Case Study 4 – Answers

Answers – Uncomplicated Urinary Tract infection in community pharmacy

 
A) Initial working diagnosis and differentials:

Uncomplicated urinary tract infection: Uncomplicated lower urinary tract infection (UTI) is a bacterial infection (cystitis) occurring in an otherwise healthy individual with no comorbidities, and with no anatomical or functional abnormalities of the urinary tract. It is usually self-limiting.

  • DDx: bacterial vaginosis, vaginitis, overactive bladder, sexually transmitted infection (STI).
    • Vaginal discharge: 80% do not have a UTI, treat OTC if signs and symptoms of thrush.
    • Check sexual history to exclude STIs which warrants referral to GP.
  • Diagnostic criteria of note:
    • Screen for: Dysuria (discomfort, pain, burning, tingling, or stinging during urination), New Nocturia (urinating at night) and Cloudy Urine.
      • Ask patient is the pain external (more associated with vaginitis or STIs) or internal (more associated with UTI) when urinating.
      • Ask if there is new onset incontinence (suggestive of pelvic floor dysfunction)
      • Ask is there is suprapubic pain or tenderness (pain over or near the bladder, more associated with cystitis).
      • Ask is the urine red or brown stained – could be blood – refer to GP.
      • Ask if any UTIs in the last 6 or 12 months.
    • If any one of these present, screen for other symptoms and follow the Pharmacy First Clinical pathway. And the TARGET-UTI leaflet.
    • As this patient also has frequency, a UTI is ‘equally likely to other diagnosis’.

 
RED FLAG symptoms: the following are screened by questions in the pharmacy to rule out any complications or need for medical referral:

  • Fever or chills – suggestive of systemic issue e.g. complicated UTI, acute pyelonephritis, urosepsis
  • Flank or back pain – suggestive of complicated UTI or acute pyelonephritis
  • Nausea/vomiting – suggestive of acute pyelonephritis
  • Haematuria
  • Ensure not pregnant – ask about missed or lighter periods, conduct pregnancy test if unsure.
  • Recurrent UTI history
  • Immunosuppression: is the patient taking any immunosuppressive medications or have a medical history of same.

If any of the above are positive, referral to the GP or Sexual Health Clinic or other provider is needed as appropriate.
As none of the above are present, management in the community setting is appropriate.

 
B) Further Investigations: these could be considered in the GP clinic, not common in pharmacy practice.

  • MSU for culture & susceptibilities would be useful to ascertain potential causative bacteria. But usually MSU reserved for cases where UTI does not respond to antimicrobial treatment so not recommended as an initial step in this case.
  • Dipstick urinalysis may be useful as an aid to diagnosis when a UTI is suspected, based on the presenting signs and symptoms. To reduce false negative results, urine should be retained in the bladder for at least four hours before carrying out dipstick urinanlysis. Interpretation in females <65 years old:
    • Nitrite positive OR leukocyte PLUS red blood cells positive: UTI likely.
    • Leukocyte positive but nitrite negative: UTI equally likely to other diagnosis.
    • All nitrite, leukocyte and blood negative: UTI less likely.

 
C) Management plan:

  • Check with patient what their concerns and expectations are regarding treatment.
  • As per TARGET: Treat Your Infection – Urinary Tract Infection leaflet:
  • Patient has none or only one of dysuria, new nocturia, cloudy urine; AND/OR vaginal discharge so UTI is much less likely, she may need a urine test to check for a UTI, antibiotics are less likely to help, usually lasts 5-7 days.
  • “Wait and see” approach should be adopted for 48 hours for individuals is presenting with new onset of one or two of dysuria, frequency, urgency AND Absence of symptoms of systemic and/or upper urinary tract infection AND Absence of new onset or significant change in vaginal discharge
  • In view of this, recommended care is pain-relief and the symptoms may self-resolve.
    • Adequate hydration with water.
    • Avoid alcohol, caffeine, fizzy drinks that can irritate your bladder.
    • Take paracetamol or ibuprofen at regular intervals for pain relief.
    • A hot water bottle may provide relief.
    • There is not enough evidence to support the use of probiotics currently, but may be useful and present no harm.
    • Cranberry products or cystitis sachets may provide symptomatic relief, however there is no evidence currently to support this.
    • Avoid sexual intercourse which may exacerbate symptoms.

 
D) Counselling

  • Advises patient that this UTI may get better on its own without the need for antibiotics.
  • Explains that antibiotics are not always needed for uncomplicated UTIs and that antibiotics can cause harm e.g. affect our gut bacteria, increase our risk of antibiotic resistance and thrush, and may make future UTIs more difficult to treat.
  • Explains as she has no serious symptoms or background issues that warrant medical review, that watch and wait is appropriate along with supportive management as outlined above.
  • Explore any triggers or risk factors for UTI with the patient e.g. sexual activity or intercourse, dehydration, use of products (creams, lotions, gels, shampoos) in the genital area and to identify steps for future prevention.

Safety-netting:

  • Take the time to carefully explain to the patient that if her symptoms have not resolved or get worse within 48-hours she should visit her GP.
  • Explains that if she has any signs or symptoms of serious infection, she should go to her GP or seek medical attention:
    • Shivering, chills, muscle pain
    • Confusion or drowsy
    • Not passing urine all day
    • Vomiting
    • See blood in your urine
    • Temperature >38°C or <36.5°C
    • Kidney pain in your back just under your ribs
    • Symptoms get worse

Use of the TARGET Treat your Infection UTI leaflet in the consultation can support effective communication.

 
Marking pointers (what an excellent answer shows)

  • Conducts a thorough background history and presenting complaint check, including red flag issues, to ascertain all signs and symptoms to enable an accurate diagnosis.
  • Recognises not all uncomplicated UTIs require antimicrobial treatment, able to screen the presenting signs and symptoms in line with the evidence-based guidelines to guide this decision making.
  • Addresses supportive care and safety-netting.
  • Addresses antimicrobial stewardship and takes the time to explain to the patient that antibiotics are not always needed for UTIs.

 
Uncomplicated UTI – common pitfalls

1. Not conducting a detailed questioning and check of relevant signs, symptoms and red flag symptoms.
2. Jumps to recommending a short-course antimicrobial treatment as the first step in management. As per the TARGET-UTI guidance, this patient does not require antimicrobials at this time.
3. Not providing adequate supportive care and recommendations to relieve symptoms.
4. Insufficient safety-netting

  • Not outlining about what signs and symptoms to monitor in case infection does not self-resolve or in the event she deteriorates.
  • Not providing a timeframe within which she should see an improvement.