1. 1 Types of UTI ‘Simple’ or ‘uncomplicated’ –Female –First presentation –No signs of pyelonephritis –Not pregnant ‘Complicated’ –Pregnant –Male –Children –Recurrent –Pyelonephritis –Elderly

2. 2 So what could it be? Prodigy Urinary Tract Infection (cystitis) Typical features include: –Dysuria, frequency, urgency, nocturia, haematuria, suprapubic pain, cloudy or smelly urine –Caused by bacteriuria, defined as >10 5 organisms/ml (10 2 -10 4 if under sterile conditions) –‘Simple’ UTIs are rarely associated with renal failure or sepsis ( Hummers- Pradier. Br J Gen Pract 2002; 52: 752-761) Acute pyelonephritis As above plus: –fever (>38.5 o C), loin/flank pain/tenderness, rigors, nausea, vomiting and malaise –Can be life-threatening so requires urgent treatment ‘Urethral syndrome’ As cystitis but no bacteriuria Sexually transmitted disease e.g. chlamydia, gonorrhoea, herpes simplex, Candida Other causes can include drugs (e.g. cyclophosphamide, NSAIDs), parasitic infection, female menopause

3. 3 A 25 year old lady presents with a 48 hour history of needing to “go the toilet a lot to pee” and it hurts when she does. She also thinks she may have seen blood in her urine. So what are the management options here? If we diagnose a ‘simple’ UTI (assuming she is not pregnant and she has no history of UTI): Prognosis is good: –Unlikely to cause serious complications –But symptoms are unpleasant (to say the least) Up to 50% have no significant bacteriuria. Up to 50% will self-resolve in a few days, even without treatment. –Giving antibiotics may cause more harm than good –May disturb natural gut/vaginal flora and encourage Candida growth. Can we predict who is more likely to have a bacterial cause for their UTI?

4. 4 Signs and symptoms to help predict a bacteriuria Bent S, et al. JAMA 2002; 287: 2701-2710 The prevalence of a bacterial UTI in a young woman is around 12% If she has certain signs and symptoms, this likelihood increases: –Dysuria (by about 1-2 times) –Frequency (by about 1-2 times) –Blood in urine (by about 2 times) –No vaginal discharge (by about 3 times) –No vaginal irritation (by about 3 times) So if more than 3 of these are present, it is reasonable to assume a bacterial cause for the symptoms –>70 out of 100 women will have a bacterial cause

5. 5 What do the guidelines recommend wrt dipstick testing? Prodigy If the woman has several clinical features typical of lower UTI –Treat empirically without testing as urine dipstick test not helpful If the woman has few clinical features typical of lower UTI –Dipstick test the urine: Dipstick test positive (nitrite and LE both positive), diagnose UTI Dipstick test equivocal or negative (either or both negative), consider other causes Our thinking: If ‘barndoor’ symptoms (>3), don’t bother with the dipsticks – a negative test may mislead you If diagnosis is unsure (1-2 symptoms) use them But don’t expect them to tell you the ‘right’ answer each time

6. 6 What agent and for how long? Prodigy, SIGN: A 3 day course of trimethoprim is effective for ‘simple’ UTI Nitrofurantoin is an option, but may be less convenient for patients Cochrane Review – Milo G, et al. Date of last amendment 22 Feb 2005 Compared the success of 3 day regimens with 5 days or more For symptomatic failure rates, no differences were seen For bacteriological failure rates, 3 days was slightly less effective Adverse effects were more common with longer courses Bottom line:- 3 days is fine for simple UTI, but not for those in whom bacteriological cure is important, such as pregnancy

7. 7 Trends in Prescribing of Trimethoprim Tabs 200mg (% of 6/10/14 Tabs) in General Practice in England 0 5 10 15 20 25 30 35 40 45 Jan-Mar 97Jan-Mar 98Jan-Mar 99Jan-Mar 00Jan-Mar 01Jan-Mar 02Jan-Mar 03Jan-Mar 04Jan-Mar 05 % 61014 © Copyright NHSBSA 2006

8. 8 Simple UTIs - conclusion Look for ALARMS (temp>38.5 o C, rigors, vomiting etc) Simple UTIs are generally self-limiting, non-serious infections but can be very unpleasant Use decision rules to help with diagnosis: –>3 symptoms (and self-reported) very likely to be bacterial cause – 1-2 symptoms only - test with dipsticks (but they can mislead) Management options: –Empirical antibiotics 3 days trimethoprim or nitrofurantoin –Delayed prescription –Symptomatic treatment ± delayed prescription