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Urinary Tract Infection (UTI) in females

Scope

Management of females with urinary tract infections (UTI)

Pre-menopausal women with single relapsing or recurrent UTI's can be managed in the community. Referral should only be considered if antibiotic prophylaxis has failed

Post-menopausal women should be referred if red flags are suspected or indications below. If no evidence of red flags patient should be given an adequate trial of antibiotic prophylaxis as per Formulary guidance before referral.

Formulary chapter 5 - Infections - Urinary-tract-infections

Out of scope

  • Urethral syndrome
  • Interstitial Cystitis or painful bladder syndrome
  • Pregnant women
  • Catheter related infections

Formulary chapter 5 - Infections - Urinary-tract-infections

Definitions
  • Asymptomatic bacteriuria: there is significant bacteriuria without symptoms and signs of infection. In the absence of other significant findings e.g. microalbuminuria these patients do not require antibiotics or referral.
  • Urinary tract infection (UTI): there is significant bacteriuria and characteristic symptoms and signs
    • Lower UTI means infection of the bladder, the term lower UTI is used only with reference to UTI in women with an indwelling catheter, because in this situation the symptoms and signs of UTI are seldom typical of cystitis.
    • Cystitis is used as a synonym for lower UTI (although technically it means inflammation of the bladder and there are rare non-infectious causes of cystitis, such as radiation and chemicals).
    • Upper UTI includes pyelitis (infection of the proximal part of the ureters) and pyelonephritis (infection of the kidneys and the proximal part of the ureters).
  • Recurrent UTI: repeated UTI, 3 or more culture proven UTI in 12 months,
    • May be due to relapse or reinfection.
    • Relapse is recurrent UTI with the same strain of organism. Relapse is the likely cause if infection recurs within a short period (for example within 2 weeks) after treatment.
    • Reinfection is recurrent UTI with a different strain or species of organism. Reinfection is the likely cause if UTI recurs more than 2 weeks after treatment.
  • Uncomplicated UTI: infection of the urinary tract by a usual pathogen in a woman with a normal urinary tract and with normal kidney function.
  • Complicated UTI: UTI when one or more factors are present that predispose the person to persistent infection, recurrent infection, or treatment failure. Examples include UTI with:
    • Abnormal urinary tract (for example calculus, vesicoureteric reflux, reflux nephropathy, neurogenic bladder,urinary obstruction, recent instrumentation).
    • Virulent organism (such as Staphylococcus aureus).
    • Impaired host defences (for example poorly controlled diabetes mellitus, immunosuppressive treatment).
    • Impaired renal function.
Risk factors
  • Most urinary tract infections (UTIs) in women are not associated with a risk factor.
  • In women with recurrent UTIs, risk factors include
    • Sexual intercourse — common risk factor for young women.
    • Atrophic urethritis and vaginitis (in postmenopausal women).
    • Abnormalities of urinary tract function (for example, neuropathic bladder, vesicoureteric reflux, outflow obstruction, anatomical abnormalities, significant asymptomatic bacteriuria).
    • Incomplete bladder emptying (for example dysfunctional urination,
    • Female diaphragm, spermicide-coated condoms.
    • Previous urinary tract surgery.
    • Immunocompromise.
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History & examination

Typical features include:

  • Urinary frequency and/or urgency, and/or the feeling of needing to pass urine despite having just done so.
  • Dysuria (pain or discomfort on passing urine).
  • Urine that is offensive smelling, cloudy, or contains blood.
  • Constant lower abdominal ache.
  • Non-specific malaise, such as aching all over, nausea, tiredness and cold sweats.
  • Urge incontinence
  • Confusion or cognitive impairment in the elderly

Consider vaginal examination, looking for example for atrophic vaginitis and prolapse

Suspected urological cancer see 2ww referral form

Diagnosis is primarily clinical:
  • If symptoms are highly suggestive of a lower UTI: treat without doing any further tests.
  • Only arrange urine testing if there is diagnostic uncertainty, to guide antibiotic choice, or if there are signs of upper UTI
Dipstick
  • Dipsticks are not as sensitive as clinical symptoms at picking up UTIs.
  • Only perform a dipstick to exclude or help confirm a diagnosis of UTI in a woman with minimal or atypical symptoms.
    • If dipstick tests are negative, a UTI is unlikely.
    • If the leucocyte esterase test alone is positive, a UTI is moderately likely. 20%
    • If the nitrite test is positive, with or without a positive leucocyte esterase test, a UTI is highly likely, 75%
    • If both positive more likely, 84%

DO NOT perform dipsticks in women over 65 years of age as bacteriuria is common in this age group so does not indicate infection.

MSU
  • Consider MSU if first antibiotic course is unsuccessful
  • Always send an MSU before starting treatment in a patient with upper UTI symptoms
STI screening
  • If there is risk of an STI: perform pelvic examination and swabs
USS Bladder & Renal Tract
  • If recurrent UTIs, consider renal and bladder USS with post void residual to exclude anatomical abnormality and check on bladder masses and stones (KUB x-ray if available) Post void residual (if below 150mls unlikely to be significant)

General measures and advice:

  • Include increase fluid intake, and ensuring bladder emptying.

Formulary chapter 5 - Infections - Urinary-tract-infections

Referral Criteria

Pre-menopausal women with single relapsing or recurrent UTI's should be managed in the community. Referral should only be considered if antibiotic prophylaxis has failed or investigations show abnormalities or risk factors present see below

Post-menopausal women should be referred if red flags are suspected or risk factors present. If no evidence of red flags patient should be given an adequate trial treatment (see above) before referral

Arrange urgent 2-week wait referral if a urological cancer is suspected.

Consider routine referral for women with recurrent UTIs and with any of the following risk factors:

  • A past history of urinary tract surgery or trauma.
  • A proven bladder or renal calculi on imaging
  • Obstructive symptoms such as straining, hesitancy, poor stream.
  • Urea splitting bacteria on culture of the urine such as Proteus or Yersinia.
  • Persistent bacteriuria despite appropriate antibiotic treatment.
  • A past history of abdominal or pelvic malignancy.
  • Symptoms of a fistula such as pneumaturia.
  • Immunocompromise
  • Who have a known abnormality of their renal tract that might benefit from surgical correction, such as cystocele, vesicoureteric reflux, or bladder outlet obstruction.
  • Who have not responded to preventive treatments.

Referral Instructions

e-Referral Service Selection

  • Specialty: Urology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS-South Devon & Torbay-Urology - Devon ICB - 15N

Referral Form

DRSS referral form

Evidence

https://cks.nice.org.uk/urinary-tract-infection-lower-women

Pathway Group

This guideline has been signed off by NHS Devon.

Publication date: February 2019

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