NOVEMBER 2013 • PHARMACY PRACTICE • 17

Managing urinary tract infections in the community

pharmacy setting

renal flow obstruction, patients may also Classification decision to start empirical treatment:
By Ernieda Md Hatah experience nausea and vomiting. Although Although there are many ways to catego- • Visual examination of the appearance of
Faculty of Pharmacy patients with UTI usually present with rize UTI, the commonly used classification the urine sample
Universiti Kebangsaan Malaysia symptoms, not all patients with UTI are is uncomplicated and complicated UTI. • Microscopy
symptomatic. Uncomplicated UTI is UTI that occurs in pa- • Testing with a dipstick6
tients with no known susceptible risk factors
Prevalence and risk factors that make them more prone to UTI such as Urine turbidity is reported to have a low
Earn UTI is a common diagnosis in women and the presence of foreign bodies or anatomic specificity (66.4%), but high sensitivity
1 CPD point its treatment incurs a substantial cost. It abnormalities. The term is also used to de- (90.4%) for predicting symptomatic bacte-
every month was estimated that more than US$218 mil- scribe simple urinary tract infections, for ex- riuria.6 A turbid sample can be positive for
lion was spent in 1995 for prescription med- ample, in cases where the infection occurs bacteriuria and a clear sample can be nega-
ications to treat UTIs in the US. Although only in the bladder (cystitis). Complicated tive for bacteriuria. The visual appearance

U
rinary tract infections (UTI) are re- UTIs occur in both females and males of all UTI includes more serious infections that test, however, is prone to observer error and
ported to be the most common ages, women have higher prevalence than are associated with the presence of foreign may not be a useful discriminator.6 Although
reason for women to visit their men. Approximately 50% of all women will bodies or anatomic abnormalities. urine microscopy can predict significant
healthcare professionals. The urinary tract, experience at least one episode of symp- bacteriuria, there are concerns about health
the body’s system that produces, stores tomatic UTI during their lifetime4 with many Diagnosis and safety at work, maintenance of equip-
and eliminates urine, is made up of the kid- having episodes of recurrent infection.5 Fe- UTI can be diagnosed on the basis of clini- ment and training of staff that does not jus-
neys, ureters, bladder and urethra. males have higher chances of getting UTI cal signs and symptoms, in combination tify its use at point of consultation.6
Infection can occur in any part of the than males due to several factors, such as with urinalysis. UTI is described where there The dipstick test (reagent strip test) is
urinary tract, including the kidney (pyelo- anatomic differences i.e. women have short is presence of bacteria in the urine or ‘bacte- usually used to guide treatment in women
nephritis) or the bladder (cystitis). In seri- and straight anatomy of the urethra, and riuria’.3 A urinalysis that reveals both bacte- with mild or less than two UTI symptoms,
ous cases, bacteria from the lower part of hormonal effects. The difference in anat- riuria and pyuria (occurrence of ≥104 white whose prior probability of UTI is in the inter-
the tract, such as urethra and bladder, can omy causes retrograde ascent of bacteria blood cells (WBC)/ml in a freshly voided mediate range (50%). There are at least four
travel up to the kidneys and cause pyelo- from the perineum, and this is the common specimen of urine) is considered a clinical categories of dipstick tests: testing for nitrite
nephritis. UTI is associated with significant cause of cystitis in females.1 Changes in diagnosis of UTI. Traditionally, confirmatory only; testing for leucocyte esterase (LE)
morbidity and even mortality. The bother- hormone levels, for example lack of estro- cultures have been obtained to verify the in- only; disjunctive pairing (dipstick positive if
some urinary symptoms may cause pa- gen in post-menopausal women, also in- fection and identify the specific organism(s) either nitrite or LE or both are positive); and
tients to be absent from work and decrease crease their risk for UTI.1 Genetic factors, involved, however this practice is evolving. conjunctive pairing (dipstick positive only if
their ability to engage in activities of daily including expression of HLA-A3 and Lewis There is no absolute gold-standard bac- both nitrite and LE are positive). Of all the
living. In complicated UTI, the disease may blood group Le(a-b-) or Le(a+b-), may terial count for diagnosis of UTI. If a culture categories, the disjunctive pair test is signifi-
lead to urosepsis and death. also put women at higher risk for recurrent is obtained, the presence of at least 105 cantly more accurate than the LE test alone
Symptoms of UTI usually depend on UTI (diagnosed when patients have more colony-forming-units (cfu)/ml in freshly- (p=0.0001). A combination of symptoms
the part of the urinary tract involved, the than three UTI episodes in a year).1 voided urine is used as a threshold for cul- such as dysuria and frequency is reported
infection-causing organism(s), the severity The risk for UTI also increases in wom- ture-based definition of UTI.1 However for to be more likely to predict bacteriuria than
of infection and the ability of the immune en who are sexually active.1 In addition, women who are experiencing symptoms of positive dipstick test for LE or nitrite. Since
system to eliminate the infection.1 the use of certain types of spermicides for UTI, a lower number of cfu may also reflect the quality of evidence from the dipstick test
Common clinical manifestations of cys- birth control may increase the risk for UTI.1 significant bacteria.6 The criterion of ≥102 is poor, a negative test does not exclude
titis are pain or burning during urination A person may also be predisposed to the cfu/ml can be used as a guide in the diag- bacteriuria.
(dysuria), frequent urge to urinate and su- disease by the presence of foreign bod- nosis of UTI in women with UTI symptoms.6 The probability of bacteriuria becomes
prapubic discomfort.2 In more serious in- ies such as renal calculi and in-dwelling The lower cut-off point is reported to have lower if patients present with vaginal dis-
fections, such as pyelonephritis, patients catheters which act as nidus for infection.1 95% sensitivity and 85% specificity.6 charge. Pelvic examination is usually indi-
may present with fever, flank pain and/or Greater prevalence of UTI is also observed At the point of consultation, the follow- cated in such cases to exclude alternative
costovertebral angle tenderness.2 In se- in women aged below 65 years and with ing non-laboratory tests can also be done to
vere pyelonephritis or in the presence of diabetes. support the diagnosis of UTI and help in the CONTINUED ON PAGE 18
18 • PHARMACY PRACTICE • NOVEMBER 2013

FROM “MANAGING URINARY TRACT Suggested Treatment

Infection/Condition &
INFECTIONS IN THE COMMUNITY Comments
Likely Organism Preferred Alternative
PHARMACY SETTING” PAGE 17
Acute Uncomplicated Cystitis Trimethoprim 300 mg PO Cefuroxime 250 mg PO q12h *Avoid sulfonamides in
diagnoses such as sexually transmitted dis- E. coli q24h for 7 days for 7 days pregnancy
eases (STDs) and vulvovaginitis. Enterobacteriaceae: OR
UTI in men is usually complicated as Klebsiella Nitrofurantoin 50 mg PO q6h
they commonly result from an anatomic or Proteus for 7 days
functional anomaly or instrumentation of the Enterobacter species OR
genitourinary tract. Appropriate diagnostic Staphylococcus saprophyticus *Trimethoprim/
tests should be considered to exclude other Enterococcus Sulphamethoxazole 160/800
common conditions associated with dysuria mg PO q12h for 3 days
and increased frequency such as prostati- Acute Cystitis in Pregnancy Cefuroxime 250 mg PO q12h Nitrofurantoin 50 mg PO q6h Modify treatment based on
tis, chlamydial infection and epididymitis. for 7 days for 7 days culture
In men with symptoms of UTI, urine culture OR
should be performed. A possibility of upper Cephalexin 500 mg PO q12h
UTI, e.g., pyelonephritis, should be consid- for 7 days
ered if patients have a history of fever and OR
back pain. UTI in symptomatic men can be β-lactam/ β-lactamase
diagnosed if the colony count shows ≥103 inhibitors e.g. Amoxycillin/
Clavulanate 625 mg PO q12h
cfu/ml, with 80% of the growth being of one
for 7 days
organism.
Recurrent Urinary Tract Trimethoprim/ Nitrofurantoin 50 mg PO ON As Prophylaxis
Pathogens Infections: Sulphamethoxazole 80/400 for 3-12 months
The common cause of infection in the uri- >3 episodes/year mg PO ON for 3-12 months OR
nary tract is bacteria. The organism that is Cephalexin 250 mg PO ON for
frequently reported as the cause of UTI in 3-12 months
women is Escherichia coli. Approximately OR
Trimethoprim 100 mg PO ON
85% of community-acquired and 50% of
for 3-12 months
hospital-acquired UTI is associated with this
organism. Other organisms include Entero- Table 1: Antibiotic treatment guideline for urinary tract infection (adapted from the National Antibiotic Guideline 2008, Ministry of Health Malaysia).
coccus faecalis, Klebsiella pneumoniae and
Staphylococcus saprophyticus. Hospital-ac- with co-trimoxazole (trimethoprim/sulpha- patients may require a six- to nine-month plenty of water. Drinking a lot of fluids can
quired infection and those associated with methoxazole).6 course of prophylactic antibiotic.3 The Ma- help flush the bacteria from the genitouri-
foreign bodies may involve more aggressive Alternatively, other antibiotics such as laysia antibiotic guidelines suggest trim- nary system. Most people require about six
organisms such as Pseudomonas aerugi- cefuroxime or nitrofurantoin or co-trimox- ethoprim/ sulphamethoxazole 80/400 mg to eight glasses a day. This, however, does
nosa, Serratia, Enterobacter and Citrobacter azole can be used to treat acute uncom- ON for three to 12 months as the first-line not apply to patients with kidney failure. Pa-
species. In recurrent UTI, the infections may plicated cystitis (see Table 1).7 The use of treatment for recurrent UTIs.7 Alternatively, tients with kidney failure should consult their
be caused by the same or different organ- broad-spectrum antibiotics such as cepha- a daily dose of nitrofurantoin, cephalexin or healthcare provider about the amount of flu-
isms e.g. a re-infection by an organism from losporins, quinolones and co-amoxiclav as trimethoprim can be prescribed.7 Re-infec- ids that is safe to be taken. Patients should
a source outside the urinary tract or from first-line treatment in uncomplicated cystitis tion due to sexual intercourse may require a also be advised to urinate when the need
bacteria that is persistent within it. should be avoided as they may increase the pericoital prophylaxis (taking a prophylactic arises and avoid resisting the urge to uri-
Although UTI can also be caused by risk of Clostridium difficile infection, MRSA dose of antibiotic prior to sexual intercourse) nate. Bacteria can grow if urine stays in the
fungi and viruses, infections by these organ- and resistant UTIs.6 In cases where first- or self-medication when infection occurs.3 bladder too long. It is advisable for women
isms are less common. Non-bacterial infec- line treatment fails, a urine culture should Treatment with non-antibiotics e.g. life- and men to urinate after sexual intercourse.
tions in UTI tend to occur more commonly be performed and it is recommended that style changes such as alternative treatment, This habit could flush away the bacteria that
in immunosuppressed individuals or those prescribing be based on the urine culture should also be considered to prevent the might have entered the urethra during sex.
with diabetes mellitus. The most common results.6 long-term use of antibiotics, which have In addition, women should always wipe from
non-bacterial organism that causes UTI is Pregnant women with cystitis should the potential to cause antimicrobial resis- front to back after using the toilet to avoid
Candida sp. Other less common pathogens be treated with cefuroxime for seven days.7 tance. Lifestyle changes may allow patients the movement of bacteria to the urethra.
for UTI include Mycobacterium tuberculosis Alternatively, a seven-day course of oral ni- to self-manage the prevention of recurrent Women who experience UTI due to the use
and a variety of anaerobic organisms. trofurantoin 50 mg q6H or cephalexin 500 UTIs, thereby improving their quality of life. of diaphragms or spermicides should try
mg q12H or amoxicillin/clavulanate 625 mg These include practicing double micturition switching to other forms of birth control.
Treatment of UTI q12H can be used.7 Although a three-day by those with residual urine after voiding.3 Unlubricated condoms or spermicidal con-
Antimicrobial therapy remains the mainstay course of nitrofurantoin has been shown to Others include taking cranberry products doms can increase irritation that may pro-
of treatment for symptomatic UTI. Other be effective in non-pregnant women with and avoiding the use of spermicidal cream.3 mote bacterial growth.
general measures that could help in reduc- uncomplicated cystitis, there is no direct When UTI is associated with sexual inter-
ing the symptoms of UTI include drinking evidence comparing the use of the short course, emptying the bladder after inter-
more fluids, taking oral agents to alkalinize course of antibiotics with a longer course course or taking a prophylactic dose of
urine e.g. potassium citrate solution (this e.g. seven days. The Infectious Disease antibiotic may also reduce the risk of UTI.3
does not have an effect on bacteriuria) or Society of America (IDSA) recommends the In post-menopausal women whose UTI is
drinking cranberry juice (inconclusive evi- use of a seven-day course of nitrofurantoin associated with lack of estrogen, the use of
dence for this). in such cases. vaginal estrogen cream may reduce the risk References: 1. Griebling TL. Chapter 13: Urinary
Empirical treatment with antibiotics can Care should be taken when prescribing of UTI.3 tract infection in women. In: Litwin MS, Saigal CS,
(eds). Urologic diseases in America. US Department of
be considered in healthy women aged be- nitrofurantoin in the elderly as they may be Acute pyelonephritis, or infection in the Health and Human Services, Public Health Service, Na-
low 65 years who are experiencing severe at increased risk of toxicity. The drug is also upper urinary tract, can be associated with tional Institutes of Health, National Institute of Diabetes
or three or more symptoms of UTI.6 The contraindicated in patients with significant bacteremia that could be life-threatening. and Digestive and Kidney Diseases. Washington, DC:
US Government Printing Office, 2007; NIH Publication
first-line treatment of uncomplicated lower renal impairment. The British National For- Hospitalization is usually required, espe-
No.07-5512 [pp.589]. 2. Bjerklund Johansen TE, Botto
UTI e.g. cystitis in both men and women, mulary advises against its use in patients cially when patients do not respond to H, Cek M, et al. Critical review of current definitions of
includes the use of narrow spectrum anti-in- with a glomerular filtration rate of below antibiotics within 24 hours. For acute py- urinary tract infections and proposal of an EAU/ESIU
fectives such as trimethoprim 300 mg once a 60 ml/min. Nitrofurantoin activity can also elonephritis, the first-line treatment includes classification system. International Journal of Antimicro-
bial Agents. 2011;38S:64-70. 3. Lee J, Neild G. Urinary
day for seven days .3,6 Although a seven-day be affected by urine pH. Increase in urine the use of antibiotics with broader spectrum
tract infection. Medicine. 2007;35(8):423-428. 4. Kunin
course is recommended, a three-day course pH (more alkaline) increases the minimum such as IV cefuroxime, or alternatively IV cef- CM. Urinary tract infections in females. Clin Infect Dis.
of trimethoprim has been shown to be as inhibitory concentration (MIC) of nitrofuran- triaxone, co-amoxiclav or ciprofloxacin. This 1994;18:1-12. 5. Foxman B, Gillespie B, Koopman J, et
effective as the longer course.6 The longer toin. Therefore, when taking nitrofurantoin, is to cover the broad-spectrum organisms al. Risk factors for second urinary tract infection among
college women. Am J Epidemiol. 2000;151:1194-1205.
course has been reported to have additional patients should be advised not to take alka- that usually cause acute pyelonephritis. In 6. Scottish Intercollegiate Guideline Network 88: Man-
side effects.3 However, in men with uncom- linizing agents such as potassium citrate. addition, these agents also have excellent agement of suspected bacterial urinary tract infection
plicated lower UTI, a seven-day course of For patients with recurrent UTIs who kidney penetration. in adults. Updated July 2012. 7. Ministry of Health Ma-
laysia. National Antibiotic Guideline 2008. Available at:
oral antibiotic is preferred. In uncomplicated have more than three episodes of UTI in a
www.pharmacy.gov.my/v2/sites/default/files/document-
lower UTI, the use of trimethoprim alone has year, a prophylactic antibiotic should be giv- Counseling points upload/national-antibiotic-guideline-2008-edit22.pdf
been considered as effective as treatment en to prevent future infection. In this case, Patients with UTI should be advised to drink Accessed on 4 October.

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