1. Urinary Tract Infection in
Adults
Linda Nazarko
Nurse consultant

2. Aims and objectives
To be aware of:
 How urinary tract infection is diagnosed
 How urinary tract infection should be
diagnosed
 Hazards inappropriate diagnosis and
treatment
 Clinical features of UTI
 Treatment considerations

3. Diagnosis
 87, female,
 Attends A&E
 Fall, confused
 Smells of urine
 Urine shows blood,
protein, leukocyte
 Does the patient have a
UTI?

4. Dipstick testing
 Twenty percent false negatives
 Dipstick not diagnostic UTI
 Diagnosis based on clinical features
 Bacteriuria common as people age –
17-40 percent older people

5. Specimens for C&S
 Poor collection
technique not mid
stream, rung out of
pads, taken from
commodes, and
catheter bags.
 Poor handling,
cooking in the ward
or care home,
inadequately filled

6. Diagnosis
 Pyrexia
 Raised white cell
count
 Raised CRP
 Does the patient
have a UTI?

7. What is a UTI?
 “Bacterial growth
105 colony forming
units/ml in a clean
voided midstream
urine specimen”.
(Kontiokari et al,
2001).

8. Bacterial causes UTI
Causative Bacteria Percentage UTIs
E coli 66.6
E cloacae 2.8
E faecalis 5.9
K oxytoca 1.8
K pneumoniae 5.9
P aeruginosa 3.1
P mirabilis 4.3
Other pathogens 9.7

9. HPA guidance
Do not send routine urine cultures
Only send urine for culture if two or more signs of
infection, especially dysuria, fever > 38 or new
incontinence.
Do not treat asymptomatic bacteriuria in the elderly
as it is very common.
Treating does not reduce mortality or prevent
symptomatic episodes, but increases side effects &
antibiotic resistance.

10. Types of UTI
 Asymptomatic
 Symptomatic
 Complicated
 Uncomplicated
These need to be treated differently

11. Evidence based practice
 Evidence and evidence based guidance identify four
groups of patients:
1. Adult women (non pregnant)
2. Adult men
3. Older adults
4. Adults with indwelling urinary catheters
All guidance relating to treating suspected infection in
adults (other than pregnant women) emphasises
the importance of treating symptomatic urinary
tract infections and not diagnosing solely on the
basis of urinalysis.

12. Clinical features UTI
 Frequency
 Urgency
 Dysuria
 Pain, pressure or tenderness in the area of the
bladder or in the side or mid to upper back
 Urine cloudy, foul strong
 Fever
 Nausea and vomiting
 Nocturia — awakening from sleep to pass urine
 Onset of enuresis

14. Adult women
(Women under 65)
 Severe symptoms – may be px antibiotics solely on the
basis of clinical symptoms (HPA, 2011) but around half of these
symptoms are caused by urethritis (Brumfitt et al, 1991).
Consider alternative diagnosis such as Chlamydia trachomatis .
Consider gonorrhoea in adults who complain of very severe
dysuria. Check for a green, pussy discharge. STDs are not just
for the young. The biggest increase is in the over 50’s (Hope,
2008).
 Mild symptoms treat if urinalysis further suggests
infection.
 Equivocal give advice on symptom management rather than
an antibiotic.
Urine cultures should not be sent routinely in adult women (HPA,
2011: Carr, 2006: SIGN, 2006: CKS, 2010a: Bent et al, 2002).
Normally three days antibiotic treatment is prescribed in adult
women.

15. Adult women
(Women under 65)
Urine cultures should not be sent routinely (HPA, 2011:
Carr, 2006: SIGN, 2006: CKS, 2010a: Bent et al, 2002).
Normally three days antibiotic treatment is
prescribed.

16. Adult men
(Men under 65)
 Lower risk of urinary tract infection because urethral length and voiding
differences reduce the risk of contamination with e coli . Men pass urine
standing up and shake dry. Women pass urine sitting down and wipe dry. Less
than 1% of young men (those aged under 65) develop urinary tract infections
but 10% of older men develop UTIs (Wallach, 2001).
 Urinary tract infections in men should be viewed as complicated because they
occur because of anatomical or functional problems or because of
instrumentation SIGN (2006). Grabe et al (2009) state that simple urinary tract
infections are rare in men under the age of 50. They recommend that such men
should receive a minim of seven days antibiotic therapy. They point out that
most men with febrile UTI also have an infection of the prostate. They
recommend that Urological evaluation should be carried out routinely in adult
men with febrile UTI, pyelonephritis, recurrent infections, or whenever a
complicating factor is suspected.
 All experts agree that urine cultures should be sent routinely in adult men
(Grabe et al, 2009: CKS, 2010b, SIGN, 2006; HPA, 2011).
 Normally 7-10 days antibiotic treatment is prescribed in adult men.

17. Adult men
(Men under 65)
 UTI rare under 50 consider alternative
diagnosis e.g. Chlamydia trachomatis,
gonorrhoea, Reiter’s syndrome.
 Send cultures in all cases
 Treat 7-10 days if diagnosed
 Urological evaluation those febrile UTI,
pyelonephritis, recurrent infections, or
whenever a complicating factor is
suspected

18. Older adults
(Over 65)
Over diagnosed and over treated in older people
 UTI should be diagnosed on the basis of a full clinical assessment,
including checking clinical symptoms, temperature, pulse and blood
pressure (SIGN, 2006: McMurdo and Gillespie, 2000).
 Don’t rely on dipstick and C&S – 46% samples contaminated (Gazzani et
al,2001)
 One symptom + bacteriuria = 50-80% correct DX
 Dysuria and frequency + bacteriuria = 90% correct DX (Bent et al,
2002).
 Asymptomatic bacteriuria – 17-40% of woman 75+ years (SIGN,2006: Beyer
et al, 2001).
 Older women who have bacteriuria in the absence of clinical features of
 a urinary tract infection do not require antibiotic therapy (Brocklehurst et al,
1997; Beyer et al, 2001; SIGN, 2006; Juthani-Mehta, 2007: HPA, 2011).

19. Catheter associated urinary tract infection
 One million urinary catheters inserted annually in NHS hospitals (Nazarko, 2010)
 Twenty percent of HAI are urinary tract infections, eighty percent of
these are associated with urinary catheters. CAUTI and UTI can lead to
life-threatening bacteraemia (National Audit Office, 2009).
 Portal entry Bacteria colonise bladder within seven days in hospital and
thirty days in community
 Bacteriuria can be misdiagnosed as CAUTI and inappropriately treated

20. Preventing catheter associated
UTI

21. Risks inappropriate prescribing
 C. difficile
 Antibiotic resistance
 Adverse effects,
allergy, diarrhoea,
thrush
 Missing the real
problem

22. Clostridium difficile & antibiotics
High risk antibiotics for CDI
Second-generation cephalosporins e.g. cefaclor, cefuroxime
Third-generation cephalosporins e.g. cefixime, cefotaxime, ceftazidime, ceftriaxone
Clindamycin
Quinolones e.g. ciprofloxacin, levofloxacin, ofloxacin, norfloxacin
Intermediate risk antibiotics for CDI
Macrolides e.g. erythromycin, clarithromycin
Aminopenicillins* e.g. co-amoxiclav, amoxicillin, ampicillin
* risk increases with prolonged courses
Low risk antibiotics for CDI
Trimethoprim
Tetracyclines e.g. tetracycline, oxytetracycline, doxycycline, minocycline
Benzylpenicillin / Phenoxymethylpenicillin
Aminoglycosides e.g. gentamicin
Vancomycin
Piperacillin with tazobactam

23. Antibiotic Stewardship
 Every antibiotic expected by a patient,
every unnecessary prescription written
by a doctor, every uncompleted course
of antibiotics, and every inappropriate
or unnecessary use in animals or
agriculture is potentially signing a death
warrant for a future patient.”
 (Donaldson, 2008)

24. Antibiotic Resistance
0
10
20
30
40
50
60
70
Coamoxiclav Ampicillin Cefalexin Cefpodoxime Ciprofloxacin Gentamycin Nitrofurantoin Trimethoprim
Community Hospital

25. Diagnosis
 87, female,
 Attends A&E
 Fall, confused
 Smells of urine
 Urine shows blood,
protein, leukocyte
 Does the patient have a
UTI?

26. Diagnosis
 Pyrexia
 Raised white cell
count
 Raised CRP
 Does the patient
have a UTI?

27. Red herrings
 If pyrexia, raised WCC & CRP what
else could it be?
 Are symptoms new?
 Is confusion “usual”
 Is UTI the easiest diagnosis to
make?

28. Treatment considerations
 Treatment failure – resistance, non
compliance, wrong diagnosis
 Predisposing causes- retention, diabetes
 Prevention- hygiene, undiagnosed
diabetic
 Cranberry juice (not with Warfarin)
 Fluids

29. Final tips
 UTI is over diagnosed and over treated
 Inappropriate diagnosis and treatment causes
harm and increases antibiotic resistance
 Antibiotics don’t work if the patient doesn’t
take them
 Resistance increasingly common
 Consider DX problems, resistance and
underlying causes if treatment failure

30. Thank you for listening
Any questions?

31. References (1)
Bent S, Nallamothu B. K, Simel DL, Fihn SD Saint S (2002) Does This Woman Have an Acute
Uncomplicated Urinary Tract Infection? JAMA: 287:2701-2710.
Beyer I, Mergam A, Benoit F, Theunissen C, Pepersack T (2001) Management of urinary tract
infections in the elderly. Z Gerontol Geriatr 34:2: 153–157
Brocklehurst JC, Bee P, Jones D, Palmer MK (1997) Bacteriuria in geriatric hospital patients: its
correlates and management. Age Ageing 6:4: 240–245
Brumfitt W, Hamilton-Miller JM, Gillespie WA (1991). The mysterious urethral syndrome.
Editorial. BMJ 303:6793:1-2.
Carr J (2006) . Urinary tract infections in women: diagnosis and management in primary care.
BMJ; 332: 94-97.
Clinical Knowledge Summaries (CKS) (2010a). Urinary tract infection (lower) – women.
Management http://www.cks.nhs.uk/urinary_tract_infection_lower_women
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http://www.cks.nhs.uk/urinary_tract_infection_lower_men/management/quick_answers/scenari
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32. References (2)
Hope J (2008). Experts blame high divorce rates for increase of sexually transmitted diseases
among over-50s. Daily Mail.
http://www.dailymail.co.uk/health/article-561326/Experts-blame-high-divorce-rates-increase-
sexually-transmitted-diseases-50s.html#ixzz1ZePmitt5
Juthani-Mehta M (2007) Asymptomatic bacteriuria and urinary tract infection in older adults. Clin
Geriatr Med 23(3): 585–94, vii
McMurdo ME, Gillespie ND (2000) Urinary tract infection in old age: over-diagnosed and over-
treated. Age Ageing: 29:4: 297–298
National Audit Office (2009) Reducing Healthcare Associated Infections in Hospitals in England
(Page four) The Stationery Office. London
http://www.nao.org.uk/publications/0809/reducing_healthcare_associated.aspx
Nazarko L (2010). Effective evidence based catheter management: an update. British Journal of
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http://www.internurse.com/cgi-
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Scottish Intercollegiate Guidelines Network (SIGN)(2006). Management of suspected bacterial
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Wallach, F.R. (2001) Infectious disease. Update on treatment of pneumonia, influenza, and
urinary tract infections. Geriatrics 56, 43-47.