Patient with: 3 or more UTI in 6 months 4 or more UTI in 12 months

Transcription

1 Recurrent UTI Management Pathway adult females Initial assessment Assessment questionnaire questionnaire bladder scan dipstick dipstick of of urine urine pregnancy neurological disease long - term catheters renal stones Yes pneumaturia haematuria not No a.w UTI pyelonephritis palpable bladder urea - splitting organisms on MSU No Advice sheet Lifestyle management Advice sheet Consider urinary ultrasound Lifestyle management scan If normal consider prophylactic or rescue pack antibiotics Post - menopausal UTI a/w intercourse Patient with: 3 or more UTI in 6 months 4 or more UTI in 12 months NB. does not include asymptomatic bacteruria (bacteruria in the absence of UTI symptoms) Referral to Urology CU or Obstetrics Consider Integrated Case Management if appropriate If ultrasound scan is abnormal refer to urology Vaginal oestrogens Post - coital antibiotics Follow - up assessment at 6/12 Improved Follow - up assessment at 12/12 Improved No better No better Referral to Urology Discharge Review: Nov

2 Definitions: UTI Symptomatic episode (eg frequency, dysuria, malaise) attributed to bacterial infection of bladder Recurrent UTI (RUTI) 3 or more UTI episodes over 6 month period or 4 or more UTI episodes over 12 month period Asymptomatic bacteruria Presence of bacteria in urine on urine culture or microscopy in the absence of symptoms of UTI Pyelonephritis Severe loin pain, fever, rigors attributable to bacterial infection of upper urinary tract CU Community urology service Review: Nov

3 First visit: Rule out red-flag factors requiring specialist referral (utilise the recurrent urinary tract infections questionnaire on page 5 as appropriate): o pregnancy o neurological disease (esp spina bifida, spinal cord injury) o long-term catheters o other significant urological problems (eg renal stones) o pneumaturia (air in urine) o history of frank haematuria not associated with proven UTI o persistence of microscopic haematuria (dipstick positive) in the absence of UTI Dipstick of urine Introital swab for STI screen where appropriate MSU samples MSUs can be useful in the diagnosis of RUTI: o to establish a firm diagnosis of RUTI, esp if symptoms are equivocal o in order to establish the causative organism and sensitivities if UTIs are resistant to conservative treatment o where the above questions have been answered, further MSUs may not be required MSUs sent in the absence of symptoms are unlikely to be helpful and may be counterproductive. The presence of bacteriuria in the absence of symptoms of UTI (ie asymptomatic bacteriuria ) does not need treatment except in certain key groups (eg pregnant women). Antibiotic treatment of asymptomatic bacteriuria is more likely to be harmful than beneficial 1,2,3. MSU only to be sent if dipstick positive for nitrites or leukocytes patient has symptoms of UTI Symptoms of lower urinary tract infection include frequency, dysuria and malaise. In the elderly, confusion may be the only symptom. Review: Nov

4 Initial Management Antibiotics 4 may be given if clinical evidence of UTI. For recurrent UTIs treatment course can be 3 to 7 days of antibiotics. o Trimethoprim 200mg bd OR o Nitrofurantoin 100mg bd (7 days in pregnancy or symptoms of fever and/or flank pain) o 2 nd line: Co-amoxiclav 375mg tds OR o For penicillin allergy: Cefalexin 500mg bd Prevention Advice sheet should be given to the patient (see appendix) Vaginal oestrogens if post-menopausal 5,6,7,8,9 (even if on HRT) o eg vagifem pessaries, oestriol cream Option of antibiotics to be taken prior to sexual intercourse as a stat dose suitable for women with UTI precipitated by intercourse 10 o trimethoprim 100mg po /Nitrofurantoin 50mg-100mg po Self Management and Rescue Packs (GP or Integrated Case Management Service) UTI diary (see appendix) provided for patient to record symptomatic episodes Sample pots provided for MSUs if patient develops symptoms of UTI at home o MSU to be sent prior to starting antibiotics during initial assessment period in order to confirm diagnosis of recurrent UTI and establish antibiotic sensitivities Option of home supply of antibiotics as a rescue pack to enable selfinitiation of treatment if patient becomes symptomatic o Trimethoprim 200mg bd 3 to 7 days OR o Nitrofurantoin 100mg bd 3 to 7 days Self-management and rescue pack advice sheet should be given to the patient (see appendix) If adequate conservative measures have already been properly instigated and the patient is still symptomatic, then referral to the urology clinic can be made at the doctor s / nurse s discretion. Follow-up: Follow-up at no less than 6 months allows accurate assessment of response to initial management. Record: number of UTIs reported by patient over last 6 months (diary) number of positive MSUs on hospital records Refer to urology clinic if 3 or more symptomatic episodes needing antibiotics over last 6 months. Complete the referral template to ensure all relevant information is provided. Discharge at 12 months if no referral indicated Review: Nov

5 Management of Recurrent UTIs in Patients with Chronic Kidney Disease (CKD) For recurrent UTIs treatment course can be 3 to 7 days of antibiotics Trimethoprim egfr 15-30mL/minute/1.73m 2 egfr less than 15mL/minute/1.73m 2 egfr less than 15mL/minute/1.73m 2 Nitrofurantoin egfr less than 60mL/ minute/1.73m 2 Co-amoxiclav egfr 10-30mL/minute/1.73m 2 egfr less than 10mL/minute/1.73m 2 200mg bd for the first three days. Thereafter use 100mg bd (halfdose)for any remaining treatment length 100mg bd 100mg bd. Monitor plasmatrimethoprim concentration AVOID Risk of peripheral neuropathy Ineffective because of inadequate urine concentrations 375mg bd 375mg od Risk of crystalluria with high doses Cefalexin egfr less than 10mL/minute/1.73m 2 250mg bd (maximum 750mg daily) Additional Drug Information for Pregnancy and Breast Feeding Trimethoprim Pregnancy Teratogenic risk in the first trimester (folate antagonist). Manufacturers advise to avoid Breast Feeding Nitrofurantoin Pregnancy Present in milk short-term use is not known to be harmful Avoid at term may produce neonatal haemolysis Co-amoxiclav Cefalexin Breast Feeding Pregnancy Breast Feeding Pregnancy Breast Feeding Avoid; only small amounts are found in milk but could be enough to produce haemolysis in G6PD-deficient infants Not known to be harmful Trace amounts in milk, but appropriate to use Not known to be harmful Present in milk in low concentrations, but appropriate to use Review: Nov

6 Recurrent Urinary Tract Infections Questionnaire: 1 How long ago did you first start getting water infections? < 6 months 6-12 months < 2 years < 5 years > 5 years 2 How many infections have you had in the last 6 months?.. 12 months?.. 3 Are your water infections usually brought on by sexual intercourse? 4 What symptoms do you get with a water infection? (tick all that apply, or none) burning or stinging passing urine frequently rushing to the toilet pains in the abdomen or flank (side to lower back) fever 5 How soon after antibiotics finish does the infection come back? < 1 week > 1 week 6 Have you ever passed air in the urine? (This could be seen as air bubbles in the urine stream or may interrupt your urine stream) Review: Nov

7 7 What urinary symptoms do you have when you don t have an infection? (tick all that apply, or none) burning or stinging passing urine frequently rushing to the toilet abdominal pain fever straining to pass water poor flow of urine or slow urine stream feeling of incomplete bladder emptying 8 Have you ever had blood in your urine? during an infection at other times 9 Have you had problems with constipation? 10 Do you still have menstrual periods? when did they stop?.. do you use hormone replacement therapy (HRT)? 11 Do you have, or have you had any of the following diabetes kidney stones operations on your kidneys or bladder Multiple Sclerosis (MS) or other neurological disease do you use a catheter? are you on steroid tablets? are you pregnant? 12 Do you smoke? Thank-you for completing this questionnaire. Please return it to the nurse. Review: Nov

8 Prevention Advice sheet Urinary tract infections (UTIs) are a common problem for women. Patients with urinary tract infections may complain of some or all of the following symptoms: Lower abdominal pain or pressure Frequent and urgent urination Burning or stinging during urination Back pain Fever Blood in the urine Dark, foul-smelling urine Urinary tract infections usually get better on their own within a few days, and drinking plenty of fluids can help. Sometimes, a short course of antibiotics for 3 to 5 days is required. It is helpful to provide a urine specimen that can be sent for testing when the symptoms start, and this must always be done prior to starting antibiotics. There are a number of things you can do to prevent urinary tract infections: Avoid long intervals between urination. Have at least eight to ten drinks (mug-size) daily. These could be water or sugar free cranberry juice, squash or other fluids. Caffeinated drinks are best avoided. Shower instead of taking a bath. Avoid using bubble bath or other cosmetic bath products. Avoid using any feminine hygiene sprays and scented douches. Avoid using a vaginal diaphragm for birth control. Empty your bladder after sexual intercourse, as sexual relations can often trigger UTIs. After urination, wipe from front to back. After a bowel movement, clean the area around the anus gently, wiping from front to back and never repeating with the same tissue. Soft, white, non-scented tissue is recommended. Some patients find that drinking cranberry juice with no added sugar regularly can reduce the numbers of infections they get. Drink a large glass of juice taken twice a day. Cranberry juice should be taken with caution if you are on Warfarin tablets. If you don t like cranberry juice, then cranberry tablets or capsules are also available. Review: Nov

9 Urinary Infections Diary Name.. Date of start of symptoms Date urine sample provided Date of start of antibiotics (if given) Date symptoms settled Review: Nov

10 Self-management and rescue pack patient advice sheet You have been provided with a urine sample pot and a rescue pack of antibiotics What to do if you experience urinary tract infection symptoms 1. Collect a sample of your urine in the sample pot provided 2. Place the pot of urine in a sealed plastic bag and store this in a fridge if you can t hand it in to the GP practice straight away 3. Take the first dose of the antibiotic supplied 4. Follow the instructions for when to take the second dose of antibiotics 5. If you have stored the urine sample in the fridge, this should be taken to the GP practice on the next day working day 6. Continue to take the full course of the antibiotics 7. Contact your GP practice to discuss the results of the urine test and to obtain a new urine sample pot and a rescue pack of antibiotics What to do if the urinary tract infection symptoms do not improve 1. Your symptoms should improve once you start the antibiotics 2. If your symptoms worsen even though antibiotics have been started please contact the GP practice or telephone 111 if the GP practice is shut Review: Nov

11 References 1 Harding NEJM 2002;347(20): Abrutyn J Am Geriatr Soc 1996;44(3):293 3 Nicolle Am J Med 1987;83(1):27 4 BHR CCGs Antimicrobial prescribing guidance for primary care, June Rozenberg Int J Fertil Womens Med Mar-Apr;49(2): Cardozo, Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(1): Perrotta C. Cochrane Database of Systematic Reviews Raz NEJM 1993; 329: Dason Can Urol Assoc J. 2011; 5(5): Melekos J Urol. 1997;157(3): Review: Nov