1. 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

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

4. 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

5. PGD
Treatment of uncomplicated lower urinary tract infection in females aged 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)

6. 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.

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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 ) Choice then – low risk of resistance = trimethoprim and high risk pevmicillinam)
Ony use nitrofurantoin in egfr if no alternative and short course

14. 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.

15. 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

16. 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

17. Nitrofurantoin
100mg bd m/r for 3 days Can’t use nitro if eGFR less than 45 (although with caution if Choice then – low risk of resistance = trimethoprim and high risk pivmicillinam) Only use nitrofurantoin in egfr 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-

18. 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.

19. 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

20. 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

21. UTI Audit
March 2018
STEPS service

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

23. 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

24. DISCUSSION TIME