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 4 CFU – 1 organism > 10 5 CFU – mixed growth 1 organism predominant E coli / staph saprophyticus >10 3 White cells - >10 4 = 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

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)

HPAweb_C/ HPAweb_C/

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….