Read This Article To Learn More About:
- the new PHE diagnostic flowcharts for urinary tract infection and how they can improve patient outcomes and antimicrobial stewardship
- why dipstick tests are no longer recommended in older people with suspected UTI
- when to send urine for culture, and when to prescribe an antibiotic.
Symptoms associated with urinary tract infections are one of the most common, acute reasons for women to seek health care. UTIs cause significant pain and interfere with daily routine. The results of a 2014 UK-based survey revealed that:1
- in the previous year, 11% of women reported a UTI and 3% reported recurrent UTI
- of all women who had ever had a UTI, 95% reported consulting a healthcare professional and of these, 76% had a urine culture test
- of all women who contacted an HCP about their last UTI, 74% were prescribed an antibiotic
- 48% of women rated their last UTI as fairly or very severe.
Optimising the diagnosis of UTIs is important as studies indicate that, of all women in the UK with a suspected UTI who are prescribed an antibiotic and have urine sent for culture, only 2466% have a confirmed UTI.2,3
Clinical Presentation Of Urinary Tract Infection
The clinical presentation of a patient with UTI ranges from asymptomatic bacteriuria to acute pyelonephritis or urosepsis. The presentation depends on the localization and the severity of the infection. It is essential to differentiate further between uncomplicated and complicated UTI in order to select the appropriate treatment strategies. It is sensible to categorize UTI according to the level of the urinary tract involved, the presence of symptoms and the presence of complications.
Why Asymptomatic Bacteriuria Usually Doesnt Warrant Antibiotics
Clinical studies overwhelming find that in most people, treating asymptomatic bacteriuria with antibiotics does not improve health outcomes.
A 2015 clinical research study found that treatment of asymptomatic bacteriuria in women was associated with a much higher chance of developing a UTI later on, and that these UTIs were more likely to involve antibiotic-resistant bacteria.
Even for frail nursing home residents, there is no proof that treating asymptomatic bacteriuria improves outcomes, but it does increase the presence of antibiotic-resistant bacteria.
Despite the expert consensus that this condition doesnt warrant antibiotics, inappropriate treatment remains very common. A 2014 review article on this topic notes overtreatment rates of up to 83% in nursing homes.
Is there a role for cranberry to treat or manage urine bacteria?
The use of cranberry juice or extract to prevent UTIs has been promoted by certain advocates over the years, and many patients do prefer a natural approach when one is possible.
However, top quality clinical research has not been able to prove that cranberry is effective for this purpose. In a 2016 study of older women in nursing homes, half were given cranberry capsules daily. But this made no difference in the amount of bacteria or white blood cells in their urine.
A 2012 systematic review of high-quality research studies of cranberry for UTI prevention also concluded that cranberry products did not appear to be effective.
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Inflammation In The Urinary Tract: Host/parasite Interaction
Frequency and severity of UTI are determined by the balance between local uroepithelial defence mechanisms and pathogenity of uropathogenic micro-organisms. Specific virulence factors allow bacteria to survive and to replicate in the host. Virulence factors of E. coli and Proteus mirabilis are well established and include synthesis of aerobactin and enterobactin as well as production of haemolysin and expression of fimbriae. Mannose-sensitive fimbriae have been found on pathogenic and non-pathogenic E. coli species, whereas mannose-resistant fimbriae have been detected on uropathogenic species only. P-fimbriae are called pyelonephritis-associated pili because they can attach specifically to epithelial receptors of the urogenital tract and can further ascend from the bladder up to the kidneys . Abnormalities of the urinary tract or diagnostic procedures favour ascension of pathogenic bacteria.
Table 2.
Host-specific factors associated with UTI include production of secretory immunoglobulin A interfering with adhesion, presence of TammHorsfall mucoprotein causing bacterial aggregation and washout, bactericidal properties of the serum as well as urodynamic factors, i.e. bacterial washout . THP has specific receptors for several uropathogens and the bound bacteria are washed out in the urine.
We thank Prof. E. Ritz for constructive discussion.
Complicated Vs Uncomplicated Urinary Tract Infection
Persistent or recurrent UTI in adults with anatomically and functionally normal urinary tracts leads rarely, if ever, to renal damage. Therefore, it is important to distinguish between complicated and uncomplicated UTI. Complicated UTI implies infections of urinary tracts which are anatomically or functionally altered . Associated conditions complicating UTI are summarized in . Uncomplicated infections occur mainly in otherwise healthy females with structurally normal urinary tract and intact voiding mechanisms. In contrast, complicating factors put individuals of both genders at a higher risk of developing progressive renal damage, bacteraemia, and urosepsis.
Table 1.
Complicated UTI is a clear contraindication against short-term treatment . In such patients antibiotic therapy is recommended for 26 weeks. Furthermore, for accurate treatment of UTI it is important whether the complicating factor could be eliminated during therapy or whether it persists .
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Diagnosis Performance Of Rut Versus Urine Culture
Table shows the performance of RUT compared to urine culture with two different bacterial thresholds in this population of female patients with symptoms suggestive of AUC. RUT had a negative predictive value of 92% when standard thresholds were used, lessening to 84% with reduced thresholds. Hypothetically, had GPs decided to treat only patients with leukocytes or nitrites detected at RUT, 310 patients would have been treated. Of these 310 patients, 115 patients would not finally be diagnosed with AUC according to urine culture at standard thresholds and 60 at reduced thresholds. Of the 37 non treated patients , 6 patients would finally be diagnosed with cystitis according to urine culture at standard thresholds and 7 at reduced thresholds.
Table 3 Performance of the rapid urine test for the diagnosis of AUC according to the bacterial concentration in urine culture
Asymptomatic Bacteriuria And Dipstick Tests
Diagnosing suspected UTIs in older people is made more complex by an increasing prevalence of dementia and asymptomatic bacteriuria. Up to half of all older people, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. Although this asymptomatic bacteriuria will test positive on a urine dipstick and is associated with pyuria, it is not harmful and therefore antibiotics are not beneficial and may only contribute to increasing antibiotic resistance.1114 For this reason, dipstick tests are no longer recommended by PHE in people aged over 65 years.
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What Is Asymptomatic Bacteriuria
Asymptomatic bacteriuria means having significant quantities of bacteria in the urine, but no clinical signs of inflammation or infection.
In other words, in asymptomatic bacteriuria, a urine culture will be positive.
When bacteria are present in the bladder but not provoking an inflammatory reaction, this can also be called bacterial colonization of the bladder.
Urinary Tract Infections In Adults
ROBERT ORENSTEIN, D.O., Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
EDWARD S. WONG, M.D., Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia
Am Fam Physician. 1999 Mar 1 59:1225-1234.
See related patient information handout on urinary tract infections, written by the authors of this article.
Urinary tract infections remain a significant cause of morbidity in all age groups. Recent studies have helped to better define the population groups at risk for these infections, as well as the most cost-effective management strategies. Initially, a urinary tract infection should be categorized as complicated or uncomplicated. Further categorization of the infection by clinical syndrome and by host helps the physician determine the appropriate diagnostic and management strategies. Uncomplicated urinary tract infections are caused by a predictable group of susceptible organisms. These infections can be empirically treated without the need for urine cultures. The most effective therapy for an uncomplicated infection is a three-day course of trimethoprim-sulfamethoxazole. Complicated infections are diagnosed by quantitative urine cultures and require a more prolonged course of therapy. Asymptomatic bacteriuria rarely requires treatment and is not associated with increased morbidity in elderly patients.
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How Common Is Asymptomatic Bacteriuria
Asymptomatic bacteriuria is more common in older adults than many people including practicing clinicians may realize:
- In women aged 80 or older, 20% or more may have this condition.
- In healthy men aged 75 or older, 6-15% have been found to have bacteria with no UTI symptoms.
- Studies of nursing home residents have found that up to 50% may have asymptomatic bacteriuria.
This condition also affects 2-7% of premenopausal women, and is more common in people with diabetes.
Asymptomatic bacteriuria becomes more common as people get older, in part because it is related to changes in the immune system, which tends to become less vigorous as people age or become frailer.
Studies have found that in older adults, asymptomatic bacteriuria does sometimes go away on its own, but it also often comes back or persists.
History And Physical Examination
Clinical signs and symptoms of a UTI depend on the age of the child. Newborns with UTI may present with jaundice, sepsis, failure to thrive, vomiting, or fever. In infants and young children, typical signs and symptoms include fever, strong-smelling urine, hematuria, abdominal or flank pain, and new-onset urinary incontinence. School-aged children may have symptoms similar to adults, including dysuria, frequency, or urgency. Boys are at increased risk of UTI if younger than six months, or if younger than 12 months and uncircumcised. Girls are generally at an increased risk of UTI, particularly if younger than one year.3 Physical examination findings can be nonspecific but may include suprapubic tenderness or costovertebral angle tenderness.
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Diagnosis And Management Of Uncomplicated Urinary Tract Infections
SUSAN A. MEHNERT-KAY, M.D., University of Oklahoma College of MedicineTulsa, Tulsa, Oklahoma
Am Fam Physician. 2005 Aug 1 72:451-456.
Patient information: See related handout on urinary tract infections, written by the author of this article.
Most uncomplicated urinary tract infections occur in women who are sexually active, with far fewer cases occurring in older women, those who are pregnant, and in men. Although the incidence of urinary tract infection has not changed substantially over the last 10 years, the diagnostic criteria, bacterial resistance patterns, and recommended treatment have changed. Escherichia coli is the leading cause of urinary tract infections, followed by Staphylococcus saprophyticus. Trimethoprim-sulfamethoxazole has been the standard therapy for urinary tract infection however, E. coli is becoming increasingly resistant to medications. Many experts support using ciprofloxacin as an alternative and, in some cases, as the preferred first-line agent. However, others caution that widespread use of ciprofloxacin will promote increased resistance.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A three-day course of trimethoprim-sulfamethoxazole is recommended as empiric therapy of uncomplicated urinary tract infections in women, in areas where the rate of resistanceEscherichia coli are less than 20 percent.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
What Role Do Nitrite Tests Play In Urinary Tract Infection Diagnosis
Nitrite tests detect the products of nitrate reductase, an enzyme produced by many bacterial species. These products are not present normally unless a UTI exists. This test has a sensitivity and specificity of 22% and 94-100%, respectively. The low sensitivity has been attributed to enzyme-deficient bacteria causing infection or low-grade bacteriuria.
A positive result on the nitrite test is highly specific for UTI, typically because of urease-splitting organisms, such as Proteus species and, occasionally, E coli however, it is very insensitive as a screening tool, as only 25% of patients with UTI have a positive nitrite test result.
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Treatment Options And Resistance
Increasing resistance to narrow spectrum antibiotics limits the available treatment options in all ages. There remains a difficult balance between the clinical, empirical management of UTIs using broad-spectrum antibiotics in all age ranges, and the development of antibiotic resistance in the community.12 Table 1 shows the level of resistance of E. coli to antibiotics used to treat UTI in 2018. Trimethoprim resistance in England is now at 28.6% of E. coli urine isolates, compared with only 2% for nitrofurantoin, and 6% for pivmecillinam.15 Nitrofurantoin is therefore a first-line antibiotic to consider in all patients . Nitrofurantoin attains low urinary concentrations in patients with poor renal function, so other antibiotics should be considered if estimated glomerular filtration rate is < 45 ml/min, including trimethoprim , pivmecillinam, or fosfomycin.
NICE and PHE now recommend cefalexin as a first-line treatment for oral treatment of pyelonephritis in the community as resistance to this antibiotic is now lower than resistance to co-amoxiclav and randomised controlled trials show that it is equally effective.16,17
Escherichia coli
Table 1. resistant to different antimicrobials in 2018-Quarter 3 15| Antimicrobial tested against | |
|---|---|
|
Public Health England. Field Epidemiology Field Service NIS. Antibiotic drug-bug resistance profile workbooks . PHE 2018. |
|
| No. tested against given antimicrobial | 118,913 |
| No. resistant to given antimicrobial | 2,459 |
| 28.60% |
Management Of Urinary Tract Infections In Women
When two or more courses of antibiotic therapy fail to suppress ASB, then suppressive therapy can be used for the remainder of the pregnancy. Nitrofurantoin 50 to 100 mg once at bedtime is a common option for suppressive therapy cephalexin 250 to 500 mg once at bedtime is a recommended alternative.9 These prophylactic therapies can also be used in women who have recurrent UTIs during pregnancy.9 Of note, nitrofurantoin is contraindicated at term due to a risk of hemolytic disease in infants who have a G6PD deficiency. This risk is low, however, and many physicians will still use it after weighing the risks versus the benefits of its use.9 In addition, nitrofurantoin is not recommended for the treatment of pyelonephritis due to its inadequate tissue penetration. If a pregnant woman presents with acute cystitis, then the infection is generally considered complicated.9 Treatment for acute cystitis in pregnant women is listed in Table 2. Beta-lactams are appropriate and usually work more efficiently when used for more than three days.9
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Enhancing Healthcare Team Outcomes
UTIs are usually managed by the primary care provider, nurse practitioner, and internist. however, not all UTIs are due to gram-negative organisms. In some cases, the organism may be S.Saprophyticus, which can only be identified following culture. While culture is not routine in all patients with a UTI, when the patient fails to improve, one must suspect a different organism and send the urine for culture.
Treatment with outpatient antibiotics is indicated in symptomatic or complicated UTIs and pyelonephritis. It is important to take into consideration specific local resistance patterns when choosing appropriate antibiotic coverage.
Patients who are hemodynamically unstable, have associated kidney injury, abscess formation, or emphysematous pyelonephritis, have failed outpatient treatment, have intractable nausea, vomiting, or pain, are unable to tolerate oral intake, or are unable to comply with medical treatment may require admission. These patients may need IV antibiotics and radiological studies to determine the extent of the infection.
When treated promptly, most patients have good outcomes.
Can Home Remedies Quickly Treat A Uti
As resistance to antibiotics is becoming more common, many people are looking for ways to avoid using them. While this can be a good thing in some cases, it can draw out your illness in other instances.
The most commonly asked about home remedy for UTIs is cranberry. Drinking cranberry juice or taking cranberry tablets has been long-touted as a natural alternative for treating UTIs. The thought is that cranberry makes your urine more acidic which, in turn, kills the bacteria causing your infection.
Unfortunately, cranberry does not treat UTIs very well. On the flip side, though, it can be useful for helping to prevent infections if youre prone to them. This seems to also be the case for other acidic fruits like lemon. Just be sure if youre going to try this for preventing future UTIs that you drink unsweetened juice, as sugar actually helps bacteria to grow.
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Amoxicillin/potassium Clavulanate Cefdinir Or Cephalexin
How it Works: is another combination drug that belongs to the penicillin class of antibiotics. and belong to a different class of antibiotics thats closely related to penicillins.
All three antibiotics kill bacteria by destroying one of its most important components: the cell wall, which normally keeps bacteria structurally intact.
Common doses:
-
Amoxicillin/clavulanate: 500 twice a day for 5 to 7 days
-
Cefdinir: 300 mg twice a day for 5 to 7 days
-
Cephalexin: 250 mg to 500 mg every 6 hours for 7 days
Notable side effects: Diarrhea, nausea, vomiting, and rash are common side effects of these antibiotics. In rare cases, all three have the potential to cause the dangerous skin reactions, SJS and TEN.
If you have a penicillin allergy, your healthcare provider wont prescribe amoxicillin/clavulanate. They may or may not prescribe cefdinir or cephalexin since there is a small chance that a person with a penicillin allergy may also be allergic to these two.
What Is A Urinary Tract Infection
The urinary tract is comprised of the kidneys, ureters, bladder, and urethra . A urinary tract infection is an infection caused by pathogenicorganisms in any of the structures that comprise the urinary tract. However, this is the broad definition of urinary tract infections many authors prefer to use more specific terms that localize the urinary tract infection to the major structural segment involved such as urethritis , cystitis , ureterinfection, and pyelonephritis . Other structures that eventually connect to or share close anatomic proximity to the urinary tract are sometimes included in the discussion of UTIs because they may either cause or be caused by UTIs. Technically, they are not UTIs and will be briefly mentioned in this article.
UTIs are common, leading to between seven and 10 million doctor visits per year . Although some infections go unnoticed, UTIs can cause problems that range from dysuria to organ damage and even death. The kidneys are the active organs that produce about 1.5 quarts of urine per day in adults. They help keep electrolytes and fluids in balance, assist in the removal of waste products , and produce a hormone that aids in the formation of red blood cells. If kidneys are injured or destroyed by infection, these vital functions can be damaged or lost.
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