The assessment and management of urinary tract infections in adults: Guidelines for pharmacists

• Published in: Canadian pharmacists journal Vol. 150; no. 5; pp. 298 - 305
• Main Authors: Beahm, Nathan P., Nicolle, Lindsay E., Bursey, Alistair, Smyth, Daniel J., Tsuyuki, Ross T.
• Format: Journal Article
• Language: English
• Published: Los Angeles, CA SAGE Publications 01.09.2017; SAGE PUBLICATIONS, INC
• Subjects: Ambulatory care; Antibiotics; Antimicrobial agents; Bacterial infections; Berries; Catheters; Clinical medicine; Drug resistance; Infectious diseases; Long term health care; Pain; Pathogens; Patients; Pharmacists; Research and Clinical; Surveillance; Urinary tract diseases; Urinary tract infections; Urine; Urogenital system
• ISSN: 1715-1635; 1913-701X
• DOI: 10.1177/1715163517723036

[4],[14],[17] Table 1 Criteria for symptomatic UTI in elderly patients with comorbidities Noncatheterized Catheterized Minimum criteria include 1 of the following:* Acute dysuria or acute pain, swelling or tenderness of testes, epididymis or prostateOR* Fever (≥38°C or increase of at least 1.1°C above baseline), rigors or leukocytosis and at least 1 of the following symptoms (see below)OR* At least 2 of the following symptoms :* New or increased frequency* New or increased urgency* New or increased incontinence* Suprapubic pain* Acute flank pain or tenderness* Gross hematuria Minimum criteria include no alternative diagnosis AND 1 of the following:* Fever (≥38°C or 1.1°C above baseline), rigors or new-onset hypotension* Leukocytosis and either an acute change in mental status or acute functional decline* New-onset flank or suprapubic pain or tenderness* Purulent discharge from catheter site* Acute pain, swelling or tenderness of testes, epididymis or prostate In women with dysuria, if there is also vaginal discharge or odour, pruritis, painful intercourse, and no urinary frequency or urgency, vaginitis becomes more likely than UTI. Box 1 Examples of complicating factors[2],[11],[19] Male sex Chronic obstruction Nephrolithiasis Poorly controlled diabetes Indwelling urinary catheter Indwelling urinary stent or nephrostomy tube Chronic renal insufficiency Pregnancy Immunosuppression (e.g., chronic high-dose corticosteroid use, use of other immunosuppressives, neutropenia, etc.) Instances where patients should be referred for physician assessment include likely upper UTI (pyelonephritis), patients who appear systemically unwell or septic, suspicion of obstruction requiring urologic investigation, patients with a history of recurrent UTI and an increase in the frequency or severity of symptoms, pregnancy, recent urologic intervention or surgery, or if other aspects of the patient's presentation are felt to be beyond the ability of the individual pharmacist to assess. [1],[11] Table 2 Recommended first-line empiric treatment of urinary tract infection Uncomplicated[*] Complicated, nonsevere Severe/septic/pyelonephritis[[dagger]] * Nitrofurantoin PO × 5 days* TMP/SMX PO × 3 days* TMP PO × 3 days* Fosfomycin tromethamine PO × 1 dose * Cefixime PO × 7-10 days* Amoxicillin-clavulanate PO × 7-10 days* TMP/SMX PO × 7-10 days* Fluoroquinolones[[Dagger]] PO × 7-10 days * Ceftriaxone IV ± ampicillin IV* Gentamicin IV ± ampicillin IVIf clinically appropriate, may step down to PO therapy to complete 7-14 day course PO, orally; TMP, trimethoprim; SMX, sulfamethoxazole; IV, intravenously. * Longer durations should be considered if relapse (recurrent infection within 4 weeks of treatment completion). [dagger] The decision of which antibiotic to use should always be based on knowledge of local antimicrobial resistance of Escherichia coli or other gram-negative organisms [Dagger] Resistance to fluoroquinolones is increasing and has reached unacceptable levels in some regions. 13, Hooton, TM, Bradley, SF, Cardenas, DD, et al, Diagnosis, prevention and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America, Clin Infect Dis, 2010, ;50, 625-63.