UTIs

• Tania Jones


  Jan 2024
• Tania Jones is a Lecturer in Clinical Pharmacy
• Email: [e-mail]
• Urinary System


  • Urethritis
  • Cystitis (LUTI)
  • Pyelonephritis (UUTI)
• Causes of UTI


  • E. coli
  • Proximity to anus
  • Pregnancy
  • Catheters
  • Kidney stones
  • Enlarged prostate
  • Constipation (kids)
  • Weakened immune system
  • Familial link
  • Urinary tract abnormality
• Infection Symptoms


  • Haematuria
  • New Nocturia
  • Dysuria
  • Incomplete Emptying Feeling
  • Increased Urgency
  • Cloudy Urine
  • Suprapubic Pain
  • Systemically Unwell
  • Vaginal Discharge
  • Fever
  • Babies - Failure to Thrive
  • Babies – Poor Feeding
  • Increased Frequency
  • Malodorous urine
• Differential Diagnosis


  • Thrush
  • Pelvic Inflammatory Disease
  • Kidney Stones
  • Chlamydia
  • Urological, gynaecological, prostate or kidney cancer
  • Bacterial Vaginosis
  • Benign Prostatic Hyperplasia
  • Gonorrhoea
  • Herpes simplex HSV-2
  • Reactive arthritis or Behcet’s syndrome
  • Dermatological e.g. psoriasis, dermatitis
  • Menopausal symptoms e.g. atrophic vaginitis
• Diagnostic Testing


  1. Mid Stream Culture

  2. Dipstick
• How to test urine: Observations

  1. ODOUR: fishy – UTI or STI; pear-drop sweet smell – ketones ++; Remember foods can cause smell e.g. asparagus

  2. COLOUR: Colourless, pale yellow, amber – normal; Dark – dehydration; Strong yellow, brown or green – bilirubin; Green – Pseudomonas infection or excretion of cytotoxic drugs, recent propofol anaesthetic; Red-brown or bright red – haematuria or menstrual blood contamination; CLARITY: Clear – normal; Cloudy to turbid - can be normal or presence of mucus, semen, prostatic fluid, skin cells, white or red blood cells, pus or bacteria; Frothy – Presence of protein
• Understanding urinalysis


  1. Leucocytes: Detects leucocyte esterase, produced by WBC

  2. Nitrites: From nitrates

  3. Bilirubin and urobilinogen: From breakdown of RBC: Not normally in urine

  4. Protein: Damage to glomerulus

  5. pH: 4.5-8.0 is normal; extreme acidity: urine stones; extreme alkalinity: presence of Pseudomonas, Proteus or Klebisella. Also consider meds

  6. Hb: Infection, tumour, trauma, menstrual blood, kidney disease or stones

  7. Specific gravity: how concentrated urine is – higher gravity, more concentrated

  8. Glucose: Not normally in urine: DM, gestational or steroid-induced diabetes

  9. Ketones: Not normally in urine: fat breakdown instead of glucose - hyperemesis gravidarum, or fasting and starvation, dieting, episodes of diarrhoea, or as a sign of raised blood glucose (diabetic ketoacidosis)
• Self Care


  • The Baddies: Alkalinising Agents – NOT recommended by NICE; Cranberry products – NOT recommended by NICE
  • The Goodies: NSAID Suitability?; Empirical Antibiotic Choice: Nitrofurantoin MR 100mg BD for 3 Days (or 50mg QDS) (If eGFR ≥45ml/minute); Trimethoprim 200mg BD for 3 Days (If Low Risk of Resistance) OR Check Local Antimicrobial Resistance Patterns and Prescribing Guidelines; Other options after 1st-line: Pivmecillinam (a penicillin) 400mg initial dose, then 200mg three times a day for a total of 3 days or Fosfomycin 3g single dose sachet; First-Line Safety Net: Shivering, chills, and muscle pain; Confused or drowsy; Not passed urine all day; Smelly urine; N & V; Visible blood in urine – re-test after treatment and if persistent, think pyelonephritis or urological/gynae cancer 2WW or CKD; Temper
• First-Line Safety Net


  1. Shivering, chills, and muscle pain

  2. Confused or drowsy

  3. Not passed urine all day

  4. Smelly urine

  5. N & V

  6. Visible blood in urine – re-test after treatment and if persistent, think pyelonephritis or urological/gynae cancer 2WW or CKD

  7. Temperature above 38 degrees or less than 36 degrees

  8. Kidney pain in back (just under your ribs)

  9. Symptoms worsen

  10. Symptoms do not improve within 48 hours of starting Abx
• Recurrent UTIs Suspect


  • Malignancy
  • Post Menopausal – vaginal oestrogen
  • Chronic prostatitis
  • Structural abnormalities
• Management Options for Recurrence

  1. Patient initiated self-treatment

  2. Post-coital prophylaxis

  3. Continuous prophylaxis
• Genetic susceptibility for Recurrent UTIs

  • 1st Choices
  • OR
  • 2nd Choices
  • OR
  • Strategies: A)When exposed to a trigger – a one-off dose B)Once daily prophylaxis – review 3/6 months
• Longer duration and multiple courses of antibiotics are associated with greater resistance
• Previous Antibiotic Use and Subsequent Resistance
• Nitrofurantoin MHRA Warning April 2023
• Interstititial pneumonitis = inflammation of interstitium (in and around walls of alveoli where O2 moves into capillary network)
• Pulmonary fibrosis = scarring of interstitium
• Treatment Group Considerations


  1. Complicated UTI

  2. Bacteriuria in pregnant women
• The presence of bacteriuria (with/without symptoms) is associated with premature rupture of membranes and pre-term labour
• Routine screening for asymptomatic bacteriuria by midstream urine culture recommended in early pregnancy (NICE)
• Treating asymptomatic bacteriuria in pregnancy reduces the risk of pyelonephritis and may also reduce the incidence of low birthweight and prematurity
• Symptomatic UTI in Pregnancy

  1. Paracetamol

  2. Avoid alkalizing agents and cranberry

  3. Urine culture + empirical antibiotic therapy

  4. Fever and loin pain suggests upper UTI

  5. Hospital admission and IV antibiotics recommended
• 1st Line Pregnancy Treatment

  1. Nitrofurantoin MR 100mg BD for 7 days (or 50mg QDS) (if eGFR ≥45ml/minute)

  2. Trimethoprim 200mg BD for 3 days (if low risk of resistance)
• UTI in people with a longer urethra: 3 days
• UTI in people with indwelling catheters: Check for blockages, remove or change catheter (especially if in Place for Over a Week) & assess need for ongoing catheterisation
• Bacteriuria is common
• Antibiotic resistance: Need 7 Day Antibiotic courses
• Elderly people with cognitive impairment may experience confusion due to UTI over-diagnosis and over-treatment
• Catheter management


  Check for blockages, remove or change catheter (especially if in place for over a week) & assess need for ongoing catheterisation
• Antibiotic resistance
• Need for 7-day antibiotic courses
• Elderly people may experience cognitive impairment and confusion
• UTIs are over-diagnosed and over-treated in the elderly population
• Asymptomatic bacteriuria is common and does not need treating
• New symptoms are needed to diagnose UTI
• Issues with function decline e.g. renal
• In renal impairment, the efficacy of nitrofurantoin is reduced and the potential for adverse reactions increased