Anji Curry GP2P Meeting October 2018 UTIs Anji Curry GP2P Meeting October 2018 No urologist- GP persepective 2nd commonest reason for empirical treatment and urines are commonest micro specimen tested Recently audited GPs in ST within STEPS service and 58% not managed in accordance with guidelines. This is all summarised in the UTI guidelines for ST

Plan for tonight UTIs Time for discussion Quick clinical quiz Audit of UTI management in STEPs Time for discussion

UTI quiz Need pen and paper Need to commit to action Don’t need to share answer with anyone Assume no allergies unless stated Note any learning points/ change in practice

PGD Treatment of uncomplicated lower urinary tract infection in females aged 16 -65 years and over Treat otherwise healthy, non-pregnant women presenting with three or more (≥ 3) of the following symptoms; Dysuria Urinary frequency/urgency Lower abdominal pain GP- (Haematuria)

Kim 61 yr old fit and healthy women. Presents with dysuria, inc frequency and lower abdo pain. No vaginal discharge /irritation. 1. Dip urine? 2. Treat? 3. Safety netting Advice? 1. No 2 yes 3. worsens/ fevers/ upper uti sx/ unwell/ vomiting/ confusion Both of these scenarios, we should not be sending MSUs.

Kim No UTIs in the past. Presents with dysuria and increased frequency. Urine looks cloudy. 4. Would you dip urine? 5.+ leucs and - nitrates Would you treat? 6 –ve nitrates and –ve Leucs- would you treat? 7. Pos nitrate , leucs – would you treat? 8. What advice regarding fluids would would you give her? 4 Yes – not enough to treat clinically as only 2 sx 5 Clinical opinion- equally likely 6.- no- unlikely 7.yes- likely 8. Fluids- 6-8 glasses/ day at least- avoid diuretics eg caffeine ‘flush it out’ liken the bladder to a stagnant pond Pain relief and consider back up script Use the urinalysis to help guide the clinical decision

Kim 9.Kim returns 3 days later and is no better- what do you do? 10. She asks you your thoughts about cranberry juice- what do you tell her? 9. Refer to gp 10. No evidence to say works 50% of cases will clear with no treatment by 3 days

Perrie 24 yr old woman, previously healthy. Not pregnant. Has 3d h/o increasing temps, cystitis sx and loin pain. Boyfriend is a footballer but nothing to suggest PID/STI. 11. Dip urine? 12. What do you do? LOIN PAIN- exclusion with pyrexia suggests 11. No 12. Refer for same day treatment- if it was me I’d like you to ring and explain the clinical scenario. With pyelonephritis got a bit of time at the start before they need Ivs.

Kate 32 yr old woman with no Hx of UTI comes to see you. She has dysuria , increased frequency and urgency. She’s breastfeeding her third. 13. what do you do? 13. If pregnant/ breasfeeding – needs to see GP

The Donald 71 yr old man. PMH personality disorder, suspected undiagnosed LD, Alopecia. Lone worker risk. Wife says he’s confused , dysuria with a temperature. 14. What would you do? 14- needs to see GP same day

Perrie- again… 25 year old with dysuria, suprapubic pain and increased frequency. Vaginal discharge- little bit heavier than usual. 15. What do you do? 15- vaginal dc increased- needs to see GP – needs STI screening. Chlamydia screening

Healthy, non pregnant 16-65 yr old women Severe / more than 3 sx with no vaginal dc/ irritation – empirical treatment 3d nitrofurantoin Upper- loin pain, frank hameaturia, tenderness, fever, rigors or systemically unwell- EXCLUDED Mild or 2 sx or less- cloudy urine? If not cloudy then 97% NPV Cloudy- decide with dipstick, no need to culture +ve nitrite= probable UTI -ve nitrite +ve leucs= UTI/ alternative diagnosis just as likely -ve nitrite and leucs = UTI unlikely (even if blood and protein) Symptoms being- Symptoms of uti- dysuria, frequency of urination, suprapubic tenderness, urgency, polyuria, haematuria (GP) Nitrte is key on dip. Leucs from vulva. Can’t use nitro if eGFR less than 45 (although with caution if 30-44.) Choice then – low risk of resistance = trimethoprim and high risk pevmicillinam) Ony use nitrofurantoin in egfr 30-44 if no alternative and short course

Dipsticks Nitrites and leucs best combination Poor evidence Pos nitrites and leucs is still less likely to predict than signs and sx Only useful for women with mild sx (2 sx or less) Negative tests don’t exclude bacteruria Dipstick- poor evidence. Best if have positive nitrates and leucocytes. But- positive leucs or nitrates is less likely to predict bacteruria than combination of symptoms and signs and absence of sx which would suggest an alternative diagnosis- itch dc etc. Dipstick- only useful for women with minimal signs an sx. Plus – negative tests don’t exclude bacteruria. RCT showed adult sx women with a negative dip had resolution of sx with abcs NNT 4.

Advice- PGD Drink plenty of fluids, but avoid caffeine containing, and alcoholic drinks Try to empty the bladder when urinating Passing water following intercourse may also prevent recurrent attacks Attacks may be precipitated by the use of fragranced products If symptoms have not improved after 3 days, advise patient to contact their GP If the condition becomes recurrent, contact GP for further investigation Advise that in 50% of cases, symptoms clear up within 3 days without treatment Paracetamol or Ibuprofen can be taken to alleviate symptomatic pain or discomfort Cranberry juice and urine alkalization products are not proven to be effective 48 hrs most woman noticing an improvement

Exclusion criteria Loin pain and pyrexia – consider pyelonephritis and refer immediately Under 16 years of age or over 65 Male Elderly patients with confusion suggestive of UTI Known hypersensitivity to Nitrofurantoin Acute porphyria Recurrent UTI treated with antibiotics within previous 4 weeks More than two episodes of UTI treated under this PGD within previous 12 months Catheterised patients Haematuria only Blood dyscrasias (G6PD deficiency specifically) Pregnancy and breast feeding Renal impairment Pulmonary disease Peripheral neuropathy History of kidney stones/renal colic Concomitant use of medication that has a clinically significant interaction with Nitrofurantoin. Healthy, non-pregnant women presenting with two or less (≤ 2) symptoms of UTI and Negative nitrite and leucocyte (+ protein) dipstick test(= Unlikely UTI) Healthy, non-pregnant women presenting with two or less (≤ 2) symptoms of UTI and all dipstick tests negative (= UTI very unlikely) Vaginal discharge present – refer if symptoms continue or become more severe Vaginal dc

Nitrofurantoin 100mg bd m/r for 3 days Can’t use nitro if eGFR less than 45 (although with caution if 30-44. Choice then – low risk of resistance = trimethoprim and high risk pivmicillinam) Only use nitrofurantoin in egfr 30-44 if no alternative and short course. Looking for CKD on summary- if unsure could always ring receptionist and ask for last result on ICE. So egfr is-

Perrie 24 yr old woman comes in saying she has had 3 infections in 8 months. She tells you they often occur after sex. She tells you she works away and doesn’t see her boyfriend that often (has infrequent sex). 16. What would you recommend? 16. Refer to GP , we can treat with post coital nitro (if egfr reduced could also use pivmecillinam) Depends on frequency of sex.

Recurrent UTI- women 30-44% women with acute cystitis will have recurrence (often in first 3m) Recurrence within 2w- relapse- treatment failure/ persistent source of infection eg stones 2 or more infections in last 6m or 3 or more in 12m. Think about second UTI though Can be treated without culture but can be useful (exclude other pathology) Treat recurrent episodes in same way as single episode ( no evidence to suggest should be over 3-7d Resistance can last up to 12m Recurrent UTI in otherwise healthy women is part of natural and expected disease process- not necessarily mean they need investigations Either treat postcoitally or if frequent sex / not related to sex nocte for 3-6m and review Definition of recurrence- 2 or more in 6m or 3 or more in 12m Use MSU if need to confirm diagnosis ( exclude OAB, interstiial cystitis) and guide abcs Cystoscopy and imaging- limited roles BUT if renal stones, persistent micro or macrohameaturia, history or urinary tract surgery, immunocompromise etc will be worth referral. Persistent or recurrent UTI in 60 and overs – non urgent referral to exclude bladder ca and unexplained NVH and dysuria needs urgent referral if over 45

Recurrent UTI Women- treatment Patient initiated ‘rescue pack’ Prophylaxis Use postcoitally if related to sex Daily if not or if frequent sex 6m, if recurs use longer 85% reduction in UTIs compared to placebo (NNT= 2.2) BACTERIAL RESISTANCE One study showed resistance rates in abcs other than the prophylaxis doubled in just one month No evidence for cranberry, probiotics, urinary alkalisation or immunostimulants. Topical oestrogen useful for PM women- limited data but positive studies Generally would use nitro 100mg nocte or post coitally OR in poor RF- pivmecillinam 200mg nocte or PC After that dw microbiology

UTI Audit March 2018 STEPS service

Data 14 pts identified through STEPs (GP) Suspected UTI or UTI Reviewed against local NE and C antimicrobial guidelines

Results 5/12 (42%) in line with guidelines. 7/12 (58%) not in line with guidelines. Reasons for not adhering to guidelines : 2/12 patients dipped where didn’t need it 1/12 culture not sent when should be 1/12 had dip and culture when didn’t need either 2/12 cultured when didn’t need it 1/12 had wrong length of abcs prescribed

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