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)
? Pyelonephritis
Suspected UTI in men (any age)
Failed treatment or persistent symptoms
Recurrent UTIs, urinary anatomical
abnormalities, renal impairment – more
likely to be resistant
Mid stream sample
Boric acid tube (red top)
Refrigerated
Culture interpretation
 > 10 CFU – 1 organism
 > 10 CFU – mixed growth 1 organism
predominant
 E coli / staph saprophyticus >10
4
5
3
 White cells - >10 = 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
4
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/H
PAweb_C/1194947404720
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
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 <50
Renal 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 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
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
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 months
6 months – 3 years
Above 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 years
Typical organism + responds – no
scanning
Atypical – urgent US and DMSA
Recurrent – 6 week US and DMSA
No need of MCUG after 6 months
Over 3 years
Typical – no scans
Atypical – acute US
Recurrent – 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 &
Tamsulosin
Furosemide
Gout
Glitazones
Hyperlipidaemia
PSA annually
U&E 1 week after any dose change then annually
If on Allopurinol Se Urates annually
Lft at 2 months then annually
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
Mental Health
NSAID’s
Theophyllin
Thyroid
FSH/LH day 2-6 of cycle if still appropriate. Repeat test 3
months.
Annual Fbc U&E Lft lipids & Hba1c.
Annual U&E eGFR if > 65
Pre med U&E Lft. Theophyllin levels 3 days after dose
adjustment. Then theophyllin levels annually 2-4 hours post
dose or trough.
Annual Thyroid monitoring