Consultations for UTIs can be the easiest or the most difficult, depending on the circumstances.
A straightforward uncomplicated lower UTI in a healthy woman who is not pregnant requires a three-day course of antibiotics.1,2
However, an upper UTI in a pregnant, immunosuppressed woman with diabetes may require the patient to be hospitalised. How do you decide in three minutes?
Only follow up women who are still symptomatic two days into treatment. Consider:2,4,14
Lower UTIs in adult women
Fifteen per cent of women experience a lower UTI or cystitis. In young, sexually active women, the odds of acute cystitis are increased by a factor of 60 in the first 48 hours after sex.
In these consultations, a holistic GP will also discuss contraception and safe sex, and will consider the possibility of STIs (either mimicking the urgency and frequency of a UTI, or both infections coexisting).
If this type of patient presents with more than three sex-related UTIs in a year, you can consider giving her antibiotics to take as a one-off postcoital dose.
Diagnosing a UTI
The diagnosis is essentially clinical: dysuria, frequency, suprapubic tenderness and possibly haematuria.
Patients often feel systemically unwell, with myalgia and chills. For patients with two or more acute symptoms who are otherwise fit and well, there is more than a 90% chance of the diagnosis being a UTI.2 Turbidity of urine has a sensitivity of 90%.2
Dipstick tests can be used if there are mild or only one or two symptoms: nitrite, or both leucocytes and blood, is moderately sensitive (77%) and specific (70%), with a positive predictive value of 81% and a negative predictive value of 65%.3
An MSU should be exactly what it says: midstream. Yet how many of us really explain to women how to proceed in order to collect a bit of the middle of the urine stream? Contact with perineal skin, or leaving the pot in the treatment room laboratory fridge overnight, hopelessly contaminates most MSUs. Fortunately, they are only required in relapse or reinfection.
UTIs are the second most common clinical indication for empirical antimicrobial treatment in primary and secondary care,4 accounting for 1-3% of all GP consultations a year.5
GPs are constantly reminded to avoid broad-spectrum antibiotics (co-amoxiclav, quinolones and cephalosporins) because they increase the risk of Clostridium difficile infection, MRSA and resistant UTIs.6
The Health Protection Agency suggests prescribing a three-day course of a narrow-spectrum antibiotic, trimethoprim or nitrofurantoin.1 There are regional variations across the UK for Escherichia coli bacterial resistance for trimethoprim, of about 25-39%.7-9 In Oxfordshire, nitrofurantoin has become the preferred first-line treatment, because the resistance is much lower, at 5-11%.7-9
Most regional bacteriology laboratories publish recent data on their websites that show local MSU resistance rates to different antibiotics. This is not a true reflection of general practice, because only the non-responders have MSUs sent to the laboratory, but it is a helpful indicator to CCG formulary guidelines.
Although trimethoprim is cheaper than nitrofurantoin, so is often first-line on formularies, the cost of treating an uncomplicated UTI is mostly in GP consultation time (£25-£31 per consultation), with only 13% being the drug cost.
If the resistance rate for nitrofurantoin is only 5%, versus 30% for trimethoprim, the overall cost- effective treatment is nitrofurantoin, both for making more women better quicker, and for requiring fewer repeat consultations.10
Particular care should be taken when prescribing nitrofurantoin to elderly patients, who may be at increased risk of toxicity.11 Do not treat non-pregnant women (of any age) with asymptomatic bacteriuria with an antibiotic.2
UTIs in other patients
NICE has developed guidelines for UTIs in men.12 If they have symptoms of an upper UTI, fail to respond to appropriate antibiotics or have recurrent UTIs, they should have a urological referral. In men with symptoms suggestive of prostatitis, unlike other bacterial UTIs, they should be treated empirically with a quinolone.
Only in pregnancy is asymptomatic bacteriuria treated, for seven days and with an MSU before and after treatment.
Trimethoprim should not be given if pregnancy is certain or a possibility, because it is contraindicated in the first trimester due to the teratogenic risk.2
Nitrofurantoin is the treatment of choice in all pregnant or potentially pregnant women, except those at term, when there is a possibility of neonatal haemolysis.2 Nitrofurantoin should be prescribed only when the benefit outweighs the risk.
Local vaginal estrogens may offer a useful treatment option for postmenopausal women who experience recurrent UTIs.13
- Dr Hope is a GP in Woodstock, Oxfordshire, and an honorary research fellow in women's health at the University of Oxford
1. Health Protection Agency, British Infection Association. Management of infection guidance for primary care for consultation & local adaptation. London, HPA, 2013.
2. SIGN. Management of suspected bacterial urinary tract infection in adults. SIGN 88. Edinburgh, SIGN, 2012. Available from www.sign.ac.uk/pdf/sign88.pdf
3. Little P, Turner S, Rumsby K. Developing clinical rules to predict urinary tract infection in primary care settings: sensitivity and specificity of near patient tests (dipsticks) and clinical scores. Br J Gen Pract 2006; 56(529): 606-12.
4. Car J. Urinary tract infections in women: diagnosis and management in primary care. BMJ 2006; 332: 94-7.
5. NICE. Clinical Knowledge Summaries. Urinary tract infection (lower) – women. London, NICE, November 2013. cks.nice.org.uk/urinary-tract-infection-lower-women
6. Scottish Antimicrobial Prescribing Group. Good practice recommendations for hospital antimicrobial stewardship in NHS Scotland. Edinburgh, SAPG, 2012.
7. Bean DC, Krahe D, Wareham DW. Antimicrobial resistance in community and nosocomial Escherichia coli urinary tract isolates, London 2005-2006. Ann Clin Microbiol Antimicrob 2008; 7: 13.
8. Healthcare Protection Agency. Trends in antimicrobial resistance in England and Wales: 2004-2005. London, HPA, 2006.
9. McNulty CA, Richards J, Livermore DM et al. Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care. J Antimicrob Chemother 2006; 58: 1000-8.
10. Curtis L. Unit costs of health and social care. Canterbury, University of Kent, 2011. www.pssru.ac.uk/archive/pdf/uc/uc2011/uc2011.pdf
11. Macrobid capsules 100mg BP SPC. December 2012.
12. NICE. The management of lower urinary tract symptoms in men. CG97. London, NICE, May 2010.
13. Perrotta C, Aznar M, Mejia R et al. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008, Issue 2. Art No: CD005131.
14. NICE. The management of urinary incontinence in women. CG171. London, NICE, September 2013.