERVENTION
Pharmacotherapeutics
SCOPE
OUTCOMES
Asymptomatic UTIs do not require treatment.
Symptomatic UTIs require a combination of
pharmacological and non-pharmacological
interventions. Upon diagnosis, identification of the
organism and it’s sensitivities, antibiotic treatment is
to be commenced. *see formulary for more detail.
•
•
•
•
Eradication of infection
Prevention of recurrence of infection
Symptomatic relief
Prevention of complications
Prophylactic maintenance is recommended for
resident’s with recurrent UTIs. Use of cranberry
and/or prophylactic antibiotics and intravaginal
oestrogen should be considered post treatment.
Non-pharmacological
Uncomplicated Symptomatic Urinary tract Infection.doc
Non-pharmacological interventions that should be
considered to help manage and prevent further
infections include education of resident’s and
nursing/care staff regarding effective toilet hygiene
(wipe front to back), wash skin around genitalia and
anus daily, shower rather than bathe, regular and
complete emptying of bladder, voiding and hygiene
post sexual intercourse and adequate hydration.1,8
Avoiding irritants - fragrance/feminine deodorisers,
synthetic underwear, carbonated, caffeinated,
alcoholic and acidic foods and fluids are also effective
management strategies. Heat packs can be applied
to lower abdomen to aid in relieving discomfort/pain.
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Uncomplicated Symptomatic Urinary Tract Infection
FOLLOW UP AND EDUCATION
INTERVENTION
SCOPE
Follow up appointments
Resident’s needs to be reviewed daily post
commencing antibiotic therapy to reassess symptoms
and monitor for any complications or adverse
reactions to therapy. Follow up MSU is required at
completion date of antibiotic therapy to validate
eradication of infection and determine whether further
antimicrobial treatment is required. An evidence base
care plan should be developed. Nurse practitioners
are required to follow up on all referrals to allied
health/specialists and reinforce education and
management strategies to prevent recurrent
infections.
Resident’s/staff education
Letters
Uncomplicated Symptomatic Urinary tract Infection.doc
OUTCOMES
•
Underlying disease will be detected at follow
up.
•
Upon failure of treatment, complications of
infection or recurrence of infection, referral to a
GP is required.
•
Nurse practitioners should consider referral to
continence advisor if incontinence is a
contributing factor.
•
Resident with complications outside the scope
of practice of the NP are referred to
appropriate providers.
Nursing staff and resident’s need to be educated
about the treatment plan, infection control,
importance of medication intervention & compliance
and follow up procedures (i.e. repeat diagnostics,
follow up appointments).
•
Optimise independence, awareness and
education
Optimise compliance with treatment
Optimise eradication of infection and prevent
recurrence of infection
Letter to residents GP
•
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•
•
Letters/progress reports are provided at the
discretion of the NP
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Uncomplicated Symptomatic Urinary Tract Infection PHARMACOTHERAPY
Uncomplicated UTIs should commence first line oral antibioticstrimethoprim
or
cephalexin for residents with penicillin hypersensitivity
or
amoxycillin/clavulanate
Duration of treatment depends on severity of infection, aetiology of infection, antibiotic treatment, antibiotic resistance and gender of the resident’s.
Female resident’s are recommended 3-7 days treatment, males 14 days.
If symptomatic management of suprapubic discomfort and dysuria is required
paracetamol 500mg
Prophylactic maintenance is recommended for resident’s with recurrent UTIs. Use of cranberry and/or prophylactic antibioticsmay be ordered.3,5,6,7,9
Prophylactic treatment ascorbic acid;
and/or
oestriol 1 pessary PV 1-2 times weeklyrefer to GP for review and consultation
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Uncomplicated Symptomatic Urinary Tract Infection PHARMACOTHERAPY
FORMULARY S4
st
Cephalexin 1st line treatment
Trimethoprim 1 line treatment
Drug (generic name): trimethoprim
Drug (generic name): cephalexin
Poisons schedule: schedule 4
Poisons schedule: schedule 4
Therapeutic class: 8(g) other antibiotics
Therapeutic class: 8(b) cephalosporins
Dosage range: 300mg
Dosage range: 500mg orally / 12 hourly
Route: oral
Route: oral
Frequency of administration: daily (nocte)
Frequency of administration: 6-12 hourly in uncomplicated UTI
Duration of order: females 3 days, males 14 days
Duration of order: 5 days
Actions: competitively inhibits bacterial folate production, is
Special Consideration : Renal impairment requires dose
bacteriostatic
reduction .
Indications for use: empirical Rx of lower UTIs in men and non-
Actions: intervenes in bacteria cell wall peptidoglycan synthesis
pregnant women .
Indications for use: staphylococcal & streptococcal infections
Precautions : severe renal impairment, allergy to trimethoprim,
(when mild-moderate allergy to penicillins), susceptible gram
avoid use in particular blood dyscrasias and skin disorders
negative bacterial UTIs, epididymo-orchitis
Adverse drug reactions: nausea, vomiting, hyperkalaemia, fever,
Contraindications for use: allergy to cephalosporins or
rash, itch, folate deficiency (especially long term)
carbapenems and penicillins (5%-10% cross reaction)
Adverse drug reactions: nausea, diarrhoea, electrolyte
imbalance, rash
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Uncomplicated Symptomatic Urinary Tract Infection PHARMACOTHERAPY
amoxycillin trihydrate: potassium clavulanate treatment
norfloxacin
Drug (generic name): amoxycillin with clavulanic acid
Drug (generic name): norfloxacin
Poisons schedule: schedule 4
Poisons schedule: schedule 4
Therapeutic class: 8(a) penicillins
Therapeutic class: 8(e) quinolones
Dosage range: 500mg/125mg, 875/125mg
Dosage range: 400mg
Route: oral
Route: oral 1hr before food or 2hrs after
Frequency of administration:12 hourly
Frequency of administration: 12 hourly
Duration of order: 5 days (UTI)
Duration of order: 3 days
Actions: intervenes in bacteria cell wall peptidoglycan synthesis,
Actions: blocks DNA gyrase & topoisomerase IV, thus inhibiting
is bactericidal
DNA synthesis, is bactericidal
Indications for use: UTI, epididymo-orchitis, otitis media,
Indications for use: UTI, shigellosis, traveller’s diarrhoea,
sinusitis, hospital acquired pneumonia, bites & clenched fist
campylobacter enteritis, prostatitis (when other AB options
injuries, melioidosis
ineffective or contraindicated)
Contraindications for use: allergy to penicillins, cephalosporins
Contraindications for use: allergy to quinolones
or carbapenems, cholestatic jaundice, hepatic dysfunction r/t
Adverse drug reactions: nausea, vomiting, diarrhoea, abdo.
amoxycillin with clavulanate or ticarcillin with clavulanate
pain, dyspepsia, rash, itch.
Adverse drug reactions: allergy, diarrhoea, nausea, rash,
superinfection, transient increase in liver enzymes & bilirubin
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Uncomplicated Symptomatic Urinary Tract Infection PHARMACOTHERAPY
paracetamol
Oestriol (refer to GP)
Drug (generic name): paracetamol
Drug (generic name): oestriol
Poisons schedule: unscheduled
Poisons schedule: schedule 4
Therapeutic class: 4(b) simple analgesics and antipyretics
Therapeutic class:7(d) topical vaginal medication
Dosage range: 500mg-1g
Dosage range: 0.5mg
Route: oral
Route: per vagina (pessary)
Frequency of administration: 6 hourly ,max 4g daily
Frequency of administration: daily/12 hourly
Duration of order: as required
Duration of order: long term
Actions: inhibition of prostaglandin synthesis
Actions: oestrogen replacement
Indications for use: mild-moderate pain, migraine, headache,
Indications for use: oestrogen deficiency, menopausal
fever, muscular pain
symptoms, UTI prophylaxis, adjunct to vaginal surgery
Contraindications for use: nil
Contraindications for use: undiagnosed vaginal bleeding, VTE,
Adverse drug reactions: (rare) rash, drug fever, mucosal lesions,
thrombophlebitis, porphyria, endometriosis, liver dysfunction,
neutro/pancyto/thrombocytopenia. Acute overdose –hepatitis,
disturbed lipid metabolism
renal tubular necrosis, hypoglycaemia.
Adverse drug reactions: local irritation, cystitis like symptoms,
breast pain, thromboembolism, cervical/menstrual changes,
dementia, increased size of uterine fibroids
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REFERENCES
1. Clinical Practice Guidelines for Nurses in Primary Care [monograph online]. 2000 [cited 2006 Apr 12]. Available from: http://www.hc-sc.gc.ca/msb/fnihp.
2. Tal S, Guller V, Levi S, Bardenstein R, Berger D, Gurevich I, Gurevich A. Profile and prognosis of febrile elderly resident’s with bacteremic urinary tract infection. Journal of Infection [serial online]. 2005 [cited 2006
Oct 20]; 50:296-305. Available from: ScienceDirect.
3. The Royal Australian College of General Practitioners. Medical Care of Older Persons in Residential Aged Care Facilities. 4th ed. South Melbourne: The Royal Australian College of General Practitioners; 2005.
4. Wagenlehner FM, Naber KG. Treatment of bacterial urinary tract infections: presence and future. European Urology [serial online]. 2006 [cited 2006 Oct 20]; 49:235-244. Available from: ScienceDirect.
5. Dartnell JG, editor. Therapeutic guidelines: antibiotic. 12th ed. Victoria: Therapeutic Guidelines Limited; 2003.
6. Rossi S, editor. Australian medicines handbook. Adelaide SA: Australian Medicines Handbook Pty Ltd; 2011.
7. eMIMS MIMS. MIMS medicine information [standard online]. c2005 [cited 2006 Oct 20]. Available from: eMIMS MIMS Online.
8. Hughes J. Urinary tract infections. Proceedings from The Infectious Diseases Module Lectures; 2006 Oct 9-16; Bentley, Perth: Curtin University of Technology; n.d.
9. McMurdo M, Bissett L, Price R, Phillips G, Crombie I. Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? A double-blind, placebo-controlled trial. Age and
Ageing. 2005; 34: 256-261.
10. etg complete( internet ). Melbourne : Therapeutic Guidelines Limited; 2011 Nov Accessed 2001at http://etg.com.au/ref/ref
11. Grayson ML, McDonald M, Gibson K, Athan E, Munckhof WJ, Paull P, et al. Once-daily intravenous cefazolin plus oral probenecid is equivalent to once-daily intravenous ceftriaxone plus oral placebo for the
treatment of moderate-to-severe cellulitis in adults. Clinical Infectious Diseases. 2002; 34(11): 1440-1448.
12. Ginsberg MB. Cellulitis: analysis of 101 cases and review of the literature. Southern Medical Journal. 1981; 74(5): 530-533.
13. Fleisher G, Ludwig S. Cellulitis: a prospective study. Annals of Emergency Medicine. 1980; 9(5): 246-249.
14. Kennedy M L, Fletcher KR, Plank LM. Management guidelines for nurse practitioners working with older adults. 2nd ed. Philadelphia: F. A. Davis; 2004.
15. Reuben DB, Herr KA, Pacala JT. Geriatrics at your fingertips. 6th ed. Malden, MA: Blackwell; 2004.
16. McKinnon PS, Paladino JA, Grayson ML, Gibbons GW, Karchmer AW. Cost-effectiveness of ampicillin/su;bactam versus imipenum/cilastatin in the treatment of limb-threatening foot infections in diabetic
resident’s. Clinical Infection Diseases. 1997; 24(1): 57-63.
17. Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clinical Therapeutics. 1995; 17(5): 800-810.
18. Wan W L, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. American Journal of Ophthalmology. 1986; 102(5): 575-583.
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