DRAFT FOR REVIEW: Diagnosis of urinary tract infections (UTIs) Quick reference guide for primary care: For consultation and local adaptation This document is currently being reviewed, and should not be used in isolation. We are seeking comments by 30 May 2018. Email feedback to: [email protected] Questions and responses specific to this consultation may be made public. Diagnosis of urinary tract infections (UTIs) Quick reference guide for primary care - DRAFT 1.7 About Public Health England Public Health England (PHE) exists to protect and improve the nation’s health and wellbeing, and reduce health inequalities. It does this through world-leading science, knowledge and intelligence, advocacy, partnerships, and the delivery of specialist public health services. PHE is an executive agency of the Department of Health, and is a distinct delivery organisation with operational autonomy to advise and support government, local authorities, and the NHS, in a professionally independent manner. Public Health England Wellington House 133-155 Waterloo Road London SE1 8UG Tel: 020 7654 8000 www.gov.uk/phe Twitter: @PHE_uk Facebook: www.facebook.com/PublicHealthEngland Prepared by: Professor Cliodna McNulty For queries relating to this document, please contact [email protected] © Crown copyright 2018 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government License v3.0. To view this license, visit OGL or email [email protected]. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. Any enquiries regarding this publication should be sent to [email protected] Published for external review: May 2018 PHE publications gateway number: 2018087 This document is available in other formats on request. Please call 0300 422 5068 or email [email protected]. 2 Diagnosis of urinary tract infections (UTIs) Quick reference guide for primary care - DRAFT 1.7 Contents About Public Health England 2 Contents 3 Foreword – Aims and adaptations 4 References 10 Women under 65 years with uncomplicated UTI flow chart and table key points 10 Older person (over the age of 65 years) with suspected UTI: 14 Review need for urine culture: 20 Sampling technique in men and women: 21 Interpretation of culture results in adults: 22 Infants or children under 16 years with suspected UTI: 24 Acknowledgements 26 Abbreviations 26 3 Diagnosis of urinary tract infections (UTIs) Quick reference guide for primary care - DRAFT 1.7 Foreword – Aims and adaptations Audience and target group • primary care prescribers in general practice and out of hours settings; including doctors, nurses and pharmacists • those giving first point of contact for urinary tract infections covering acute uncomplicated infections in women, older patients with urinary symptoms, and children • the flow chart for older patients may be suitable for some younger frail patients with or without catheter, especially with those with high incidence of asymptomatic bacteriuria. In contrast some older healthy patients will fit the younger flow chart. Aims • to provide a simple, effective, economical and empirical approach to the diagnosis and treatment of urinary tract infections to minimise the emergence of antibiotic resistance in the community Implications • the guidance should lead to more appropriate antibiotic use • use of this guidance may influence laboratory workload, which may have financial implications for laboratories and primary care commissioners Production • the guidance has been produced in consultation with the Association of Medical Microbiologists, general practitioners, nurses, specialists, and patient representatives • the guidance is in agreement with other publications, including CKS, SIGN and NICE • the guidance is fully referenced and graded • the guidance is not all-encompassing, as it is meant to be ‘quick reference’, clinicians should ultimately rely on their clinical judgement • if more detail is required we suggest referral to the websites and references cited • the guidance will be updated every three years; or more frequently if there are significant developments in the field Poster Presentation of Guidance • the summary table is designed to be printed out as a poster for use in practice • the RATIONALE and evidence is designed to be used as an educational tool for you, and your colleagues and trainees, to share with patients as needed Local Adaptation • we would discourage major changes to the guidance, but the format allows minor changes to suit local service delivery and sampling protocols • to create ownership agreement on the guidance locally, dissemination should be agreed and planned at the local level between primary care clinicians, laboratories and secondary care providers We welcome opinions on the advice given. Please email any evidence or references that support your requests for change so that we may consider them at our annual review. Comments should be submitted to Professor Cliodna McNulty, Head of PHE Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN. Email: [email protected] 4 Diagnosis of urinary tract infections (UTIs) Quick reference guide for primary care - DRAFT 1.7 Woman (under 65 years) with suspected UTI URINARY SYMPTOMS (e.g. dysuria, frequency, urgency) IN ADULT WOMEN under 65 This guide excludes patients with recurrent UTI (2 episodes in last 6 months, or 3 episodes in last 12 months)1D,2D YES Consider other causes of urinary symptoms: □ vaginal symptoms or discharge - only 15-20% with discharge have UTI3A+,4A+ Follow relevant □ urethritis - Urinary symptoms may be due to urethral inflammation post sexual YES diagnostic intercourse, irritants, or can be related to a sexually transmitted infection5C guide and □ sexually transmitted infections - including Chlamydia and gonorrhoea in safety netting sexually active4A+,5C □ genitourinary symptoms of menopause/atrophic vaginitis/vaginal atrophy5C,6D,7B+ NO Consider Upper UTI/pyelonephritis or Any moderate risk of sepsis? (*see box at bottom of page) or if National □ YES possible sepsis: Early Warning Score overall is 5: using respiration, pulse oximetry, blood Consider admission if pressure, pulse, consciousness, temperature required □ Any new sign of pyelonephritis or systemic infection? Send urine for culture. **see box at bottom of page Immediately start antibiotic for upper NO 8B+ UTI/sepsis using local How many of the 3 key diagnostic symptoms/signs do they have? □ dysuria (burning pain when passing urine)3A+,4A+,8B+,9B+,10B+ guidelines □ new nocturia (passing urine more often at night)3A+,8B+ 8B+ Other severe urinary □ urine cloudy to the naked eye 2 or 3 symptoms 1 symptom no symptoms symptoms: urgency3A+,4A+,9B+ YES YES visible haematuria3A+,4A+ frequency 3A+,4A+ YES YES suprapubic tenderness9B+,11B+ Perform Urine Dipstick Test Nitrite positive WBC positive ALL Nitrite, WBC, RBC OR BOTH WBC Nitrite negative8B+ negative8B+ NO and RBC positive8B+ YES YES YES UTI likely UTI equally likely to UTI LESS likely other diagnosis Offer immediate antibiotic for lower UTI Review time of specimen (morning is most reliable) Consider self-care with back- Consider other diagnosis up antibiotic if mild symptoms Send urine for culture Reassure and give self-care that do not interfere with quality Use Immediate or back-up of life and safety netting advice antibiotic depending on symptom Consider need for urine culture severity Give and discuss TARGET UTI leaflet with safety netting advice Offer ALL self-care advice: e.g. hydration, taking regular paracetamol (or ibuprofen, if with back-up antibiotic)12C,13D,14D,15B+ * Signs/symptoms of moderate risk of sepsis16C,17A,18C: **Signs of pyelonephritis or systemic □ new alteration in mental state or decreased functional ability infection19C: □ new heart rate above 90 beats/min at rest or dysthymia □ kidney pain/tenderness in back under ribs □ new dyspnoea or respiratory rate above 20 breaths/min □ new/different myalgia, flu like illness □ new low blood pressure (systolic <100mm Hg) □ shaking chills (rigors) or temperature 38°C or □ no urine passed in 12 hours (<0.5-1ml/kg urine per hour if catheter) above tympanic temperature 36°C or below nausea/vomiting □ □ impaired immune system (except if chemotherapy) □ Key: Sepsis alert UTI symptoms Action Advised Other advice 5 Diagnosis of urinary tract infections (UTIs) Quick reference guide for primary care - DRAFT 1.7 Older person (Over 65 years) with suspected UTI Use symptoms/signs to guide management. Do not perform urine dipstick: not recommended if over 65 years. Up to half of older adults will have bacteria present in the bladder/urine (asymptomatic bacteriuria) and 1A-,2A-,3B+,4B+ positive dipstick without an infection. This is not harmful and does not require treatment with antibiotics. CHECK FOR ANY SYMPTOMS/SIGNS: □ localised symptoms or signs of UTI e.g. new onset dysuria; incontinence; urgency5B+ □ temperature: 38°C or above; 36°C or below; 1.5°C above normal twice in the last 12 hours6A-,7D,8B+ NO □ non-specific signs of infection: e.g. increased confusion; loss of diabetic control6A-,7D,9B-,10A+ YES CHECK for moderate risk of sepsis (below) or if National Early Warning Score overall is 5: using respiration, pulse 11C oximetry, blood pressure, pulse, consciousness, temperature 11C Consider pyelonephritis or □ acute deterioration 13C,14D