Management of Suspected Bacterial Lower Urinary Tract Infection in Adult Women

Overview

This summary provides recommendations based on current evidence for best practice in the diagnosis and management of suspected bacterial lower urinary tract infection (UTI) in adult women. It is focused on the management of lower UTI in women:

• aged under 65 years
• aged 65 years and over
• that are recurrent
• that are catheter-associated.

Recommendations are marked up with an [R] and good-practice points are marked up with a [✓].

This guideline does not cover the following:

• diagnosis and management of upper UTI
• UTI in children under 16 years of age
• UTI in pregnant women
• UTI in men
• interstitial cystitis and bladder pain syndrome.

This guideline replaces SIGN 88: Management of suspected bacterial urinary tract infection in adults. This guideline includes younger women aged 16–64 years, older women aged 65 years and over, and women of any age using an indwelling, intermittent, or suprapubic catheter. It also includes the diagnosis and management of recurrent UTI in these groups.

Checklist for Provision of Information

Examples of the information patients/carers may find helpful at the key stages of the patient journey:

Diagnosis

• Explain the symptoms of UTI, how to tell a UTI might be present and when to seek medical advice, e.g. from GP or pharmacist
• Inform women of the cause of UTIs and the effect UTIs have on the body
• Discuss with women how having other conditions can make them more susceptible to UTIs, e.g. diabetes. Offer time to answer questions women may have
• Discuss the implications of recurring UTIs on health in general, including the bladder
• Discuss with women aged under 65 years how to provide a urine sample for dipstick testing, including advice around ensuring the bladder has not been emptied for at least four hours before taking the sample
• Provide women with the SIGN patient version of this guideline to help them understand and manage UTIs
• Explain the rationale for not prescribing and delayed prescribing.

Treatment

• Explain the difference between a 3-day and a 7-day course of antibiotics and the reasons for using one or the other
• Ensure women understand the need to finish the course of antibiotics
• Advise women how long it will be before they start to feel better after starting treatment
• Inform women of common side effects associated with treatment and advise them not to be concerned and not to stop treatment without discussion with a healthcare professional
• Discuss potential drug interactions with other prescribed medicines they may be taking
• Advise women to return to their GP or NHS24 (at weekends or evenings) if symptoms don’t improve with treatment, get worse or come back after treatment
• Explain the long-term effects that can occur when taking long-term prophylactic antibiotics
• Discuss steps women can take to reduce the chances of having further UTIs, including:
  • drinking plenty of fluid
  • avoidance of spermicide containing contraceptives
  • personal hygiene
  • voiding behaviours.

Lower Urinary Tract Infection in Women Aged Under 65 Years

Diagnosis

• [R] Do not diagnose a UTI in the presence of a combination of new onset vaginal discharge or irritation and urinary symptoms (dysuria, frequency, urgency, visible haematuria or nocturia)
• [✓] In making a differential diagnosis it is important to investigate for urethritis and other causes of symptoms to rule out conditions that present in similar ways to uncomplicated UTI 
• [R] Do not confirm the diagnosis of a UTI in the presence of a single urinary symptom (dysuria, frequency, urgency, visible haematuria or nocturia) 
• [✓] Advise the patient that a UTI cannot be confirmed based on a single urinary symptom and to return if the symptom fails to improve or worsens 
• [R] Diagnose a UTI in the presence of two or more urinary symptoms (dysuria, frequency, urgency, visible haematuria or nocturia) and a positive dipstick test result for nitrite 
• [✓] Before carrying out a dipstick test urine should be retained in the bladder for at least four hours to allow conversion of urinary nitrates to nitrite by pathogens. Shorter incubation times may lead to false negative results 
• [✓] On diagnosis of UTI in the presence of two or more urinary symptoms and a positive dipstick test result for nitrite, a urine specimen should only be sent for culture if the patient has a history of resistant urinary isolates, has taken any antibiotics in the past six months or fails to respond to empirical antibiotics 
• [✓] Consider sending a urine specimen for culture to inform the diagnosis in patients who present with suspected UTI and two or more urinary symptoms and a negative dipstick test result for nitrite. 

Algorithm 1: Diagnosis and Management Options in Non-pregnant Women Aged Under 65 years Presenting with Suspected Lower Urinary Tract Infection

Management

• [R] Consider NSAIDs as first-line treatment in women aged <65 years with suspected uncomplicated lower UTI who describe their symptoms as mild
• [✓] Consider NSAIDs as an alternative to an antibiotic following a discussion of risks and benefits in women aged <65 years with suspected uncomplicated lower UTI when symptoms are moderate to severe 
• [✓] The decision to use an NSAID or antibiotic should be shared between patient and prescriber and risks and benefits should be fully discussed and considered. This is particularly important in women with comorbidities that increase renal impairment 
• [✓] Duration of NSAIDs should be limited to 3 days to minimise adverse effects 
• [✓] Patients receiving NSAIDs should be informed to contact their prescriber if UTI symptoms do not resolve within 3 days or worsen. 

Lower Urinary Tract Infection in Women Aged 65 Years and Over

Diagnosis

• [✓] Where incontinence is a feature, causes other than UTI should be considered, for example prolapse, voiding dysfunction or functional impairment 
• [R] Be aware that women aged 65 years and over, especially those in long-term care facilities, may not display the usual symptoms and signs of UTI that are seen in younger women 
• [R] Be aware that functional deterioration and/or changes to performance of activities of daily living may be indicators of infection in frail older people
• [✓] A holistic assessment is needed in the frail elderly to rule out other causes with both classical and non-classical signs of UTI. Dehydration, constipation, electrolyte abnormality, polypharmacy, pain and urinary retention may all lead to functional decline
• Consider sepsis, non-urinary infections and other causes of delirium in an unwell older adult with abnormal vital signs (for example, fever, tachycardia, hypotension, respiratory rate and saturations)
• [R] Use of dipsticks for the diagnosis of UTI in women aged 65 years and above in long-term care facilities or in frail elderly people requiring assisted living services is not recommended 
• [✓] In women aged 65 years and over with symptoms suggestive of UTI, a positive test for nitrite in the urine is a marker for bacteriuria, and this should be assessed in the context of the background incidence of asymptomatic bacteriuria 
• [✓] Send a urine specimen for culture to confirm the pathogen and antibiotic susceptibility in women aged 65 years and above prior to starting antibiotics for a UTI.

Management

• [✓] Manage suspected UTI in ambulant women aged 65 years and over who are able to look after themselves independently with no comorbidities as in those aged under 65 years, taking into account the increasing background incidence of asymptomatic bacteriuria 
• [✓] Exercise caution in women who are on fluid restriction for medical reasons (for example, those with chronic heart failure or on renal dialysis)
• [✓] The Care Inspectorate document, Eating and Drinking Well in Care, provides best practice guidance on older people’s dietary needs and related food and fluid requirements.

Recurrent Lower Urinary Tract Infection in Women

Management

• [R] Women with a history of recurrent UTI should be advised to aim for a fluid intake of around 2.5 L a day, of which at least 1.5 L is water 
• [R] Consider prophylactic antimicrobials for women experiencing recurrent UTI after discussion of self-care approaches and the risks and benefits of antimicrobial treatment involved
• [✓] Long-term prophylactic antimicrobials for prevention of recurrent UTI should be used with caution in women aged 65 years and over, and careful consideration given to the risks and benefits involved 
• [✓] To minimise the development of resistance, antimicrobial prophylaxis should be used as a fixed course of 3–6 months in women with recurrent UTI.

Catheter-associated Lower Urinary Tract Infection (CA-UTI) in Women

Diagnosis

• [✓] Patients with indwelling catheters should have regular review to assess the ongoing need for catheterisation, including consideration of alternatives to catheterisation and trial without catheter
• [R] Clinical signs and symptoms compatible with CA-UTI should be used to diagnose infection in catheterised patients with urine culture and sensitivity testing employed to confirm the diagnosis and pathogen 
• [✓] Urinary dipsticks should not be used as part of the diagnostic assessment for UTI in patients with indwelling catheters.

Management

• [R] Do not routinely prescribe antibiotics to prevent UTI in patients using intermittent self-catheterisation for bladder emptying. Consider only after full discussion of the benefits and harms likely to apply to the individual.