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Confusion in the older patient: a diagnostic approach. 2019. https://www.gmjournal.co.uk/confusion-in-the-older-patient-a-diagnostic-approach (accessed 13 March 2023)

Haasum Y, Fastbom J, Johnell K. Different patterns in use of antibiotics for lower urinary tract infection in institutionalized and home-dwelling elderly: a register-based study. Eur J Clin Pharmacol. 2013; 69:(3)665-671 https://doi.org/10.1007/s00228-012-1374-7

Health Education England. The Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England. 2020. https://www.hee.nhs.uk/sites/default/files/documents/ACP%20Primary%20Care%20Nurse%20Fwk%202020.pdf (accessed 13 March 2023)

Hoang P, Salbu RL. Updated nitrofurantoin recommendation in the elderly: A closer look at the evidence. Consult Pharm. 2016; 31:(7)381-384 https://doi.org/10.4140/TCP.n.2016.381

Langner JL, Chiang KF, Stafford RS. Current prescribing practices and guideline concordance for the treatment of uncomplicated urinary tract infections in women. Am J Obstet Gynecol. 2021; 225:(3)272.e1-272.e11 https://doi.org/10.1016/j.ajog.2021.04.218

Lajiness R, Lajiness MJ. 50 years on urinary tract infections and treatment-Has much changed?. Urol Nurs. 2019; 39:(5)235-239 https://doi.org/10.7257/1053-816X.2019.39.5.235

Komp Lindgren P, Klockars O, Malmberg C, Cars O. Pharmacodynamic studies of nitrofurantoin against common uropathogens. J Antimicrob Chemother. 2015; 70:(4)1076-1082 https://doi.org/10.1093/jac/dku494

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Malcolm W, Fletcher E, Kavanagh K, Deshpande A, Wiuff C, Marwick C, Bennie M. Risk factors for resistance and MDR in community urine isolates: population-level analysis using the NHS Scotland Infection Intelligence Platform. J Antimicrob Chemother. 2018; 73:(1)223-230 https://doi.org/10.1093/jac/dkx363

McKinnell JA, Stollenwerk NS, Jung CW, Miller LG. Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc. 2011; 86:(6)480-488 https://doi.org/10.4065/mcp.2010.0800

Medicines.org. Nitrofurantoin. 2022. https://www.medicines.org.uk/emc/search?q=Nitrofurantoin (accessed 13 March 2023)

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O'Grady MC, Barry L, Corcoran GD, Hooton C, Sleator RD, Lucey B. Empirical treatment of urinary tract infections: how rational are our guidelines?. J Antimicrob Chemother. 2019; 74:(1)214-217 https://doi.org/10.1093/jac/dky405

O'Neill D, Branham S, Reimer A, Fitzpatrick J. Prescriptive practice differences between nurse practitioners and physicians in the treatment of uncomplicated urinary tract infections in the emergency department setting. J Am Assoc Nurse Pract. 2021; 33:(3)194-199 https://doi.org/10.1097/JXX.0000000000000472

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Singh N, Gandhi S, McArthur E Kidney function and the use of nitrofurantoin to treat urinary tract infections in older women. CMAJ. 2015; 187:(9)648-656 https://doi.org/10.1503/cmaj.150067

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Swift A. Understanding the effects of pain and how human body responds. Nurs Times. 2018; 114:(3)22-26 https://www.nursingtimes.net/clinical-archive/pain-management/understanding-the-effect-of-pain-and-how-the-human-body-responds-26-02-2018/

Taylor K. Non-medical prescribing in urinary tract infections in the community setting. Nurse Prescribing. 2016; 14:(11)566-569 https://doi.org/10.12968/npre.2016.14.11.566

Wijma RA, Huttner A, Koch BCP, Mouton JW, Muller AE. Review of the pharmacokinetic properties of nitrofurantoin and nitroxoline. J Antimicrob Chemother. 2018; 73:(11)2916-2926 https://doi.org/10.1093/jac/dky255

Wijma RA, Curtis SJ, Cairns KA, Peleg AY, Stewardson AJ. An audit of nitrofurantoin use in three Australian hospitals. Infect Dis Health. 2020; 25:(2)124-129 https://doi.org/10.1016/j.idh.2020.01.001

Urinary tract infection in an older patient: a case study and review

Advanced Nurse Practitioner, Primary Care

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Gerri Mortimore

Senior lecturer in advanced practice, department of health and social care, University of Derby

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uti case study presentation

This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin, by a non-medical prescriber, for a suspected symptomatic uncomplicated urinary tract infection in a patient living in a care home. The focus will be around the consultation and decision-making process of prescribing and the difficulties faced when dealing with frail, uncommunicative patients. This article will explore and critique the evidence-base, local and national guidelines, and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin, a commonly prescribed medication. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with a review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Urinary tract infections are common in older people. Haley Read and Gerri Mortimore describe the decision making process in the case of an older patient with a UTI

One of the growing community healthcare delivery agendas is that of the advanced nurse practitioner (ANP) role to improve access to timely, appropriate assessment and treatment of patients, in an attempt to avoid unnecessary health deterioration and/or hospitalisation ( O'Neill et al, 2021 ). The Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England recognises the application of essential skills, including sound consultation and clinical decision making for prescribing appropriate treatment ( Health Education England [HEE], 2020 ). This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin by a ANP for a suspected symptomatic uncomplicated urinary tract infection (UTI), in a patient living in a care home. Focus will be around the consultation and decision-making process of non-medical prescribing and will explore and critique the evidence-base, examining the local and national guidelines and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Mrs M, an 87-year-old lady living in a nursing home, was referred to the community ANP by the senior carer. The presenting complaint was reported as dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations. The carer reported a history of disturbed night sleep, with hallucinations of spiders crawling in bed, followed by agitation, lethargy and poor oral intake the next morning. The SBAR (situation, background, assessment, recommendation) tool was adopted, ensuring structured and relevant communication was obtained ( NHS England and NHS Improvement, 2021 ). The National Institute for Health and Care Excellence ( NICE, 2021 ) recognises that cloudy, foul-smelling urine may indicate UTI. Other symptoms include increased frequency or pressure to pass urine, dysuria, haematuria or dark coloured urine, mild fever, night-time urination, and increased sweats or chills, with lower abdominal/loin pain suggesting severe infection. NICE (2021) highlight that patients with confusion may not report UTI symptoms. This is supported by Gupta and Gupta (2019) , who recognise new confusion as hyper-delirium, which can be attributed to several causative factors including infection, dehydration, constipation and medication, among others.

UTIs are one of the most common infections worldwide ( O'Grady et al, 2019 ). Lajiness and Lajiness (2019) define UTI as a presence of colonising bacteria that cause a multitude of symptoms affecting either the upper or lower urinary tract. NICE (2021) further classifies UTIs as either uncomplicated or complicated, with complicated involving other systemic conditions or pre-existing diseases. Geerts et al (2013) postulate around 30% of females will develop a UTI at least once in their life. The incidence increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point. Further increased prevalence is found in patients who live in a care home, with up to 60% of all infections caused by UTI ( Bardsley, 2017 ).

Greener (2011) reported that symptoms of UTIs are often underestimated by clinicians. A study cited by Greener (2011) found over half of GPs did not record the UTI symptoms that the patient had reported. It is, therefore, essential during the consultation to use open-ended questions, listening to the terminology of the patient or carers to clarify the symptoms and creating an objective history ( Taylor, 2016 ).

In this case, the carer highlighted that Mrs M had been treated for suspected UTI twice in the last 12 months. Greener (2011) , in their literature review of 8 Cochrane review papers and 1 systematic review, which looked at recurrent UTI incidences in general practice, found 48% of women went on to have a further episode within 12 months.

Mrs M's past medical history reviewed via the GP electronic notes included:

  • Hypertension
  • Diverticular disease
  • Basal cell carcinoma of scalp
  • Retinal vein occlusion
  • Severe frailty
  • Fracture of proximal end of femur
  • Total left hip replacement
  • Previous indwelling urinary catheter
  • Chronic kidney disease (CKD) stage 2
  • Urinary and faecal incontinence
  • And, most recently, vesicovaginal fistula.

Bardsley (2017) identified further UTI risk factors including postmenopausal females, frailty, co-morbidity, incontinence and use of urethral catheterisation. Vesicovaginal fistulas also predispose to recurrent UTIs, due to the increase in urinary incontinence ( Stamatokos et al, 2014 ). Moreover, UTIs are common in older females living in a care home ( Bradley and Sheeran, 2017 ). They can cause severe risks to the patient if left untreated, leading to complications such as pyelonephritis or sepsis ( Ahmed et al, 2018 ).

Mrs M's medication included:

  • Paracetamol 1 g as required
  • Lactulose 10 ml twice daily
  • Docusate 200 mg twice daily
  • Epimax cream
  • Colecalciferol 400 units daily
  • Alendronic acid 70 mg weekly.

She did not take any herbal or over the counter preparations. Her records reported no known drug allergies; however, she was allergic to Elastoplast. A vital part of clinical history involves reviewing current prescribed and non-prescribed medications, herbal remedies and drug allergies, to prevent contraindications or reactions with potential prescribed medication ( Royal Pharmaceutical Society, 2019 ). Several authors, including Malcolm et al (2018) , indicate polypharmacy as a common cause of adverse drug reactions (ADRs), worsening health and affecting a person's quality of life. NICE (2015) only recommends review of patients who are on four or more medications on each new clinical intervention, not taking into account individual drug interactions.

Due to Mrs M's lack of capacity, her social history was obtained via the electronic record and the carer. She moved to the care home 3 years ago, following respite care after her fall and hip replacement. She had never smoked or drank alcohol. Documented family history revealed stroke, ischaemic heart disease and breast cancer. Taylor (2016) reports a good thorough clinical history can equate to 90% of the working diagnosis before examination, potentially reducing unnecessary tests and investigations. This can prove challenging when the patient has confusion. It takes a more investigative approach, gaining access to medical/nursing care notes, and using family or carers to provide further collateral history ( Gupta and Gupta, 2019 ).

As per NICE (2021) guidelines, a physical examination of Mrs M was carried out. On examination it was noted that Mrs M had mild pallor with normal capillary refill time, no signs of peripheral or central cyanosis, and no clinical stigmata to note. Her heart rate was elevated at 112 beats per minute and regular, she had a normal respiration rate of 17 breaths per minute, oxygen saturations (SpO 2 ) were 98% on room air and blood pressure was 116/70 mm/Hg. Her temperature was 37.3oC. According to Doyle and Schortgen (2016) , there is no agreed level of fever; however, it becomes significant when above 38.3oC. Bardsley (2017) adds that older patients do not always present with pyrexia in UTI because of an impaired immune response.

Heart and chest sounds were normal, with no peripheral oedema. The abdomen was non-distended, soft and non-tender on palpation, with no reports of nausea, vomiting, supra-pubic tenderness or loin pain. Loin pain or suprapubic tenderness can indicate pyelonephritis ( Bardsley, 2017 ). Tachycardia, fever, confusion, drowsiness, nausea/vomiting or tachypnoea are strong predictive signs of sepsis ( NICE, 2021 ).

During the consultation, confusion and restlessness were evident. Therefore, it was difficult to ask direct questions to Mrs M regarding pain, nausea and dizziness. Non-verbal cues were considered, as changes in behaviour and restlessness can potentially highlight discomfort or pain ( Swift, 2018 ).

Mrs M's most recent blood tests indicated CKD stage 2, based on an estimated glomerular filtration rate (eGFR) of 82 ml/minute/1.73m 2 . The degree of renal function is vital to establish prior to any prescribing decision, because of the potential increased risk of drug toxicity ( Doogue and Polasek, 2013 ). The agreed level of mild renal impairment is when eGFR is <60 ml/minute/1.73 m 2 , with chronic renal impairment established when eGFR levels are sustained over a 3-month period ( Ahmed et al, 2018 ).

Previous urine samples of Mrs M grew Escherichia coli bacteria, sensitive to nitrofurantoin but resistant to trimethoprim. A consensus of papers, including Lajiness and Lajiness (2019) , highlight the most common pathogen for UTI as E. coli. Fransen et al (2016) indicates that increased use of empirical antibiotics has led to a prevalence of extended spectrum beta lactamase positive (ESBL+) bacteria that are resistant to many current antibiotics. This is not taken into account by the NICE guidelines (2021) ; however, it is discussed in local guidelines ( Barnsley Hospital NHS FT/Rotherham NHS FT, 2022 ).

Mrs M was unable to provide an uncontaminated urine sample due to incontinence. NICE (2021) advocate urine culture as a definitive diagnostic tool for UTIs; however, do not highlight how to objectively obtain this. Bardsley (2017) recognises the benefit of an uncontaminated urinalysis in symptomatic patients, stating that alongside other clinical signs, nitrates and leucocytes strongly predict the possibility of UTI. O'Grady et al (2019) points out that although NICE emphasise urine culture collection, it omits the use of urinalysis as part of the assessment.

Based on Ms M's clinical history and physical examination, a working diagnosis of suspected symptomatic uncomplicated UTI was hypothesised. A decision was made, based on the local antibiotic prescribing guidelines, as well as the NICE (2021) guidelines, to treat empirically with nitrofurantoin modified release (MR), 100 mg twice daily for 3 days, to avoid further health or systemic complications. The use of electronic prescribing was adopted as per local organisational policy and the Royal Pharmaceutical Society (2019) . Electronic prescribing is essential for legibility and sharing of prescribing information. It also acts as an audit on prescribing practices, providing a contemporaneous history for any potential litigation ( Lovatt, 2010 ).

Pharmacokinetics and pharmacodynamics

Lajiness and Lajiness (2019) reflect on the origins of nitrofurantoin back to the 1950s, following high penicillin usage leading to resistance of Gram-negative bacteria. Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010, despite other antibacterial agents being discovered ( Wijma et al, 2020 ). Mckinell et al (2011) highlight that a surge in bacterial resistance brought about interest in nitrofurantoin as a first-line option. Their systematic review of the literature indicated through a cost and efficacy decision analysis that nitrofurantoin was a low resistance and low cost risk; therefore, an effective alternative to trimethoprim or fluoroquinolones. The weakness of this paper is the lack of data on nitrofurantoin cure rates and resistance studies, demonstrating an inability to predict complete superiority of nitrofurantoin over other antibiotics. This could be down to the reduced use of nitrofurantoin treatment at the time.

Fransen et al (2016) reported that minimal pharmacodynamic knowledge of nitrofurantoin exists, despite its strong evidence-based results against most common urinary pathogens, and being around for the last 70 years. Wijma et al (2018) hypothesised this was because of the lack of drug approval requirements in the era when nitrofurantoin was first produced, and the growing incidence of antibiotic resistance. Pharmacokinetics and pharmacodynamics are clinically important to guide effective drug therapy and avoid potential ADRs. Focus on the absorption, distribution, metabolism and excretion (ADME) of nitrofurantoin is needed to evaluate the correct choice for an individual patient, based on a holistic assessment ( Doogue and Polasek, 2013 ).

Nitrofurantoin is structurally made up of 4 carbon and 1 oxygen atoms forming a furan ring, connected to a nitrogroup (–NO 2 ). Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels ( Wijma et al, 2018 ). It works by inhibiting bacterial cell growth, breaking down its strands of DNA ( Komp Lindgren et al, 2015 ). Hoang and Salbu (2016) add that nitrofurantoin causes bacterial flavoproteins to create reactive medians that halt bacterial ribosomal proteins, rendering DNA/RNA cell wall synthesis inactive.

Nitrofurantoin is administered orally via capsules or liquid. Greener (2011) highlights the different formulations, which originally included microcrystalline tablets and now include macro-crystalline capsules. The increased size of crystals was found to slow absorption rates down ( Hoang and Salbu, 2016 ). Nitrofurantoin is predominantly absorbed via the gastro-intestinal tract, enhanced by an acidic environment. It is advised to take nitrofurantoin with food, to slow down gastric emptying ( Wijma et al, 2018 ). The maximum blood concentration of nitrofurantoin is said to be <0.6 mg/l. Lower plasma concentration equates to lower toxicity risk; therefore, nitrofurantoin is favourable over fluoroquinolones ( Komp Lindgren et al, 2015 ). Wijma et al (2020) found a reduced effect on gut flora compared to fluoroquinolones.

Distribution of nitrofurantoin is mainly via the renal medulla, with a renal bioavailability of 38.8–44%; therefore, it is specific for urinary action ( Hoang and Salbu, 2016 ). Haasum et al (2013) highlight the inability for nitrofurantoin to penetrate the prostate where bacteria concentration levels can be present. Therefore, they do not advocate the use of nitrofurantoin to treat males with UTIs, because of the risk of treatment failure and further complications of systemic infection. This did not appear to be addressed by local guidelines.

The metabolism of nitrofurantoin is not completely understood; however, Wijma et al (2018) indicate several potential metabolic antibacterial actions. Around 0.8–1.8% is metabolised into aminofurantoin, with 80.9% other unknown metabolites ( medicines.org, 2022 ). Wijma et al (2020) calls for further study into the metabolism of nitrofurantoin to aid understanding of the pharmacodynamics.

Excretion of nitrofurantoin is predominantly via urine, with a peak time of 4–5 hours, and 27–50% excreted unchanged in urine ( medicines.org, 2022 ). Komp Lindgren et al (2015) equates the fast rates of renal availability and excretion to lower toxicity risks and targeted treatment for UTI pathogens. Wijma et al (2018) found high plasma concentration levels of nitrofurantoin in renal impairment. Singh et al (2015) indicate that nitrofurantoin is mainly eliminated via glomerular filtration; therefore, its impairment presents the potential risks of treatment failure and increased ADRs. Early guidelines stipulated the need to avoid nitrofurantoin in patients with mild renal impairment, indicating the need for an eGFR of >60 ml/min due to this toxicity risk. This was based on several small studies, cited by Hoang and Salbu (2016) , looking at concentration levels rather than focused on patient treatment outcomes.

Primary research by Geerts et al (2013) involving treatment outcomes in a large cohort study, led to guidelines changing the limit to mild to moderate impairment or eGFR >45 ml/min. However, the risk of ADRs, including pulmonary fibrosis and hepatic changes, were increased in renal insufficiency with prolonged use. The study participants had a mean age of 47.8 years; therefore, the study did not indicate the effects on older patients. Singh et al (2015) presented a Canadian study, looking at treatment success with nitrofurantoin in older females, with a mean age of 79 years. It indicated effective treatment despite mild/moderate renal impairment. It did not address the levels of ADRs or hospitalisation. Ahmed et al (2018) conducted a large, UK-based, retrospective cohort study favouring use of empirical nitrofurantoin in the older population with increased risk of UTI-related hospitalisation and mild/moderate renal impairment. It concluded not treating could increase mortality and morbidity. This led to guidelines to support empirical treatment of symptomatic older patients with nitrofurantoin.

Dosing is highly variable between the local and national guidelines. Greener (2011) highlights that product information for the macro-crystalline capsules recommends 50–100 mg 4 times a day for 7 days when treating acute uncomplicated UTI. Local guidelines from Barnsley Hospital NHS FT/Rotherham NHS FT Adult antimicrobial guide (2022) stipulate 50–100 mg 4 times daily for 3 days for women, whereas NICE (2021) recommends a MR version of 100 mg twice daily for 3 days.

In a systematic literature review on the pharmacokinetics of nitrofurantoin, Wijma et al (2018) found that use of a 5–7 day course had similar strong efficacy rates, whereas 3 days did not, potentially causing treatment failure, equating to poor patient outcomes and resistant behaviour. Deresinski (2018) conducted a small, randomised controlled trial involving 377 patients either on nitrofurantoin MR 100 mg three times a day for 5 days or fosfomycin single dose treatment after urinalysis and culture. It looked at response to treatment after 28 days. Nitrofurantoin was found to have a 78% cure rate compared to 50% with fosfomycin. Therefore, these studies directly contradict current NICE and local guidelines on treatment dosing of UTI in women. More robust studies on dosing regimens are therefore required.

Fransen et al (2016) conducted a non-human pharmacodynamics study looking at time of action to treat on 11 strains of common UTI bacteria including two ESBL+. It demonstrated the kill rate for E. coli was 16–24 hours, slower than Enterobacter cloacae (6–8 hours) and Klebsiella pneumoniae (8 hours). The findings also indicated that nitrofurantoin appeared effective against ESBL+. Dosing and urine concentrations were measured, and found that 100 mg every 6 hours kept the urine concentration levels significant enough to reach peak levels. This study directly contradicted the findings of Lindgren et al (2015) , who conducted similar non-human kinetic style kill rate studies, and found nitrofurantoin's dynamic action to be within 6 hours for E. coli. Both studies have limitations in that they did not take into account human immune response effects.

Wijma et al (2020) highlighted inconsistent dosing regimens in their retrospective audit involving 150 patients treated for UTIs across three Australian secondary care facilities. The predominant dosing of nitrofurantoin was 100 mg twice daily for 5 days for women and 7 days for males. Although a small audit-based paper, it creates debate regarding the lack of clarity around the correct dosing, leaving it open to error. It therefore requires primary research into the follow up of cure rates on guideline prescribing regimens. Dose and timing remains an important issue to reduce treatment failure. It indicates the need for bacteria-dependant dosing, which currently NICE (2021) does not discuss.

Haasum et al (2013) found poor adherence to guidelines for choice and dosing in elderly patients in their Swedish register-based large population study. It highlighted high use of trimethoprim in frail older care home residents, despite guidelines recommending nitrofurantoin as first-line. A recent retrospective, observational, quantitative study by Langner et al (2021) involving 44.9 million women treated for a UTI in the USA across primary and secondary care, found an overuse of fluoroquinolones and underuse of nitrofurantoin and trimethoprim, especially by primary care physicians for older Asian and socio-economically deprived patients. Both these studies did not seek a true qualitative rationale for choices of antibiotics; therefore, limiting the findings.

Legal and ethical considerations

NMP regulation of best practice is set by the Royal Pharmaceutical Society framework (2019) , incorporating several acts of law including the medicines act 1968, and medicinal products prescribed by the Nurses Act (1992). As per Nursing Midwifery Council (2021) Code of Conduct and Health Education England (2020), ANPs have a duty of care to patients, ensuring that they work within their area of competence and recognise any limitations, demonstrating accountability for decisions made ( Lovatt, 2010 ).

Empirical treatment of UTIs is debated in the literature. O'Grady et al (2019) summarises that empirical treatment can reduce further UTI complications that can lead to acute health needs and hospitalisation, without increased risk of antibiotic resistance. Greener (2011) states that uncomplicated UTIs can be self-limiting; therefore, not always warranting antibiotic treatment if sound self-care advice is adopted. Chardavoyne and Kasmire (2020) discuss delayed prescribing, involving putting the onus on the patient and carers, which was not advisable in the case of Mrs M. Bradley and Sheeran (2017) found that three quarters of antibiotics in care home residents were prescribed inaccurately, hence recommended a watch and wait approach to treatment in the older care home resident, following implementation of a risk reduction strategy.

Taylor (2016) recommended an individual, holistic approach, incorporating ethical considerations such as choice, level of concordance, understanding and agreement of treatment choice. This can prove difficult in a case such as Mrs M. If a patient is deemed to lack capacity, a decision to act in the patient's best interest should be applied ( Gupta and Gupta, 2019 ). Therefore, understanding a patient's beliefs and values via family or carers should be explored, balancing the needs and possible outcomes. The principle of non-maleficence should be adopted, looking at risks versus benefits on prescribing the antibiotic to the individual patient ( Royal Pharmaceutical Society, 2019 ).

Non-pharmacological advice was provided to the carers to ensure that Mrs M maintained good fluid intake of 2 litres in 24 hours. NICE (2021) advocates the use of written self-care advice leaflets that have been produced to educate patients and/or carers on non-pharmacological actions, supporting recovery and improving outcomes. The use of paracetamol for symptoms of fever and/or pain was also recommended for Mrs M. Prevention strategies proposed by Lajiness and Lajiness (2019) included looking at the benefits of oestrogen cream in post-menopausal women in reducing the incidence of UTIs. Cranberry juice, probiotics and vitamin C ingestion are not supported by any strong evidence base.

There is a duty of care to ensure that follow up of the patient during and after treatment is delivered by the NMP ( Chardavoyne and Kasmire, 2020 ). Clinical safety netting advice was discussed with the carers to monitor Mrs M for any deterioration, and to seek further clinical review urgently. Particular attention to signs of ADRs and sepsis, and the need for 999 response if these occurred, was advocated. A treatment plan was also sent to the GP to ensure sound communication and continuation of safe care ( Taylor, 2016 ).

Professional development issues

The extended role of prescribing brings additional responsibility, with onus on both the NMP and the employer vicariously, to ensure key skills are updated. This is where continued professional development involving research, training and knowledge is sought and applied, using evidence-based, up-to-date practice ( HEE, 2020 ). Adoption of antibiotic stewardship is highlighted by several papers including Lajiness and Lajiness (2019) . They advise nine points to consider, to increase knowledge around the actions and consequences of the drug by the prescriber. Despite no acknowledgment in NICE (2021) guidance, previous results of infections and sensitivities are also proposed as vital in antibiotic stewardship.

The use of decision support tools, proposed by Malcolm et al (2018) , involves an audit approach looking at antibiograms, that highlight local microbiology resistance patterns to aid antibiotic choices, alongside a risk reduction team strategy. Bradley and Sheeran (2017) looked at improving antibiotic use for UTI treatment in a care home in Pennsylvania. They employed a programme of monitoring and educating clinical staff, patients, carers and relatives in evidence-based self-care and clinical assessment skills over a 30-month period. It demonstrated a reduction in inappropriate antibiotic prescribing, and an improvement in monitoring symptoms and self-care practices, creating better patient outcomes. It was evaluated highly by nursing staff, who reported a sense of autonomy and confidence involving team work. Langner et al (2021) calls for further education and feedback to prescribers, involving pharmacists and microbiology data to identify and understand patterns of prescribing.

UTIs can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines. Continued monitoring of nitrofurantoin use requires priority, due to its first-line treatment status internationally, as this may increase reliance and overuse of the drug, with potential for resistant strains of bacteria becoming prevalent.

Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained. The use of competent clinical practice, up-to-date evidence-based knowledge, good communication and understanding of individual patient needs, and concordance are essential to make sound prescribing choices to avoid harm. As well as the prescribing of medications, the education, monitoring and follow-up of the patient and prescribing practices are equally a vital part of the autonomous role of the NMP.

KEY POINTS:

  • Urinary tract infections (UTIs) can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines
  • The incidence of UTI increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point
  • Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010. Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels
  • Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained

CPD REFLECTIVE PRACTICE:

  • How can a good clinical history be gained if the patient lacks capacity?
  • What factors need to be considered when safety netting in cases like this?
  • What non-pharmacological advice would you give to a patient with a urinary tract infection (or their carers)?
  • How will this article change your clinical practice?

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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StatPearls [Internet].

Uncomplicated urinary tract infections.

Michael J. Bono ; Stephen W. Leslie ; Wanda C. Reygaert .

Affiliations

Last Update: November 13, 2023 .

  • Continuing Education Activity

Uncomplicated urinary tract infections (UTIs) are among the most common bacterial infections encountered in clinical practice. They primarily affect the lower urinary tract, involving the bladder and associated structures. Unlike complicated UTIs, uncomplicated cases occur in otherwise healthy individuals with no structural abnormalities of the urinary tract or significant comorbidities. Although some cases may resolve spontaneously, many patients seek therapy for symptom relief and to prevent potential complications. Prompt and accurate diagnosis of uncomplicated UTIs is essential for timely and appropriate management. Preventative strategies to reduce UTIs are critical in reducing the burden on health care resources. By understanding the key aspects of uncomplicated UTIs, health care professionals can optimize patient care and contribute to better overall outcomes. This article reviews uncomplicated UTIs, including their clinical presentation, diagnosis, and treatment approaches, and highlights the role of the interprofessional team in collaborating to provide coordinated and comprehensive care. 

  • Screen patients effectively for UTI symptoms, risk factors, and relevant medical history to prompt early diagnosis.
  • Select appropriate diagnostic tests and interpret results accurately to confirm UTIs and guide treatment decisions.
  • Implement evidence-based guidelines, treatment protocols, and preventative strategies to optimize patient outcomes.
  • Collaborate with the interprofessional team to ensure comprehensive care for patients with uncomplicated UTIs.
  • Introduction

An uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. Patients with uncomplicated UTIs have no structural abnormality of the urinary tract and no comorbidities such as diabetes, an immunocompromised state, recent urologic surgery, or pregnancy. An uncomplicated UTI is also known as cystitis or a lower tract UTI.

Bacteriuria or pyuria alone without symptoms does not constitute a UTI. Typical UTI symptoms include urinary frequency, urgency, suprapubic discomfort, and dysuria. While very common in women, UTIs are uncommon in circumcised males. When UTIs occur in circumcised males, by definition, they are generally considered complicated UTIs. [1]

Many uncomplicated UTIs will resolve spontaneously without treatment, but patients often seek therapy for symptom relief. Therapy aims to prevent infection from spreading to the kidneys or progressing into an upper tract disorder such as pyelonephritis, which can destroy delicate structures in the nephrons and eventually lead to hypertension. [2] [3] [4]

The diagnosis of a UTI is made from the clinical history and urinalysis with confirmation by a urine culture. Proper urine sample collection is essential for adequate evaluation and culture.

Complicated urinary tract infections and recurrent UTIs are covered in separate articles. See the companion StatPearls reference articles on "Complicated Urinary Tract Infections" and "Recurrent Urinary Tract Infections." [1] [5]

Pathogenic bacteria ascend from the perineum and rectum to the periurethral area, predisposing women to UTIs. Women also have much shorter urethras than men, further contributing to their increased susceptibility. Blood-borne bacteria cause very few uncomplicated UTIs.

Escherichia coli  causes the vast majority of UTIs, followed by  Klebsiella,  but other organisms of importance include  Proteus ,  Enterobacter , and  Enterococcus . [6] [7]

A significant risk factor for UTIs is the use of a urinary catheter. Manipulation of the urethra is also a risk factor. UTIs are very common after kidney transplants, with the main factors being immunosuppressive drugs and vesicoureteral reflux. Additional risk factors include the use of antibiotics with increasingly resistant bacterial strains and diabetes mellitus.

Other risk factors include:  [8] [9] [10] [11]

  • Abnormal urination (e.g., incomplete emptying, neurogenic bladder)
  • Abnormal urinary tract anatomy or function
  • Antibiotic use and increasing bacterial resistance
  • Dehydration
  • First UTI before 15 years of age
  • Frequent pelvic examinations
  • Incomplete bladder emptying
  • Immune system suppression or inadequacy
  • Irritable bowel syndrome 
  • Mother with a history of multiple UTIs
  • New or multiple sexual partners
  • Poor personal hygiene
  • Sexual intercourse
  • Urinary tract calculi
  • Use of spermicides and diaphragms 
  • Epidemiology
  • UTIs occur at least 4 times more frequently in females than males.
  • Forty percent of women in the United States will develop a UTI during their lifetime.
  • About 10% of women will get a UTI yearly.
  • Recurrences are common, with nearly half of patients getting a second infection within a year.
  • In women, UTIs usually occur between the ages of 16 to 35 years. [12] [13]
  • Pathophysiology

An uncomplicated UTI usually solely involves the bladder. Most organisms causing a UTI are enteric coliforms that typically inhabit the periurethral vaginal introitus. When these organisms ascend the urethra into the bladder, they invade the bladder mucosal wall, resulting in an inflammatory reaction called cystitis. Sexual intercourse is a common cause of a UTI as it promotes the passage and inoculation of bacteria into the bladder. [14]

Urine is naturally antimicrobial. Factors making it unfavorable for bacterial growth include a pH <5, high urea levels, hyperosmolality, and the presence of organic acids, proteins, and nitrites. [15] [16]  Urinary proteins, such as Tamm-Horsfall glycoproteins, nitrites, and urea, are all bacterial growth inhibitors. [15] [16] [17] [18] [19]  Frequent urination and high urinary volumes also decrease the risk of UTIs. The bladder wall lining is covered by a layer of mucus, which acts as a mechanical barrier to bacterial infiltration and invasion. Any defect or injury of this mucosal layer is considered a predisposing factor to a UTI and recurrent infections. [20]  

Urothelial cells also act to protect the bladder from infection. They can produce many antimicrobial peptides and pro-inflammatory cytokines, such as IL-1, IL-6, and IL-8. [21]  They can encapsulate bacteria in fusiform vesicles, and when highly infected with bacteria, the superficial urothelial layer can be shed, substantially reducing the bacterial count. [21] [22]  Premenopausal women have large concentrations of lactobacilli in the vagina and an acidic vaginal pH, preventing colonization with uropathogens. Antibiotic use can eliminate this protective effect. [23]

Bacteria that cause UTIs tend to have adhesins on their surface, allowing organisms to attach to the urothelial mucosal surface. [24]  Pathogenic bacteria develop mechanisms to survive hyperosmolality, and many can break down urea into alkaline ammonia to increase urinary pH. [21]  In addition, the short female urethra allows uropathogens to invade the bladder and lower urinary tract. [1]  Glycosuria can increase the risk of UTIs in diabetics, and recurrent infections can delay the recovery of the superficial urothelium and protective mucus layer. [25]

  • History and Physical

Symptoms of uncomplicated UTIs are typically pain on urination (dysuria), frequent urination (frequency), inability to start the urine stream (hesitancy), sudden onset of the need to urinate (urgency), suprapubic pain or discomfort, bladder spasms, and blood in the urine (hematuria). Usually, patients with uncomplicated UTIs do not have fever, chills, nausea, vomiting, or back/flank pain, which are more typical of renal involvement or pyelonephritis. [8]  Patients with neurological diseases, such as multiple sclerosis, may present with atypical symptoms, such as an acute exacerbation of neurological symptoms.

Clinical symptoms can overlap. Sometimes, it can be hard to distinguish an uncomplicated UTI from a renal infection or other serious infection. When in doubt, it is generally best to treat aggressively for possible upper urinary tract disease.

Information on prior antibiotic use and previous UTIs should be obtained.

Findings on physical examination are typically negative in a patient with an uncomplicated UTI, although suprapubic tenderness may be found in 10% to 20% of cases. Patients with recurrent UTIs, unexplained incontinence, or suspected organ prolapse should have a pelvic exam. [8]  

A UTI diagnosis is a combination of signs, symptoms, and urinalysis results confirmed with a urine culture. Be wary of a diagnosis based primarily on urinalysis or culture results in asymptomatic patients. If there are no clinical signs or symptoms, it is most commonly not a UTI.

Odoriferous or cloudy urine may often be associated with UTIs and bacteriuria. Still, these findings alone do not constitute a UTI requiring antibiotic treatment unless the patient exhibits other signs or symptoms. [26]  Increased hydration and a careful review of contributing dietary and drug factors are indicated in these situations.

Unusual urinary cloudiness (turbidity) and odor are caused or easily affected by the following:

  • Amorphous phosphates
  • Foods (see below)
  • Hormonal changes (eg, pregnancy)
  • Hydration status
  • Liver failure 
  • Medications (sulfonylurea)
  • Renal failure
  • Sexually transmitted infections
  • Trimethylaminuria
  • Vaginal infections
  • Voiding dysfunction unrelated to infection

Foods that can cause urinary odor include:

  • Brussels sprouts
  • Fish (salmon)
  • Sulfur-containing foods

Special Patient Populations

Older and/or Frail Patients

In older patients, symptoms such as changes in mental status or behavior may be present. [26]  There may be unexplained lethargy, disorganized speech, or altered perception. [27]  The most reliable indicators in older and/or frail patients are a change in mental status, abnormal urinalysis (pyuria and bacteriuria), and dysuria. [26]  Additional symptoms may include nocturia, incontinence, or a general sense of not feeling well with no specific urinary symptoms. [28]

Spinal Cord-injured Patients

Spinal cord-injured patients with paralysis may present with the following:

  • Autonomic dysreflexia presents with severe hypertension and headache in spinal cord injured patients (T-6 and above). [29]
  • Cloudy, foul-smelling urine 
  • Increased or a new presentation of spasticity
  • Unexplained fatigue

Patients with Permanent Indwelling Foley Catheters or Suprapubic Tubes  

Patients with permanent indwelling Foley catheters or suprapubic tubes   may have vague signs and symptoms, including an elevated leukocyte count and low-grade fever. Most patients with catheters will have pyuria and high urinary bacterial colony counts. This is not an actual urinary tract infection and should not be treated unless there are systemic signs or symptoms of pain, spasms, hematuria, or other abnormal bladder activity.

Urine Specimen Collection

A properly collected, clean urinalysis specimen is critical to the work-up. Patients should wash their hands before obtaining a sample. Midstream voided clean catch specimens are very accurate and preferred in non-obese women and men, assuming the patient follows the correct technique. Most obese women cannot give a clean, uncontaminated specimen. Epithelial cells in the urinalysis mean the urine sample was exposed to the genital skin surface and did not come directly from the urethra. Obtaining a sample with very few epithelial cells may require a urethral catheterization. The risk of a UTI in uninfected women from a straight urethral catheterization of the bladder is approximately 1%.

Men should wipe the glans, start the urine stream to clean the urethra, and obtain a midstream sample. In young children and patients with spinal cord injuries, suprapubic aspiration may be needed to collect a proper urine specimen. The Foley should be changed in patients with catheters, and the specimen should be collected from there. Never perform a urine culture or urinalysis from a sample taken directly from a urinary drainage bag. If necessary, keep the new Foley catheter clamped for a few minutes to allow for enough urine to collect to provide an adequate sample.

Urine should be sent to the lab immediately or refrigerated because bacteria proliferate when the sample is left at room temperature, causing an overestimation of the bacterial count and severity. [30] [31]

Do not base the diagnosis of a UTI solely upon visual inspection of the urine. Cloudy urine can be aseptic; the turbidity can come from protein or calcium phosphate debris in the sample and not necessarily from an infection. On the contrary, crystal-clear urine can be grossly infected. All urines should undergo dipstick testing, which can be done in the clinic or at the bedside.

The most helpful dipstick values diagnostically are pH, nitrites, leukocyte esterase, and blood. Remember that in patients with symptoms of a UTI, a negative dipstick result does not rule out the UTI, but positive findings can suggest the diagnosis. Look for the presence of bacteria and/or white blood cells (WBC) in the urine on microscopic urinalysis.  

  • Normal urine pH is slightly acidic, with usual values of 5.5 to 7.5, but the normal range is 4.5 to 8.0. A urine pH of 8.5 to 9.0 indicates a urea-splitting organism, such as  Proteus , Klebsiella , or Ureaplasma urealyticum.  An alkaline urine pH can signify struvite kidney stones, also known as "infection stones." [32]
  • The nitrate test is the most accurate dipstick test for a UTI because bacteria must be present in the urine to convert nitrates to nitrites. This process takes 6 hours and is why urologists often request the first-morning urine for testing, particularly in males. The overall specificity of this test is >90%. [33] [34] This test is a direct confirmation of bacteria in the urine, which is a UTI by definition in patients with symptoms. Several bacteria do not convert nitrates to nitrites, but those are usually involved in complicated UTIs, such as  Enterococcus, Pseudomonas , and Acinetobacter . The overall sensitivity of the nitrite urinary dipstick test is 19% to 48%, while its specificity is 92% to 100%. [35]
  • Leukocyte esterase identifies the presence of WBCs in the urine. The WBCs release leukocyte esterase, presumably in response to bacteria in the urine. Leukocyte esterase can detect WBCs in the urine, but this can occur for other reasons, like inflammatory disorders and vaginal infections. Its reported sensitivity is 62% to 98%, with a specificity of 55% to 96%. [11]  Despite this, leukocyte esterase is generally not considered as reliable a UTI indicator as nitrites. 
  • Hematuria can be a helpful finding because bacterial infections of the transitional cell lining of the bladder often cause some bleeding. This finding helps distinguish a UTI from vaginitis and urethritis, which do not cause blood in the urine.

The predictive values of nitrite, leucocyte esterase, and blood on a dipstick for diagnosing a UTI have been measured. The finding of urinary nitrites was more significant than leukocyte esterase, which was superior to hematuria. Both positive nitrites and leukocyte esterase have been found to have a high positive predictive value (PPV) of 85% and a 92% negative predictive value (NPV). [36]  The combination of all three (nitrites, leukocyte esterase, and hematuria) has also been found to be useful. [37]  Dysuria and new onset nocturia/frequency were also associated with UTIs.

In many labs, the presence of nitrites or leukocyte esterase will automatically trigger a microscopic evaluation of the urine for bacteria, WBCs, and RBCs and/or urine culture. On microscopy, there should be no visible bacteria in uninfected urine, so any bacteria visible on a Gram-stained urine specimen under high-field microscopy is highly correlated to bacteriuria and UTIs. A properly collected urine sample with >10 WBC/HPF is abnormal and highly suggestive of a UTI in symptomatic patients.

Urine Culture

Urine cultures are not usually required in uncomplicated UTIs but are still recommended by some due to increasing antibiotic resistance patterns and to help differentiate recurrent from relapsing infections. [8]  Cultures also help guide treatment if the patient fails to improve on initial empiric therapy. Urine should be cultured in all men, patients with diabetes mellitus, immunosuppressed individuals, and pregnant women. [8] Classic teaching for diagnosing a UTI sets the standard for culturing infected urine at >100,000 colony-forming units per milliliter (CFU/mL).

Recent literature and the American Urological Association Core Curriculum state that a patient with symptoms and a urine culture showing >1,000 CFU/mL should be diagnosed with a UTI. [5] Twenty to forty percent of women with UTIs will have ≤10 000 CFU/mL on urine culture. [5] [38]  From a practical clinical standpoint, a single organism in a symptomatic patient of 1,000 or more CFU/mL is now generally considered diagnostic for a UTI. [5] [38]

Urine cultures rarely help in the emergency department, except with recurrent UTIs, but can make subsequent treatment easier if patients do not respond to the initial antibiotic prescribed. [39]  While a single, uncomplicated UTI may not require a culture, the clinician otherwise has no objective evidence to guide therapy if the original treatment fails. Therefore, many experts recommend that all patients treated for a presumed UTI should have a urine culture, which can be extremely helpful in certain situations. [8] . 

Cystoscopy and urinary tract imaging are generally not recommended for uncomplicated UTIs as they are rarely helpful. [39]  Imaging may be beneficial for relapsing infections.

  • Treatment / Management

Asymptomatic bacteriuria is quite common and requires no treatment, except in pregnant women, those who are immunosuppressed, have had a transplant, or recently underwent a urologic surgical procedure. Significant bacteriuria should also be treated before invasive urologic surgical procedures.

Management of Uncomplicated UTIs

Antibiotic treatment has varied historically from 3 days to 6 weeks. There are excellent cure rates with "mini-dose therapy," which involves just 3 days of treatment.

E. coli resistance to common antimicrobials varies in different areas of the country. Another drug should be chosen if the resistance rate is >50% to any particular antibiotic.

First-line agents for uncomplicated UTIs include nitrofurantoin, sulfamethoxazole/trimethoprim,  fosfomycin, and first-generation cephalosporins. Outside the US, pivmecillinam is also considered first-line therapy.

  • Nitrofurantoin is perhaps the preferred choice for uncomplicated UTIs, but it is bacteriostatic, not bacteriocidal, and must be used for 5 to 7 days. It has several mechanisms of action that affect bacteria, so resistance is relatively uncommon. It is only effective in the lower urinary tract due to poor tissue concentrations and cannot be used for presumed or possible pyelonephritis. It is the preferred drug for low-dose long-term prophylaxis in patients with recurrent UTIs. [5]
  • Sulfamethoxazole/trimethoprim for 3 days is good mini-dose therapy, but resistance rates are high in many areas. It should not be used if local bacterial resistance is >20% or in patients with a sulfa allergy. [40] [41]  Sulfamethoxazole/trimethoprim is generally the alternate drug of choice for long-term prophylaxis in patients with recurrent UTIs.
  • Fosfomycin is FDA-approved as a single-dose therapy for uncomplicated UTIs. [42]  It may be effective when there is significant resistance to other antimicrobials. [43] A single dose will provide therapeutic urinary concentrations for 2 to 4 days and is comparable to 7- to 10-day therapy with other agents. [42] [44]  Adjunctive therapy with phenazopyridine for several days may provide additional symptomatic relief. [45]
  • First-generation cephalosporins are good choices for mini-dose (3-day) therapy but should not be overused to avoid resistance.
  • Fluoroquinolones have high resistance but are preferred for pyelonephritis and prostatitis due to their high tissue penetration levels, especially in the prostate. For this reason, fluoroquinolones are not preferred for uncomplicated UTIs but may be used when other agents are not acceptable. [46] [47] [48] Fluoroquinolones and nitrofurantoin are mutually antagonistic and should not be used together. Recent precautions from the FDA about fluoroquinolone side effects should be considered carefully. For simple, uncomplicated cystitis, norfloxacin is suggested. It is a quinolone specifically designed for lower urinary tract infections as it cannot be used for pyelonephritis.
  • Pivmecillinam is not available in the US but is considered first-line therapy for uncomplicated UTIs elsewhere in the world. It is not recommended in pyelonephritis or suspected systemic infections due to inadequate tissue penetration. [49]

Even without treatment, UTIs will spontaneously resolve in about 20% of women, especially with increased hydration. The likelihood that a healthy nonpregnant female will develop acute pyelonephritis is very small.

Management of Recurrent UTIs

Managing recurrent UTIs typically involves optimizing personal hygiene, using vitamin C as a urinary acidifier, taking extra precautions after sexual contact, and using prophylactic antibiotics or antiseptics such as nitrofurantoin. [39]  (See the companion StatPearls reference article on "Recurrent Urinary Tract Infections.") [5]

  • Nitrofurantoin low-dose long-term prophylaxis is the standard therapy for recurrent UTIs. The dosage is typically 50 mg QHS. It is well tolerated; treatment is limited to the urinary tract, which minimizes side effects, bacterial resistance is relatively low due to its multiple mechanisms of antibacterial activity, and allergies or intolerance is rare. [5]  Sulfamethoxazole/trimethoprim or trimethoprim alone are alternative agents. Norfloxacin and fosfomycin may also be used in selected cases.
  • Methenamine is converted to formaldehyde in the bladder if the urinary pH is <5.5. Vitamin C is often used to help acidify the urine to achieve this pH level. Methenamine appears to be of some benefit in recurrent UTI prophylaxis, but some of the data is conflicting. [50] [51]  It may be useful as an alternative to antibiotics in selected patients. [52] [53]
  • Cranberry  (juice, pills, extract) has also been suggested, and there is evidence of efficacy, although some of the data is contradictory. [51] [54] [55]  Some studies show a 30% to 40% reduction in UTIs, which is less effective than low-dose antibiotic therapy. [50] [54] [56]
  • D-mannose has been used as a prophylactic agent, and there is evidence that it may provide some benefit. [57] [58] [59] [60] [61]  However, the available data is insufficient to formally recommend it. [5] [50] [51] [62] [63]
  • Estrogen vaginal cream applied twice weekly can be helpful in postmenopausal women with atrophic vaginitis. [50] [64]
  • Increased fluid intake is  helpful in women with low urinary volumes. [64] [65]

The duration of prophylactic treatment is generally 6 to 12 months. While this can be extended, limited data is available, and many patients must return to prophylactic treatment. [39] [66] [67]  Extending the prophylactic treatment period to 2 years has also been suggested. [68] [69]  

Diagnosis and management of recurrent UTIs are described in the American Urological Association Guidelines on Recurrent Urinary Tract Infections and in our companion StatPearls reference article on "Recurrent Urinary Tract Infections." [5] [39]

For relapsing infections (where the infecting organism is identical on all cultures), a careful examination should be done to look for a source, such as a poorly emptied diverticulum or an infected stone. [1]  See our companion StatPearls reference article on "Complicated Urinary Tract Infections." [1]

  • Differential Diagnosis

The differential diagnosis of an uncomplicated UTI includes:

  • Bladder stones
  • Complicated UTI
  • Food or dietary issues
  • Herpes simplex
  • Medication effects
  • Overactive bladder
  • Pelvic inflammatory disease
  • Prostatitis
  • Pyelonephritis
  • Recurrent UTI
  • Relapsing UTI
  • Renal infarction
  • Renal stones

The majority of women with a UTI have an excellent outcome. With antibiotic treatment, the duration of symptoms is typically 2 to 4 days. Nearly 30% of women will have a recurrence within 6 months. Morbidity is usually seen in older debilitated patients, patients with significant comorbidities, or those with renal calculi. Other factors linked to recurrence include diabetes, underlying malignancy, chemotherapy, and chronic Foley catheterization. The mortality after an uncomplicated UTI is close to zero. [65] [70]  

Factors predictive of a poor long-term outcome include:

  • Advanced age
  • Chemotherapy
  • Chronic diarrhea
  • Diabetes (particularly if poorly controlled)
  • Incontinence
  • Morbid obesity
  • Nephrolithiasis
  • Neuropathy or spinal cord injury
  • Pelvic organ prolapse
  • Poor overall health
  • Previous overactive bladder
  • Presence of malignancy
  • Prior radiation therapy
  • Sickle cell anemia
  • Urethral catheterization

While mortality rates are low, the morbidity of UTIs is significant. Besides the distressing symptoms, the total cost of management is prohibitive. Missed work and school are common. In some cases, hospital admission is required due to the severity of the symptoms.

  • Complications

Complications of UTIs include:

  • Chronic prostatitis
  • Emphysematous pyelonephritis and cystitis
  • Focal renal nephronia
  • Hypertension
  • Persistent lower urinary tract symptoms
  • Prostatic abscess
  • Renal abscess
  • Staghorn urinary calculi
  • Deterrence and Patient Education

Once a UTI has been diagnosed, increased fluid intake should be encouraged. Patients should be informed of the importance of taking their medication as prescribed without stopping midway through the antibiotic course, even if they feel better. Patients should also be warned not to take prophylactic antibiotics unless prescribed, as future increased bacterial resistance may develop, making it more challenging to treat subsequent UTIs.

Preventative strategies to avoid UTIs are essential in reducing incidence and recurrence, especially in females. All women, particularly those at increased risk, should be educated regarding the following strategies:

  • Women should urinate after sexual intercourse as bacteria in the bladder can increase tenfold after sexual activity.
  • After urination, women should wipe from front to back, not from the anal area forward, which will contaminate the introitus and periurethral areas with pathogenic enteric organisms from the rectum.
  • Vigorous, high-volume urine flow is helpful in prevention.
  • Baths should be avoided in favor of showers.
  • A gentle, liquid soap without fragrance, liquid baby soap, or baby shampoo should be used in bathing. Liquid soaps are cleaner than bar soap that can collect bacteria.
  • When bathing, the soap should be applied using a freshly cleaned, soft cotton or microfiber washcloth.
  • The vaginal area should be cleaned first to avoid unnecessary contamination of the periurethral area with bacteria on the washcloth if used elsewhere first.

Some women with recurrent UTIs may benefit from the prophylactic use of antibiotics. Several other nonmedical remedies may help women with UTIs. Anecdotal reports and some studies indicate that using cranberry juice, D-mannose, methenamine, and probiotics may help reduce the severity and frequency of UTIs in some women.

  • Pearls and Other Issues
  • Other than urinalysis and culture, no further evaluation is necessary for most women with an uncomplicated UTI.
  • A urine culture from a patient with a successfully treated infection is more advantageous than a symptomatic patient after empiric therapy and no culture to guide treatment.
  • Bacteriuria and pyuria without symptoms are not diagnostic for a UTI.
  • Asymptomatic bacteriuria should generally not be treated except during pregnancy or an upcoming or recent invasive urologic procedure.
  • Enhancing Healthcare Team Outcomes

UTIs are best managed in an interprofessional fashion. The key to preventing recurrences is patient education. Nurses can be particularly helpful with patient education. Primary clinicians should refer patients with relapsing or recurrent UTIs who fail prophylactic measures to urology.

Clinicians should work closely with a pharmacist and/or infectious disease professional to ensure the best antibiotic choices for treatment. Physicians should be familiar with bacterial resistance patterns in their communities. The pharmacist can verify the appropriate coverage, dosing, and duration. Patient and community safety benefits by ensuring optimal antibiotic selection, correct duration, and medication compliance. Nurses can chart progress, counsel the patient on compliance, answer patient questions, and report concerns or results to the clinical team.

All health care team members should follow the patient's progress. If they observe any issues, including therapeutic failure or adverse events from medication, they should communicate their findings and contact the appropriate team members for corrective actions. The earlier a UTI is managed, the better the prognosis. Optimal interprofessional team collaboration significantly enhances patient outcomes. [71] [72]  

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Disclosure: Michael Bono declares no relevant financial relationships with ineligible companies.

Disclosure: Stephen Leslie declares no relevant financial relationships with ineligible companies.

Disclosure: Wanda Reygaert declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

  • Cite this Page Bono MJ, Leslie SW, Reygaert WC. Uncomplicated Urinary Tract Infections. [Updated 2023 Nov 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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PETER K. KUROTSCHKA, MD, ILDIKÓ GÁGYOR, MD, AND MARK H. EBELL, MD, MS

Am Fam Physician. 2024;109(2):167-174

Patient information: A related handout on uncomplicated urinary tract infections is available.

Author disclosure: No relevant financial relationships.

An acute uncomplicated urinary tract infection (UTI) is a bacterial infection of the lower urinary tract with no sign of systemic illness or pyelonephritis in a noncatheterized, nonpregnant adult with no urologic abnormalities or immunocompromise. In women, a self-diagnosis of a UTI with the presence of typical symptoms (e.g., frequency, urgency, dysuria/burning sensation, nocturia, suprapubic pain), without vaginal discharge, is accurate enough to diagnose an uncomplicated UTI without further testing. Urine culture and susceptibility testing should be reserved for women with recurrent infection, treatment failure, history of resistant isolates, or atypical presentation to make a definitive diagnosis and guide antibiotic selection. First-line antibiotics include nitrofurantoin for five days, fosfomycin in a single dose, trimethoprim for three days, or trimethoprim/sulfamethoxazole for three days. Symptomatic treatment with nonsteroidal anti-inflammatory drugs and delayed antibiotics may be considered because the risk of complications is low. Increased fluids, intake of cranberry products, and methenamine hippurate can prevent recurrent infections. Antibiotic prophylaxis is also effective in preventing recurrence but has a risk of adverse effects and antimicrobial resistance. Men with lower UTI symptoms should always receive antibiotics, with urine culture and susceptibility results guiding the antibiotic choice. Clinicians should also consider the possibility of urethritis and prostatitis in men with UTI symptoms. First-line antibiotics for men with uncomplicated UTI include trimethoprim, trimethoprim/sulfamethoxazole, and nitrofurantoin for seven days. Uncomplicated UTIs in nonfrail women and men 65 years and older with no relevant comorbidities also necessitate a urine culture with susceptibility testing to adjust the antibiotic choice after initial empiric treatment; first-line antibiotics and treatment durations do not differ from those recommended for younger adults.

This article provides a rapid evidence review of the best available patient-oriented evidence for acute uncomplicated urinary tract infection (UTI) in adults. An uncomplicated UTI is a bacterial infection of the lower urinary tract in a noncatheterized, nonpregnant adult without urologic abnormalities, immunocompromise, or signs of systemic illness or pyelonephritis. More than 80% of UTIs occur in women; therefore, unless specified, the recommendations in this article are for adult women younger than 65 years. Recommendations for uncomplicated UTIs in other populations, such as men and women and men 65 years or older, are reviewed briefly. Nonbinary and transgender people should be evaluated and treated according to their current urogenital anatomy.

Epidemiology and Microbiology

The self-reported annual incidence of UTI is 11% in women and 3% in men. 1 , 2 UTIs are most common in women between 18 and 29 years of age. 3

UTIs are uncommon in men younger than 60 years; by 80 years of age, women and men have similar incidence rates. 2 , 3

Most UTIs are uncomplicated. Complicating factors are listed in Table 1 . 4 – 7

Uropathogenic Escherichia coli causes 75% to 90% of UTIs; the remaining infections are caused by organisms such as Enterobacteriaceae, Enterococcus species, Staphylococcus saprophyticus , and Pseudomonas aeruginosa ( Table 2 ) . 8 , 9

In U.S. outpatients, the resistance of common uropathogens to beta-lactam antibiotics, trimethoprim/sulfamethoxazole, and fluoroquinolones is 55.8%, 22.4%, and 21.6%, respectively. 10

Multidrug-resistant uropathogens are increasingly prevalent. The primary risk factors for bacterial resistance include recent antibiotic use and hospitalization in the past three months. 11 , 12

The typical presentation includes frequency, urgency, dysuria/burning sensation, nocturia, and suprapubic pain or tenderness. Physical examination findings are usually normal. 4 , 5 , 13

The prevalence of culture-confirmed UTI among women with urinary tract symptoms is 45% to 65%. 14 Combinations of signs and symptoms suggesting other diagnoses are presented in Table 3 . 4 , 5 , 15 , 16

SIGNS, SYMPTOMS, AND URINALYSIS

According to a systematic review using a positive urine culture result as the reference standard, dysuria, frequency, urgency, nocturia, and hematuria increase the likelihood of UTI, with hematuria showing the highest predictive value, especially if combined with a dipstick test positive for nitrites. 17

Another systematic review found that dysuria, urgency, nocturia, and sexual activity with simultaneous presence of urgency and dysuria are weak diagnostic indicators of UTI, whereas vaginal discharge is a weak predictor of the absence of UTI. 18

Self-diagnosis of UTI is a stronger predictor of UTI, or no UTI, than individual symptoms or signs. 15 , 19

Based on two meta-analyses, dip-stick testing positive for nitrites is helpful in diagnosing a UTI (positive likelihood ratio = 5.3 to 6.5), whereas dipstick testing negative for both leukocytes and nitrites can exclude a UTI (negative likelihood ratio = 0.25). 18 , 20

Posttest probabilities and likelihood ratios for positive or negative clinical findings and dipstick test results are presented in Table 4 . 15 , 17 , 18

APPROACH TO THE PATIENT

No single clinical feature is accurate enough to diagnose or exclude a UTI. 14 , 15 , 17 , 18 , 20

If a woman believes she has a UTI and reports typical symptoms without vaginal discharge, there is a high likelihood of UTI. 14 , 17 , 18 In the absence of signs and symptoms of pyelonephritis or systemic illness (e.g., fever, chills, fatigue, nausea, vomiting, flank pain, costovertebral angle tenderness), the diagnosis can be made without an in-person examination or urinalysis. 13 , 14 , 16 – 19 , 21

In women with a less clear presentation, the diagnosis should be made during an in-person examination aided by a dipstick urinalysis. 13 , 14 , 16 – 19 , 21

Clinical decision aids that integrate clinical findings with urine findings can help guide management 19 , 22 ( Table 5 19 ) .

Most guidelines recommend urine culture with susceptibility testing only in women younger than 65 years of age with recurrent UTIs (i.e., two or more UTIs in the past six months or three or more UTIs in the past year), treatment failure with first-choice antibiotics, history of resistant urinary isolates, or atypical presentation. 5 – 7 , 23 – 25

Thresholds for positive urine culture results are listed in eTable A .

NONANTIBIOTICS

Treatment failures are increasing due to rising rates of antimicrobial resistance; therefore, alternatives to immediate antibiotics may be considered using patient-centered decision-making. 10

Women with no signs of pyelonephritis or complicated infection who do not want to take antibiotics can be prescribed a backup antibiotic to be filled if symptoms do not improve within 48 to 72 hours or worsen at any time. 23 , 26 – 28

Women should be advised to drink at least 1.5 L of fluids daily and use acetaminophen or nonsteroidal anti-inflammatory drugs for symptomatic relief. 5 , 6 , 23 , 26

Without antibiotics, women have a higher risk of pyelonephritis, although its overall incidence is low (1.43% with and 0.46% without antibiotics; number needed to treat to avoid one pyelonephritis over 30 days = 105). 29

Relapse within two weeks or recurrent infections are equally likely in women treated initially with or without antibiotics. 30

ANTIBIOTICS

Immediate antibiotics should be considered in women who perceive a high burden of symptoms, have a longer symptom duration at presentation, and have risk factors for complications. 5 , 6 , 23 , 26 , 31

First-line antibiotics are presented in Table 6 . 5 , 6 , 23 , 26 , 31 – 35 The antibiotic choice should be guided by local resistance data and previous susceptibility results, where available. 5 , 6 , 16 , 23 , 26 , 32 , 36

A 2010 guideline from the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases recommends extended-release nitrofurantoin for five days, fosfomycin in a single dose, and trimethoprim or trimethoprim/sulfamethoxazole for three days as first-line options. However, trimethoprim/sulfamethoxazole is recommended only if community resistance is less than 20%. 32

European and UK guidelines do not recommend trimethoprim/sulfa-methoxazole due to concerns about adverse effects (rare but severe skin and neurologic manifestations), allergy, and increasing resistance in many communities. European and UK guidelines also include pivmecillinam (awaiting approval in the United States) as a first-line antibiotic for uncomplicated UTIs. 5 , 6 , 23 , 26 , 33 , 34

Fluoroquinolones are effective in treating uncomplicated UTIs but should be avoided as first-line therapy because of the risk of serious adverse effects and increasing bacterial resistance. 5 , 6 , 23 , 26 , 32 – 34 , 37 , 38

If no susceptibility results are available, beta-lactam antibiotics should also be avoided because they are a less effective empiric treatment. 35

Screening and Prevention

Screening for asymptomatic bacteriuria should be avoided except in pregnant women. 39 , 40

Adequate fluid intake (at least 1.5 L per day), cranberry products, and methenamine hippurate are effective in reducing the risk of recurrent UTIs, whereas probiotics and D-mannose are not. 41 – 47

A systematic review of four randomized trials concluded that topical application of vaginal estrogens may reduce the risk of recurrent UTI in postmenopausal women. 48

Postcoital or long-term antibiotic prophylaxis effectively prevents recurrent UTIs (number needed to treat < 2); however, initiation and duration should be considered carefully because prophylaxis has an increased risk of adverse effects and antimicrobial resistance. 49

An evidence-based guideline recommends the following regimens for long-term prophylaxis: fosfomycin, 3 g every 10 days; nitrofurantoin, 50 mg or 100 mg once daily; or trimethoprim, 100 mg once daily, for three to six months or after sexual intercourse. 24 , 25

Other Populations

Uncomplicated UTI in men (or people with male anatomy) should be suspected in otherwise healthy men with typical symptoms (e.g., acute dysuria, frequency, urgency, nocturia) and no signs of systemic illness. 50

Rectal, pelvic, or suprapubic pain and a tender prostate on digital rectal examination suggest acute prostatitis, whereas purulent urethral discharge or multiple or new sex partners suggest acute urethritis. 51 – 53

The evidence for the optimal diagnostic workup and the type and duration of antibiotic treatment in men with suspected uncomplicated UTI is limited and primarily based on expert opinion. 54

A urine culture with susceptibility testing should always be performed in men to confirm the diagnosis and adjust the choice of antibiotic once results become available. 5 , 52

First-line antibiotics for uncomplicated UTI in men include trimethoprim, 200 mg; trimethoprim/sulfamethoxazole, 160/800 mg; and extended-release nitrofurantoin, 100 mg, twice daily. 6 , 26 , 52

A randomized trial concluded that a seven-day course of an oral antibiotic is as effective as a longer course in afebrile men with an uncomplicated UTI. 55

The diagnostic approach and treatment options for men with suspected urethritis, prostatitis, or pyelonephritis differ from those for men with suspected uncomplicated UTIs. Those topics are covered in previous American Family Physician articles. 56 – 58

OLDER PEOPLE

In nonfrail women and men 65 years and older who have no relevant comorbidities and present with typical clinical features of an uncomplicated UTI, the diagnostic workup does not differ significantly from that used for younger patients. 23 , 59 , 60

A urine culture with susceptibility testing should always be performed in older adults to confirm the diagnosis and adjust the choice of antibiotic once the results become available. 52 , 59 , 60 First-line empiric antibiotics are the same as the medications that are recommended for younger people. 52 , 59 , 60

Short courses of antibiotics (three to six days in women and seven days in men) are likely as effective as longer courses in older adults. 55 , 61

This article updates previous articles on this topic by Colgan and Williams 4 ; Mehnert-Kay 62 ; and Orenstein and Wong . 63

Data Sources: This article is based on literature searches in Essential Evidence Plus, the Cochrane database, and PubMed using the Clinical Queries database for the term urinary tract infection. Studies that used gender as patient categories did not define explicitly how these categories were assigned, but they were judged to be essential and, therefore, included in this review. Search dates: August 14, 2023, and November 28, 2023.

Editor's Note:  Dr. Ebell is deputy editor for evidence-based medicine for AFP .

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Ninan S, Walton C, Barlow G Investigation of suspected urinary tract infection in older people. BMJ. 2014; 349 https://doi.org/org/10.1136/bmj.g4070

The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018; https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

Perrotta C, Aznar M, Mejia R, Albert X, Ng CW Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev. 2008; 2 https://doi.org/10.1002/14651858.cd005131.pub2

Philips H, Huibers L, Holm Hansen E Guidelines adherence to lower urinary tract infection treatment in out-of-hours primary care in European countries. Qual Prim Care. 2014; 22:(4)221-231

Portman DJ, Gass MLS Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Maturitas. 2014; 79:(3)349-354 https://doi.org/10.1016/j.maturitas.2014.07.013

UK Standards for microbiology investigations: investigation of urine. 2019; https://bit.ly/3eDm1ml

English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR): 2019–2020. 2020a; https://bit.ly/30UWNaN

Diagnosis of urinary tract infections: Quick reference tool for primary care for consultation and local adaptation. 2020b; https://bit.ly/3tmXOEV

Annual epidemiological commentary: Gram-negative bacteraemia, MRSA bacteraemia, MSSA bacteraemia and C. difficile infections, up to and including financial year April 2019 to March 2020. 2020c; https://bit.ly/2OR0yLM

30-day all-cause fatality subsequent to MRSA, MSSA and Gram-negative bacteraemia and C. difficile infections, April 2019 to March 2020. 2021; https://bit.ly/3lsvGgE

Rowe TA, Juthani-Mehta M Urinary tract infection in older adults. Aging Health. 2013; 9:(5)519-528 https://doi.org/10.1016/j.idc.2013.10.004

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Risk reduction and management of delirium. SIGN 157. 2019. https://bit.ly/3bPcgQ5

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The management of urinary tract infections in older patients within an urgent care out-of-hours setting

Justine Dexter

Advanced Nurse Practitioner, Urgent Care, South Derbyshire, DHU Health Care

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Gerri Mortimore

Lecturer, Faculty of Education Health and Sciences, University of Derby

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uti case study presentation

This article critically analyses the prevalence, assessment and management of urinary tract infections (UTIs) in patients over the age of 65, in an urgent care out-of-hours service in order to enhance care. It is undertaken from the perspective of working as an Advanced Nurse Practitioner (ANP). A synopsis of UTI is presented, examining the epidemiology and aetiology. The process of assessment, diagnosis and management of UTI in older people is appraised based on current evidence. Difficulties associated with the recognition of UTI in elderly are evaluated. Finally, recommendations are made for the improvement of future practice as an ANP.

Urinary tract infections (UTIs) are among the most frequent bacterial infections seen within primary care ( National Institute for Health and Care Excellence (NICE), 2020a ). They are caused by the presence of multiplying microorganisms in the urinary tract with infection being determined by a combination of bacteria in the urine plus clinical features ( NICE, 2015 ). It is estimated that more than 92 million people are affected worldwide and among older people, UTI is a substantial cause of mortality ( NIHR Community Healthcare Medtech and In Vitro Diagnostics Cooperative, 2016 ). It is estimated that 1-3% of primary care attendances are due to UTI-related symptoms and they comprise the main reason for 13.7% of antibiotic prescribing ( NIHR Community Healthcare Medtech and In Vitro Diagnostics Cooperative, 2016 ). The prevalence is approximately 20% in women aged over 65, compared with 11% in the overall population ( Chu and Lowder, 2018 ). However, both genders are at risk of UTI in older age, with a male-to-female ratio of 1:2 ( Cove-Smith and Almond, 2007 ). The risk increases substantially in patients over the age of 85 ( Rowe and Juthani-Mehta, 2013 ).

Definitions and wider context

UTI is defined as an infection of the urinary system, involving lower tract, upper tract or both ( NICE, 2020a ). The pathogens responsible for UTI include Escherichia coli (E. coli), which accounts for 70% to 95% of uncomplicated cases, with Staphylococcus saprophyticus responsible for 5% to 20% of cases ( NICE, 2020a ). Less common pathogens in uncomplicated UTIs include Proteus mirabilis, Klebsiella species, Citrobacter genus, Pseudomonas aeruginosa, group B streptococci and enterococci ( BMJ Best Practice, 2020 ). UTIs generally occur when uropathogens found in faecal flora contaminate the peri-urethral area; these then ascend into the bladder via the urethra causing a lower UTI. Uropathogens may migrate further from the bladder into the kidneys, via the ureters, resulting in pyelonephritis, an upper UTI ( BMJ Best Practice, 2020 ).

The presence of bacteria in the urine is known as bacteriuria, and the occurrence of bacteria in the urine without signs and symptoms of a UTI is defined as asymptomatic bacteriuria ( Ninan et al, 2014 ). The prevalence of asymptomatic bacteriuria is high in older people, especially those living in long-term care, making diagnosis and treatment difficult because it does not essentially signify acute infection, and in isolation it is not an indication for antibiotics ( Nicolle et al, 2005 ). These diagnostic challenges may lead to over-diagnosis, excessive antibiotic treatment and delay in making accurate diagnoses ( Ninan et al, 2014 ).

Antibiotic prescribing

UTI is the second most frequent reason for the prescription of antibiotics within primary and secondary care, with over 50% of prescriptions in older adults believed to be unnecessary ( Public Health England (PHE), 2020a ). Over-treatment can lead to adverse reactions from antibiotics, and with ever-increasing antimicrobial-resistance (AMR) antibiotic reduction in this age group is essential ( Mayne et al, 2019 ). AMR is a growing threat to public health; antimicrobial stewardship and national guidelines are aimed at opposing these challenges and must be adhered to in practice ( Scottish Intercollegiate Guidelines Network (SIGN), 2012 ; NICE, 2018a ; 2020a; 2020b; PHE, 2020b ).

E. coli can enter the bloodstream following a UTI, manifesting as urosepsis, with E. coli bacteraemia being the most common cause of sepsis in the UK ( Thornton et al 2018 ). Urosepsis is increasing each year, with studies revealing that only 18% of cases are of hospital-based onset ( PHE, 2020c ). In England, 43 294 E. coli bacteraemia cases were reported in 2019/20, with 6005 deaths reported ( PHE, 2021 ). With no definite cause highlighted, it has been suggested that it could be related to delayed treatment of UTI in primary care, and antimicrobial stewardship initiatives ( Thornton et al, 2018 ).

However, increasing incidence of older people with frailty and increasing resistance could explain the growing morbidity associated with UTIs ( Allison and McNulty, 2019 ). Cases of E. coli bacteraemia increased by 35% over 2013–2017, with the highest rates in England noted among older people, with significant risk factors including recurrent UTIs, frequent antibiotic use and indwelling catheters ( Abernethy et al, 2017 ). This presents challenges to working as an autonomous advanced nurse practitioner (ANP) in out-of-hours (OOH) care. The burden of UTI in older people is anticipated to grow due to an increase in the ageing population. In addition, there are wide variations in presenting symptoms and management of UTI, with overall adherence to guidance varying between services ( Philips et al, 2014 ). It is therefore essential to improve diagnostic, management and prevention approaches to enhance the health outcomes of older adults ( Gharbi et al, 2019 ).

There is an increasing prevalence of ANP roles throughout the urgent care OOH service, including urgent care centres, walk-in centres, on-day home visiting services and urgent care home visiting. ANPs are well positioned to have crucial roles in the assessment and management of UTIs in patients aged over 65. In this age group, NICE stipulates that a full clinical assessment and examination is required prior to formulating a working diagnosis of UTI ( NICE, 2015 ), including the completion of vital signs ( SIGN, 2012 ). This is due to the complexity of assessment in older patients; various indicators can affect assessment and restrict the ability to assess for acute symptoms. For example, cognitive impairment may reduce the ability to communicate or give a history about symptoms and coexisting illnesses that present with nonspecific symptoms such as urinary incontinence ( Ninan et al, 2014 ).

The clinical decision-making process in urgent care OOH depends on quickly assessing whether a patient is presenting with an infection or displaying signs of sepsis or deterioration. ANP development requires acquisition of comprehensive assessment skills ( Health Education England (HEE), 2017 ). It is crucial, as an ANP, to have the ability to assimilate information, formulate decisions and apply these decisions correctly into practice ( HEE, 2017 ). Working within the HEE framework for advanced clinical practice ( HEE, 2017 ) it is vital to holistically assess patients, incorporating a comprehensive history and identifying risk factors.

To help obtain a clinical picture it is essential that a full and thorough history is taken ( NICE, 2020a ). If patients have reduced ability to give an exact history, clinical staff, carers, friends or relatives are asked whether cognitive decline, functional or behavioural changes are new, ongoing or acute ( NICE, 2020a ).

Considerations in assessment and management

Symptoms of uti.

Symptoms of UTI include dysuria, urgency, urinary frequency, changes to urine consistency or appearance, nocturia and suprapubic pain ( NICE, 2020a ). However, in older patients these features may not be present; also patients with UTI generally present with non-specific clinical features such as increased confusion or delirium, lethargy, reduced appetite, incontinence, reduced mobility or the inability to carry out normal activities of daily living ( NICE, 2020a ). Pyrexia, renal angle pain, loin pain, vomiting or rigors can indicate pyelonephritis ( NICE, 2020a ; 2020b ). If undiagnosed, this can progress adversely to sepsis and renal failure ( Kalra and Raizada, 2009 ). Importantly, it is essential to be aware that older patients are vulnerable and may have impaired immunity, therefore a low threshold for sepsis is assumed when a patient shows signs of UTI, plus acute disease ( NICE, 2017 ; UK Sepsis Trust, 2019 ).

National Early Warning Score

To assist in the detection of deterioration in adult patients the National Early Warning Score 2 (NEWS2) tool is used ( Royal College of Physicians (RCP), 2017 ). NEWS2 comprises the physiological readings of patients, including systolic blood pressure, heart rate, temperature, oxygen saturation, respiratory rate, and consciousness level, with adjusted scoring when there is a need for oxygen therapy ( RCP, 2017 ). The values are measured, recognising that patients with a high score are more at risk of deterioration ( RCP, 2017 ). For patients with a NEWS2 score of five or more, the local sepsis protocol is adhered to and a 999 transfer to secondary care is made ( NHS England, 2017 ).

PHE (2020b) indicates that UTI is likely in patients of more than 65 years who have new onset dysuria with two or more of the following: new urgency or frequency, new incontinence, new or worsening delirium, new suprapubic pain, visible haematuria or an increased temperature 1.5°C higher than the patient's normal temperature. However, if fever and delirium or debility are present, other sources of infection and causes of delirium other than UTI must be excluded before making a diagnosis of UTI ( NICE, 2020a ; PHE, 2020b ). Other sources of infection may include respiratory, gastrointestinal, skin and soft tissue, and should be investigated and treated in line with local guidance ( PHE, 2020b ).

A systematic review analysed the association between UTI and delirium and found that, in patients without a UTI, delirium rates were 7.7% to 8% compared with patients who had a confirmed UTI, where delirium rates were 30% to 35% ( Balogun and Philbrick, 2014 ). However, with methodological flaws and bias being noted, more research is needed in this area ( Balogun and Philbrick, 2014 ). Nevertheless, it is practical to accept the association between symptomatic UTI and delirium just as it is with delirium and numerous other conditions and infections ( Balogun and Philbrick, 2014 ). It is noted that the presence of asymptomatic bacteriuria, without frequency, dysuria, pyrexia or suprapubic discomfort, is a doubtful cause of delirium, and other contributing factors are always considered and investigated ( Gau et al, 2009 ).

For the assessment of delirium or new confusion, PHE (2020b) recommends the use of the mnemonic PINCH ME, which stands for: pain, other infection, reduced nutrition, constipation, hydration, medications and environmental changes. This is applied in practice when assessing older patients and is a useful tool for the review of possible causes for delirium. Another tool used for the rapid assessment of delirium is the Arousal, Attention, Abbreviated Mental Test 4, Acute change tool (4AT) ( MacLullich, et al, 2014 ). It is quick to apply in practice with high sensitivity and no training is required for its use ( SIGN, 2019 ). With patients who have no new signs of UTI, when other infections have been ruled out, PHE (2020b) advises that ‘watchful waiting’ is employed, whilst investigations for further causes are completed.

Patients with symptoms of a UTI who have a urinary catheter in situ are checked for signs of blockage and removal or replacement is considered ( NICE, 2020a ; PHE, 2020b ). Competing differentials are considered during assessment including urethritis, prostatitis, vulvovaginal atrophy or genitourinary syndrome of menopause, and sexually transmitted diseases, as all of these can cause symptoms of UTI ( Portman and Gass, 2014 ; Michels and Sands, 2015 ).

For the diagnosis of patients over the age of 65 the use of urine dipsticks is not recommended ( PHE, 2020b ). Most patients with catheters and half of older patients will have asymptomatic bacteriuria in the bladder without infection ( PHE, 2020b ). Although asymptomatic bacteriuria is not harmful to patients it will create a positive dipstick reaction, thereby giving misleading results ( PHE, 2020b ). The diagnosis of asymptomatic bacteriuria without UTI symptoms is made by a midstream urine sample indicating bacterial growth greater than 10⁵ colony-forming units per millilitre (cfu/ml) in one single sample in men and two consecutive samples in women ( Bonkat et al, 2020 ).

Diagnosis of UTI in all patients over the age of 65 is based on taking a full history including associated symptoms, previous episodes of UTI, risk factors, past medical history, prescribed medications, previous antibiotics and a full examination including vital signs and abdominal examination ( SIGN, 2012 ; NICE, 2020a ). Change to urine colour or smell is also not a diagnostic tool but may be specifically related to dehydration, so a history of fluid intake is essential ( Ninan et al, 2014 ). If either non-visible or visible haematuria continues following treatment of a UTI, it requires further investigation to rule out the cause, with referral to secondary care as required ( NICE, 2021 ).

Midstream specimen of urine

To confirm a diagnosis and guide antibiotic prescribing a midstream specimen of urine (MSU) must be sent for culture and sensitivity in patients over the age of 65 ( PHE, 2020b ). This diagnostic certainty is not always possible working within OOH urgent care, where there is no facility to send MSU samples for pathology, and delays in sending are unavoidable. However, a boric acid preservative may be used, or refrigeration at 4°C is suggested, and the sample can then be sent the following day ( PHE, 2019 ). Difficulties arise when collecting an MSU from older people due to incontinence, and it is recommended to only take an MSU if a patient is symptomatic and capable of collecting a satisfactory sample ( PHE, 2019 ). A clean catch in a disinfected container and for men the use of condom catheters may be feasible options for incontinent patients but there is poor evidence to support these techniques ( Latour et al, 2013 ). MSU samples from patients with indwelling catheters should be taken from a newly inserted catheter using an aseptic technique ( PHE, 2019 ).

It is recognised that within the guidance the diagnosis and management of UTI in older people uses the age of 65 years as a cut off ( SIGN, 2012 ; PHE, 2020b ); however, in practice, it is evident that this is not a standardised group and may include self-caring, fit and healthy older women, who may be managed similarly to those aged under 65 years, and they are assessed on an individual basis, to allow for patient-centered care ( HEE, 2017 ). However, in males, management does not change and an MSU is always required ( NICE, 2020b ).

Culture results are interpreted alongside the severity of signs and symptoms that patients present with because false negatives can occur ( PHE, 2020b ). In patients who present with urinary symptoms, urine culture results may indicate a UTI if there is a growth of 10⁴-10⁵ cfu/ml, whereas in results that have a mixed growth or epithelial cells a retest may be required if symptomatic ( PHE, 2020b ).

Antibiotic choice

Best practice for the treatment of a lower UTI is to send an MSU prior to antimicrobial prescribing so that results can be tailored to sensitivities. However, this is only possible if the patient is systemically well, not considered high risk and it is deemed safe to wait for treatment. In an OOH setting, this is challenging, and safety of patients is paramount ( HEE, 2017 ). If antibiotics are required, previous sensitivity, resistant patterns and previous treatments must be noted ( NICE, 2018a ), with narrow spectrum antibiotics prescribed where possible, to minimise the chance of Clostridium difficile and AMR. In E. coli urine isolates 28.6% are resistant to trimethoprim, in comparison nitrofurantoin resistance is 2%, and pivmecillinam 6% within England ( PHE, 2020b ).

Nitrofurantoin is consequently the first-line antibiotic to consider in all patients ( NICE and PHE, 2020 ). In patients with reduced renal function nitrofurantoin achieves low urinary concentration and if an estimated glomerular filtration rate (eGFR) is below 45 ml/minute other antibiotics must be considered ( Joint Formulary Committee, 2021 ), including trimethoprim, pivmecillinam, or fosfomycin ( NICE and PHE, 2020 ). The recommended treatment length for a lower UTI is 3 days for women and 7 days for men ( NICE and PHE, 2020 ). There is good evidence to support the use of 3 days in women where a meta-analysis of 1644 older women proved that 3 to 6 days of antibiotics was comparable with 7 to 14 days, with no differences in patient satisfaction, re-infection rates, symptom duration or adverse events ( Lutters et al, 2008 ). However, there is a poor amount of evidence in relation to antibiotic duration in older men and 7-day treatment is principally founded on expert consensus within national guidelines ( SIGN, 2012 ; NICE, 2018a ; Bonkat et al, 2020 ).

For the management of pyelonephritis, referral must be considered if patients present as very unwell, with signs of sepsis, dehydration, are not taking fluids, have an increased risk of acquiring complications including structural or functional defect of the genitourinary tract, immunosuppression or diabetes mellitus ( NICE, 2020b ). For patients who are well and can be managed within primary care, latest guidance recommends cefalexin as first line treatment for 7–10 days, as it has a lower resistance than co-amoxiclav and ciprofloxacin, with randomised controlled trials demonstrating that it is similarly effective ( NICE, 2018b ).

For patients with an indwelling catheter and new signs of symptoms of a UTI, this should be treated with antibiotics and a catheter change if over 7 days old ( NICE, 2018c ). Antibiotic treatment and management remain as per guidance for associated symptoms of lower UTI or pyelonephritis ( NICE, 2018a ; 2018b ). However, in patients without new symptoms and who are well, treatment should not be commenced without MSU results ( NICE, 2018c ).

Communication

Communication is vital to the role of the ANP with verbal and written information given to the patient or their carer during the consultation, this includes actions to be taken if their condition fails to improve, changes or if they have further concerns about their health (referred to as ‘safety netting’ advice) ( HEE, 2017 ). Advice is provided regarding diagnosis and treatment, self-care including fluids and paracetamol, clear instructions regarding worsening symptoms or ongoing symptoms that are not improving within 48 hours of treatment and details of who they need to contact to access further care ( NICE, 2018b ). Patients' or carers' levels of understanding concerning safety netting advice are assessed, and related referrals are made as a duty of care for observational reasons ( Nursing and Midwifery Council, 2018 ). Written advice is available from the Royal College of General Practitioners TARGET antibiotics toolkit website (https://www.rcgp.org.uk/TARGETantibiotics) regarding UTI for older adults and carers and is used in practice to allow for education regarding self-care and understanding of ‘safety netting’ advice (the advice leaflet is available in several languages: https://bit.ly/30QacBb).

Recognition of UTI in elderly patients is not always straightforward. Older women can exhibit signs of a UTI as a consequence of oestrogen deficiency and evidence supports the use of vaginal oestrogen cream or pessaries to reduce the risk of re-occurring UTI diagnosis ( Perrotta et al, 2008 ). Elderly patients may have existing medical conditions such as benign prostatic hyperplasia disease, dementia and constipation that may predispose them to incontinence and UTIs ( NICE, 2012 ; SIGN, 2012 ). A full history of patients' prescribed medications is essential, since drugs such as antimuscarinics also may predispose patients to symptoms of UTI, as they are known to cross the blood–brain barrier, and may cause confusion, reduce bladder emptying and trigger or exacerbate constipation ( NICE, 2012 ).

National guidance

Previous national guidance regarding UTI was not specifically aimed at patients over the age of 65; however, the latest guidance includes diagnostic flow charts for this age group ( PHE, 2020b ) and should be used in practice. This will aid diagnosis and treatment with potential to allow for improved prescribing alongside antimicrobial stewardship and result in improved outcomes for patients. Working as an ANP it is important to understand the necessity for changes to healthcare policy and guidance and to use leadership skills to influence junior staff and other members of the multidisciplinary team to promote best practice ( Anderson, 2018 ).

The correct management of elderly patients who are seen within OOH urgent care with UTI is challenging for ANPs since the signs and symptoms might vary widely ( PHE, 2020b ). With a broad variation in practice, interpretation of symptoms, diagnostic tests, and commencement of antibiotic treatment, the diagnosis of UTI is extremely difficult in older patients, especially as they may have asymptomatic bacteriuria ( Butler et al, 2015 ). To prevent variation in practice and unnecessary treatment, latest evidence-based guidance should be adhered to, with outdated practices such as urine dipstick tests only being used where guided, to reduce unwarranted antibiotics and reduce the emergence of AMR in the community. ANPs should educate patients about self-care measures regarding hydration, catheter and incontinence care to prevent re-occurring symptoms ( PHE, 2020b ). Crucial knowledge regarding the signs and symptoms, assessment and management of patients presenting with symptoms of UTI allows patients to be safely managed, which is pertinent to the role of the advanced practitioner ( HEE, 2017 ). Ensuring high-quality, safe, patient-centred care requires excellent communication skills, as well as education of staff and MDT, patients and relatives.

  • Among older people, urinary tract infection (UTI) is a substantial cause of mortality—it affects approximately 1 in 5 in women aged over 65, but both genders are at risk of UTI in older age
  • UTI is the second most frequent reason for the prescription of antibiotics within primary and secondary care, with over 50% of prescriptions in older adults believed to be unnecessary
  • There are challenges for the advanced nurse practitioner in out-of-hours urgent care in balancing the need for antibiotic stewardship with concerns about urosepsis and mortality associated with UTIs in older adults
  • The clinical decision-making process depends on quickly assessing whether a patient is presenting with an infection or displaying signs of sepsis or deterioration, and requires a holistic assessment

CPD reflective questions

  • What clinical features should you consider, in an older patient, that may mean they have a urinary tract infection (UTI)?
  • UTI is the second most frequent reason for prescription of antibiotics, yet 50% of these prescriptions are believed to be unnecessary. What can you do to reduce this percentage?
  • Sending a mid-stream specimen of urine (MSU) for testing before commencing antibiotics for the treatment of lower UTI is considered best practice. In your practice is this appropriate and safe?
  • Reflect on the advantages/disadvantages of a dipstick urinalysis
  • What important safety advice should you communicate to your patient regarding medications, fluids or deteriorating symptoms?

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Urinary Tract Infection Case Study

  • Jordan Bittengle
  • Kellie Berry
  • Kristina Hickman
  • Leslie Starkey

Our rationale for choosing this condition:

We chose urinary tract infection as our case study because we all have experience taking care of patients that have had urinary tract infections. Our group thought this was a good topic because we know that moving forward in our careers, we will take part in treating patients with urinary tract infections no matter what setting we work in.

Male urinary system

https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447

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Urinary Tract Infection Clinical Case

Urinary tract infection clinical case presentation, free google slides theme and powerpoint template.

A urinary tract infection (UTI) is a common medical condition that affects many people each year. When it comes to clinical cases of UTI, there are certain warning signs and symptoms that must be taken into account. Present them with the help of this Google Slides or PowerPoint template. Create a visually engaging and informative presentation on UTIs with the modern design of these slides. Add images, charts or animations to present a clinical case very effectively.

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Proposing the "Continuum of Urinary Tract Infection (UTI)" for a Nuanced Approach to Diagnosis and Management of UTIs

Affiliations.

  • 1 Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
  • 2 Duke Aging Center, Duke University School of Medicine, Durham, North Carolina.
  • 3 Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
  • 4 Departments of Urology and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
  • 5 Duke Clinical Research Institute, Durham, North Carolina.
  • 6 Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina.
  • 7 Durham VA Medical Center, Durham, North Carolina.
  • PMID: 38330392
  • DOI: 10.1097/JU.0000000000003874

Purpose: Patients with suspected urinary tract infections (UTIs) are categorized into three clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach.

Materials and methods: This was a retrospective cohort study of a random sample of adult non-catheterized inpatient and ED encounters with paired urinalysis and urine cultures from 5 hospitals in three states between January 01, 2017 and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the "continuum of UTI," a 5-level classification scheme that includes two new categories: lower urinary tract symptoms/other urologic symptoms (LUTS/OUS) and bacteriuria of unclear significance (BUS). The newly defined "continuum of UTI" categories were compared to current UTI classification scheme.

Results: Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the "continuum of UTI" categories, 68% of patients (n = 478) with ASB were reclassified as BUS and 29% of patients (n = 467) with "no UTI" were reclassified to LUTS/OUS.

Conclusions: Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by front line clinicians, and promote a nuanced approach to diagnosis and management of UTIs.

Keywords: BUS; LUTS; antibiotic stewardship; asymptomatic bacteriuria; bacteriuria; bacteriuria of unclear significance; urinary tract infection.

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Introduction to Urinary Tract Infections (UTIs)

, MD, University of Riverside School of Medicine

Urinary tract infections (UTIs) can be divided into upper and lower tract infections:

Upper tract infections involve the kidneys ( pyelonephritis Acute pyelonephritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more ).

Lower tract infections involve the bladder ( cystitis Cystitis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more ), urethra ( urethritis Urethritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more ), and prostate ( prostatitis Prostatitis Prostatitis refers to a disparate group of prostate disorders that manifests with a combination of predominantly irritative or obstructive urinary symptoms and perineal pain. Some cases result... read more ).

However, in practice, and particularly in children, differentiating between the sites of infection may be difficult or impossible. Moreover, infection often spreads from one area to the other. Although urethritis and prostatitis are infections that involve the urinary tract, the term UTI usually refers to pyelonephritis and cystitis.

Bacterial urinary tract infections Bacterial Urinary Tract Infections Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more cause most cases of cystitis and pyelonephritis. The most common nonbacterial pathogens are fungi Fungal Urinary Tract Infections Fungal infections of the urinary tract primarily affect the bladder and kidneys. (See also Introduction to Urinary Tract Infections [UTIs].) Species of Candida , the most common cause... read more (usually candidal species) and, less commonly, mycobacteria, viruses, and parasites. Nonbacterial pathogens usually affect patients who are immunocompromised; have diabetes, obstruction, or structural urinary tract abnormalities; or have had recent urinary tract instrumentation.

Other than adenoviruses (implicated in hemorrhagic cystitis), viruses have no major contribution to UTI in immunocompetent patients.

Bancroftian and Brugian Lymphatic Filariasis

Urethritis is usually caused by an STI Overview of Sexually Transmitted Infections Sexually transmitted infection (STI) refers to infection with a pathogen that is transmitted through blood, semen, vaginal fluids, or other body fluids during oral, anal, or genital sex with... read more . Prostatitis Prostatitis Prostatitis refers to a disparate group of prostate disorders that manifests with a combination of predominantly irritative or obstructive urinary symptoms and perineal pain. Some cases result... read more is usually caused by a bacterium and is sometimes caused by an STI.

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  1. UTI Case Study

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  2. Preventing and Controlling Infectious Diseases Case Study Example

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  3. UTI Case Presentation

    uti case study presentation

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    uti case study presentation

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    uti case study presentation

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    uti case study presentation

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  1. Patient Presentation

    Patient Presentation | Urinary Tract Infection Case Study Patient Presentation Ms. Smith is a 27-year-old woman who presents to her PCP after just finishing a course of antibiotics for an upper respiratory infection with complaints of dysuria and foul-smelling urine.

  2. Diagnosis and Treatment of Urinary Tract Infections: A Case-Based Mini

    Case 1 A 75-year-old man presented with a 3-day history of dysuria, urinary frequency, hesitancy, dribbling of urine, and transient hematuria. He denied fever, chills, nausea, vomiting, scrotal pain, or back pain. He is not sexually active.

  3. Urinary tract infection in an older patient: a case study and review

    ISSN (online): 2052-2940 References Abstract This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin, by a non-medical prescriber, for a suspected symptomatic uncomplicated urinary tract infection in a patient living in a care home.

  4. Educational Case: Acute Cystitis

    Patient Presentation A 27-year-old woman presents to her primary care physician with a report of urinating more frequently and pain with urination. She denies blood in her urine, fevers, chills, flank pain, and vaginal discharge. She reports having experienced similar symptoms a few years ago and that they went away after a course of antibiotics.

  5. Urinary Tract Infection

    This guideline applies to adult patients with urinary tract infection. The objective is to create an evidence-based and cost-effective strategy for management of UTI in adults. ... D = individual observation studies (case or case series) ... Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments ...

  6. Uncomplicated Urinary Tract Infections

    An uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. Patients with uncomplicated UTIs have no structural abnormality of the urinary tract and no comorbidities such as diabetes, an immunocompromised state, recent urologic surgery, or pregnancy. An uncomplicated UTI is also known as cystitis or a lower tract UTI.

  7. PDF Urinary Tract Infections

    UTI: Definitions. Uncomplicated UTI - Infection in a structurally and neurologically normal urinary tract. Simple cystitis of short (1-5 day) duration. Complicated UTI - Infection in a urinary tract with functional or structural abnormalities (ex. indwelling catheters and renal calculi). Cystitis of long duration or hemorrhagic cystitis.

  8. Urinary Tract Infection Case Study (45 min)

    UTI nursing case study with answers for nursing students. Start learning now. Urinary Tract Infection Case Study (45 min) Watch More! Unlock the full videos with a FREE trial ... Each case study was written by experienced nurses with first hand knowledge of the "real-world" disease process.

  9. Acute Uncomplicated UTIs in Adults: Rapid Evidence Review

    The self-reported annual incidence of UTI is 11% in women and 3% in men. 1, 2 UTIs are most common in women between 18 and 29 years of age. 3 UTIs are uncommon in men younger than 60 years; by 80 ...

  10. Urinary tract infection in an older patient: a case study and review

    The aim of this study was to determine the risk of adverse outcomes in patients aged ≥65 years presenting to primary care with a UTI, by estimated glomerular filtration rate (eGFR) and empirical ...

  11. CASE STUDY ON Urinary Tract Infection

    Case study urinary tract infection Case presentation (COPD) Benign Prostatic Hyperplasia (Surgical Case Presentation) Similar to CASE STUDY ON Urinary Tract Infection (20) Case presentation on hepatits E Uti with renal caliculi with type2 dm CKD WITH MALARIA & ACUTE GE Lipoprotein glomerulopathy.pptx

  12. British Journal of Nursing

    UTI is defined as an infection of the urinary system, involving lower tract, upper tract or both (NICE, 2020a). The pathogens responsible for UTI include Escherichia coli (E. coli), which accounts for 70% to 95% of uncomplicated cases, with Staphylococcus saprophyticus responsible for 5% to 20% of cases (NICE, 2020a).

  13. UTI Case Presentation

    normally colonized by diphtheroids, streptococcal species, lactobacilli, and staphylococcal species. Dysfunction use of catheters for bladder drainage and is favored by the prolonged stasis of urine in the bladder. UTI Case Presentation - Download as a PDF or view online for free.

  14. Urinary Tract Infection Case Study

    Our rationale for choosing this condition: We chose urinary tract infection as our case study because we all have experience taking care of patients that have had urinary tract infections. Our group thought this was a good topic because we know that moving forward in our careers, we will take part in treating patients with urinary tract ...

  15. Urinary Tract Infection Clinical Case

    A urinary tract infection (UTI) is a common medical condition that affects many people each year. When it comes to clinical cases of UTI, there are certain warning signs and symptoms that must be taken into account. Present them with the help of this Google Slides or PowerPoint template.

  16. Proposing the "Continuum of Urinary Tract Infection (UTI)" for a

    Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach. Materials and methods: This was a retrospective cohort study of a random sample of adult non-catheterized inpatient and ED encounters with paired urinalysis and urine cultures from 5 hospitals in three states ...

  17. Introduction to Urinary Tract Infections (UTIs)

    Bacterial urinary tract infections Bacterial Urinary Tract Infections Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more cause most cases of cystitis and pyelonephritis. The most common nonbacterial pathogens are fungi Fungal Urinary Tract ...

  18. Case study of urinary tract infection

    Nov 16, 2018 • 10 likes • 5,313 views S SATYAM PANDEY Student at K S INTER COLLEGE Health & Medicine A Therapeutic topic on Urinary Tract Infection, covering various subtopics like the causative organism, clinical features and more importantly, the laboratory diagnosis. 1 of 32 Download Now Recommended Urinary Tract Infection DivyanshuRajput7

  19. Urinary Tract Infections in Pregnancy Clinical Presentation

    The presentation varies according to whether the patient has asymptomatic bacteriuria, a lower urinary tract infection (UTI; ie, cystitis) or an upper UTI (ie, pyelonephritis). ... In a prospective study of cases of pregnant women with acute pyelonephritis, complications included anemia (23%), bacteremia (17%), respiratory insufficiency (7% ...

  20. CASE Study UTI

    A urinary tract infection (UTI), also known as acute cystitis or bladder infection, is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a simple cystitis (a bladder infection) and when it affects the upper urinary tract it is known as pyelonephritis (a kidney infection).