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Urinary tract infections

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

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Urinary tract infections

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  1. Urinary tract infections … I can’t wait…

  2. Symptoms of UTI: • Dysuria, frequency, urgency, suprapubic tenderness, haematuria, polyuria

  3. 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.

  4. If mild symptoms or 1-2 symptoms (+ cloudy??) THEN urine dipstick • Wait 2 minute to interpret

  5. 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

  6. 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

  7. 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.

  8. 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

  9. Mid stream sample • Boric acid tube (red top) • Refrigerated

  10. Culture interpretation • > 104CFU – 1 organism • > 105 CFU – mixed growth 1 organism predominant • E coli / staph saprophyticus >103 • White cells - >104 = 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

  11. Follow up MSU • Only in asymptomatic bacteriuria of pregnancy

  12. 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)

  13. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947404720

  14. 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

  15. Haematuria • Painless macroscopic haematuria refer urgently urology • Symptoms of UTI + macroscopic haematuria = Rx and investigate as UTI + if not confirmed refer urgently

  16. 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

  17. UTI in children

  18. 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

  19. 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

  20. 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

  21. Dipstick • If leuk or nitrites +ve sent for MC+S • If both negative don’t send unless unwell or hx of recurrent UTI

  22. What about imaging? • Nice guidelines • Below 6 months • 6 months – 3 years • Above 3 years

  23. 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

  24. 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

  25. Over 3 years • Typical – no scans • Atypical – acute US • Recurrent – 6 week US and DMSA

  26. HOWEVER • Trust guidelines completely different….

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