UTI is a bacterial infection of the urinary tract which encompasses the lower (cystitis) and upper (pyelonephritis) urinary tract. Symptoms of cystitis are dysuria (with frequency lacking or present), urgency, suprapubic pain or hematuria. Further symptoms like fever, chills, flank pain or tenderness indicate pyelonephritis
When a patient walks in claiming symptoms congruent to UTI, the preceptor further assesses by running confirmatory signs that may mean an infection. If the symptoms are non-specific placebo treatment is issued and patients are closely monitored. Otherwise, or if the symptoms manifest, the treatment protocol is initiated. Urinalysis is a first step for elderly patients where presence of pyuria calls for urine culture. Even in normal patients, urine culture is the first step in therapy. Antibiotic treatment is then taken after the results of the culture are back and they are targeted at the specific pathogens. The treatment issued is Nitrofurantoin PO × 5 days during which relief may be experienced after the 3 rd day. If the symptoms persist then the urine culture would have anticipated this and the treatment is then followed up on. If the condition recurs, then treatment with an appropriate microbial is issued.
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Evidence suggests that if a patient complains of symptoms pertaining to UTI, inquiries about the prescriptions they may be taking are first issued. Patients are then asked about symptoms such as dysuria, frequency and urgency, suprapubic pain, flank pain or tenderness or fever. If the symptoms are present and have no identifiable source, then presence of UTI can be confirmed. Once the patient is confirmed to be infected with UTI, the next step is to identify if it is uncomplicated or complicated (Roberts, 2011). This is done by evaluation of complicating factors, since these may increase the likelihood of failure in medication. If the UTI is complicated then urine culture is sent and if uncomplicated, this option is not pursued. Beahm et al. (2017) also notes that, “Clinical diagnosis and limited interpretability of quantitative urine cultures in uncomplicated UTI makes empirical treatment without a culture a reasonable option.”
The issuing of antimicrobial medication is then taken as the next step. The following options are then explored (Beahm et al., 2017):
Nitrofurantoin PO × 5 days
TMP/SMX PO × 3 days
TMP PO × 3 days
Fosfomycin tromethamine PO × 1 dose
Improvements should then be noted within three days of therapy. If the relief is not experienced, then patients should be reassessed for alternative sources of infection, or the nature of the infection and the treatment issued. Care should, however, be taken to avoid some microbial treatment, specifically fluoroquinolones, unless the case is severe (Fahey, 2019). Relapse (recurrence of the same infection within a month) warrants the urine culture to be sent for. If the results show a resistant pathogen, alternative microbial treatment is issued. Alternatively, the presence of a complicated UTI and its solutions are considered (Rowe & Juthani-Mehta, 2014) in the form:
Cefixime PO × 7-10 days
Amoxicillin-clavulanate PO × 7-10 days
TMP/SMX PO × 7-10
The current clinical protocol adheres with the evidence though the first line of action when the infection is identified differs.
The current protocol practices the urine culture regardless of the nature of the UTI. While this is precautionary and caters for complicated and uncomplicated variations, it may be unnecessary. Furthermore, it may lay pressure on the preceptor to treat other infections that may present themselves in the culture. Analysis of the nature of the infection and empirical treatment of UTI should be the first step.
References
Fahey T, e. (2019). Clinical management of urinary tract infection in women: a prospective cohort study. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12509362 [Accessed 2 Jun. 2019].
Beahm, N. P., Nicolle, L. E., Bursey, A., Smyth, D. J., & Tsuyuki, R. T. (2017). The assessment and management of urinary tract infections in adults: Guidelines for pharmacists. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada, 150(5), 298-305.
Rowe, T. A., & Juthani-Mehta, M. (2014). Diagnosis and management of urinary tract infection in older adults. Infectious disease clinics of North America, 28(1), 75.
Roberts, K. B. (2011). Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 128(3), 595-610.
