Author Francisco Machado

1. A 32 year old woman rings requesting an antibiotic for "cystitis". She complains of dysuria and frequency.
She had a similar episode 3 years ago. What do you do?

2. A mother brings her 3 year old son with symptoms of urinary frequency. Outline your mangement

3. A 23 year old complains of dyusria but repeated MSUs have been negative. What are possble diagnoses?
How can she reduce the frequency of infections?

5% of women present to GP’s with dysuria and frequency of which half will have a UTI. The remainder will 
have urethral syndrome.

UTIs can be classified as either being:

·         Uncomplicated

Risk factors include sexual intercourse, diaphragm, personal or family history of UTI

·         Complicated

Associated with an anatomical or functional defect of urinary tract, recent UT instrumentation 
or catherterisation

 

Features of urinary tract infection

·         Cystitis produces symptoms of frequency, dysuria, and urgency

·         Ascending infection causes pyelonephritis, which typically presents with loin pain, 
      fever, malaise, nausea and vomiting.

·         Patients may complain of cloudy or offensive urine

·         May present as confusion in the elderly

·         4-7% pregnant women associated with LBW and premature delivery

1.       Nitrite test

Bacteria convert nitrates in urine to nitrites. This takes several hours, therefore 
early morning specimen is best sample.

2.       Leucocyte esterase detects WBCs

 

So one management protocol might be

·         If both leucocytes and nitrites negative send MSU

 

Urine culture essential in the management of women with:

 

But start treatment with best guess antibiotic and modify with results.



Any woman who has recurrent, symptomatic and unexplained urinary infections to 
exclude anatomical abnormalities



Any man who has a confirmed UTI should be investigated.

Trimethoprim, nitrofurantoin, and oral cephalosporins are effective first line empirical treatment.

 

IF symptoms do not settle send MSU.

 

Treatment failures should probably be treated with a quinolone.

·         relapse of previously treated infection i.e. same bug

·         determine any anatomical problem



Then prophylactic antibiotics with trimethoprim, nitrofurantoin or norfloxacin can reduce
likelihood of further attacks. Treatment should last for 3-6 months.

·         Treat empirically while waiting for culture e.g. trimethoprim, cephalosporins, or quinolone

·         Increased anatomical problem and therefore refer for investigation.

Urethral syndrome is the presence of symptoms of a urinary tract infection when the usual evidence of an infection is not found. It occurs in adults of all ages.

· Soaps, antiseptic creams, or spermicides may irritate the genital area. Dyes or perfumes in toilet tissue and feminine hygiene products, such as pads, tampons, and sprays, may also cause urethral syndrome.

Symptoms

Investigations

· MSU negative

· PV examination and swabs if indicated

· May require imaging of renal tract

Treatment

Avoiding products that are known to cause irritation and allergic reactions, practicing good personal hygiene, and drinking a lot of fluids might help.

Urethral syndrome may develop into a full-blown urinary tract infection. Call your doctor if you develop any new symptoms, such as headache, fever, chills, or blood in your urine.

Self help

· Drink 6 to 8 glasses of fluids each day to cleanse the bladder and rest of the urinary tract.

· Keep the genital area clean, using clear water. Do not wash the genital area with soap.

· Don't use feminine hygiene sprays and other perfumed feminine hygiene products.

· Wear cotton underwear, which allows better air circulation than nylon. Pantyhose should have a cotton crotch.

· Avoid tight clothes in the genital area, such as control-top pantyhose and tight jeans.

Bandolier commenting on a RCT published in JAMA that looked at whether cranberry juice 
can reduce the frequency of  UTIs.

Is cranberry juice effective?

The answer seems to be a very definite yes! It would appear that cranberry juice reaches parts
that other juices can't reach, and that the components of the juice which affect bacterial 
adhesion to cells lining the urothelial tract are effective in vivo as well as in vitro. Only cranberry 
and blueberry juice seem to contain the large molecular weight component.

Jepson RG, Mihaljevic L, Craig J. Cranberries for preventing urinary tract infections (Cochrane Review). 
In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software.

The small number of poor quality trials gives no reliable evidence of the effectiveness of cranberry 
juice and other cranberry products. The large number of dropouts/withdrawals from the trials 
indicates that cranberry juice may not be acceptable over long periods of time. Other cranberry 
products such as cranberry capsules may be more acceptable. On the basis of the available 
evidence, cranberry juice cannot be recommended for the prevention of urinary tract infections 
in susceptible populations. Further properly designed trials with relevant outcomes are needed.

S Saint, BA Lipsky. Preventing catheter-related bacteriuria. Should we? Can we? How? Archives of Internal Medicine 1999 159: 800-808.

This article was reviewed in Bandolier and the following recommendations were highlighted.

1. Avoid using a urinary catheter whenever possible. When used, remove as soon as possible.

2. Always insert a catheter aseptically, use a closed drainage system, and properly maintain the catheter.

3. Consider systemic antibiotics only during short term (3-14 days) in patients at high risk for complications of catheter-associated bacteriuria.

4. Consider using a silver alloy catheter in patients at high risk of complications.

5. Suprapubic catheters may be desirable in patients needing long-term catheterisation.

6. A condom catheter may be sensible for incontinent men who will not manipulate the device.

7. Prophylaxis with trimethoprim-sulphamethoxazole should be given to patients undergoing renal transplantation who need a catheter.

8. Systemic antibiotic prophylaxis should probably be given to men undergoing transurethral resection of the prostate.

9. No good evidence that bladder irrigation, antibacterial instillation in the drainage bag, rigorous meatal cleaning, and use of meatal lubricants and creams prevent bacteriuria. They should not be used.

Main concern about UTIs in children is the effect of ascending infection and subsequent renal scarring.

UTIs in children was recently reviewed by Clinical Evidence 1999.

· Treating symptomatic acute urinary tract infection in children with an antibiotic is accepted clinical practice and trials would be considered unethical

· We found little evidence on the effects of delaying treatment while awaiting microscopy or culture results, but retrospective observational studies suggest delayed treatment may be associated with increased rates of renal scarring

· One systematic review of randomised controlled trials (RCTs) has found that antibiotic treatment for seven days or longer is more effective than shorter courses

· We found no convincing evidence of benefit from routine diagnostic imaging of all children with a first urinary tract infection, but subgroups at increased risk of future morbidity may benefit from investigation. Because such children cannot currently be identified clinically, investigating all young children with urinary tract infection may be warranted

· Two small RCTs found that prophylactic antibiotics prevented recurrent urinary tract infection in children, particularly during the period of prophylaxis. The long term benefits of prophylaxis have not been adequately evaluated, even for children with vesicoureteric reflux. The optimum duration of treatment is unknown

· One systematic review and a subsequent multicentre RCT found no difference between surgery for vesicoureteric reflux and medical management in preventing recurrence or complications from UTI

Management of UTI in general practice: a cost effective analysis. Fenwick et al. BJGP 2000; 50: 635-639.

Authors concluded that the most cost-effective management of uncomplicated UTIs in non pregnant women was empirical treatment with an antibiotic based on patients history and no investigation. Sending MSU as well as empirical treatment increased the cost-effectiveness ratio 15 fold. Women treated empirically recovered faster. Near patient testing is imperfect and a wait and see approach to await MSU culture results in 50% of women having delayed treatment.

This paper is discussed in an excellent editorial by Andrew Ross in the same journal

UTI antimicrobial resistance: tricky decisions ahead. Ross A. BJGP 2000; 50: 612-3.

· Duty to do what is best for the patient, e.g. if you treat then at least 50% of patients will not have to wait for the result and suffer. In some cases “minor” short lasting illnesses recover spontaneously even when not treated e.g. tonsillitis, otitis media, antibiotics merely shortening the recovery interval by 24 hours. What would you do if your child had OM. An excellent analogy is given from a BMJ editorial which stated:

“We may need to give up our antibiotics for minor illnesses as we may need to give up our cars for minor journeys”

· If GPs are to act for utilitarian reasons i.e. not prescribe they need to be backed by authorities and the government e.g. NICE

The results of this paper will not be a surprise to many experienced GPs who have experimented with the various clinical pathways in the management of UTIs.

MSU result	MSU positive	MSU negative
Nitrite result	89% Nitrite positive	79% nitrite negative
Leucocyte result	66% leucocyte positive	90% leucocyte negative

	Date of last update 24/08/2000
Author Francisco Machado	Feedback: fran@abersychan.demon.co.uk