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International Primary Care Association

Treat Well, Treat Safe - A guide to optimising the treatment of Urinary Tract Infections in Adults

Abstract

Urinary tract infections (UTIs) are one of the commonest infections encountered in general practice .One in three women will have a UTI by the age of 24 years and one in two will be treated for a symptomatic UTI in their life time.

The antimicrobial management of these infections is so crucial in determining not only individual outcomes of adults with UTIs but also whether resistant organisms will emerge or not and, therefore be more difficult to treat in subsequent infections. Furthermore, there is a wider dimension of potential spread of such resistant organisms whether in the community or hospital setting. Indeed these resistant, including multi-antimicrobial resistant, organisms are common causes of healthcare associated infections not only in the form of UTIs but as other types of infections. As the title suggests clinicians need to ensure that the use of antimicrobials is mindful of the collateral damage incurred and harm to patients in general practice and the hospital setting.

There are different types of UTIs and therefore the way they are managed vary. The good practice approach is to rely heavily on the clinical side and make a working diagnosis and then decide whether a urine sample needs to be obtained for dipstick testing, when appropriate, followed by culture and sensitivity.

Traditionally the cut-off diagnosis of a UTI was the presence of significant growth of bacteria in urine i.e. more than 100,000 bacteria per ml of urine, and this was the gold standard whether to treat or not. The current practice has changed in terms of not necessarily treating a significant bacteriuria unless the symptoms are significant enough and causing suffering to the patient. However, in the absence of symptoms treatment would still be warranted if there is a urological abnormality, renal impairment, or immunosuppression.

In pregnancy asymptomatic bacteriuria should be treated because of the 20-40% risk of progressing towards a UTI subsequently. In recurrent UTIs treatment is the same as other UTIs except that referral should be considered and actions taken to prevent further infections including the use of least broad-spectrum long-term antimicrobial prophylaxis. With indwelling catheters, the risk of UTIs is higher and best management is to avoid them when possible or resort to self-catheterisation. Once in place, a gold standard aseptic technique should be followed. Antimicrobials should only be used in the presence of clinical symptoms, renal abnormality or immunosuppression. Change of catheter should also be considered when in place longer than seven days and in the presence of a genuine UTI and not only bacteriuria.

It is imperative that the Microbiology request form is fully completed in addition to checking for previous microbiology culture results and their sensitivity patterns as this will guide to more appropriate antimicrobial prescribing. Equally important is looking for previous colonization or infection with an alert organism such as MRSA (Methicillin Resistant Staphylococcus Aureus), ESBL (Extended Spectrum Beta Lactamase) or C.diff. This will guide the choice of an antimicrobial with the least collateral damaging effect.

Therefore, the most appropriate antimicrobials to be used are those with the least broad-spectrum activity. The choice of antimicrobials should also be based on current or recent microbiological evidence including sensitivity to infective agents and duration should usually be short i.e. 3 days and only longer when indicated.

The Hippocratic Corpus is reiterated: “First do no harm”.

Additional Info

  • Authors: W Al-Wali, YM Pang & C Hughes
  • Keywords: Urinary Tract Infections; Antimicrobials; Urinary Catheters; Recurrent UTI; Antimicrobial Resistance; Collateral Damage
  • Login: Please login to view Full Text of the article
Read 14302 times Last modified on Tuesday, 25 October 2016 17:35

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