Journal of Community Nursing - page 91

2013,Vol 27, No 4
Enterococci, group B Streptococci,
Pseudomonas aeruginosa
, and
In recent years, the development
E. coli
strains with antibiotic
resistance mediated by extended
spectrum beta lactamase (ESBL)
production has been observed
(SIGN, 2012). ESBL is an enzyme
produced by some pathogens,
which breaks down beta-lactam
antibiotics (penicillins and
cephalosporins), meaning they are
no longer effective.
The HPA produced a useful guidance
document for the diagnosis of UTIs
in primary care (HPA, 2010). The
guidance advises that if a patient
presents with severe symptoms —
or with at least three or more of
the common signs and symptoms
described above — there is a 90%
probability that a urine culture would
be positive for a UTI.
Broad spectrum antibiotics
(e.g. co-amoxiclav, quinolones and
cephalosporins) should be avoided
as first-line agents as they increase
the risk of
Clostridium difficile
infection, methicillin-resistant
Staphylococcus aureus
and resistant UTIs. The HPA and
British Infection Association (2010)
guidance suggests considering
narrow spectrum antibiotics such as
trimethoprim or nitrofurantoin as
first-line treatments when there are
three or more symptoms of UTI.
Previous studies have
shown that trimethoprim and
nitrofurantoin are broadly
equivalent in efficacy for the
treatment of uncomplicated UTI
where there are no resistant
pathogens. However, there is now
some evidence to suggest that
resistance to trimethoprim is rising,
whereas resistance to nitrofurantoin
remains relatively low (McKinnell
et al, 2011; National Institute for
Health and Care Excellence [NICE],
(i): review time of specimen
collection (morning is most
(ii): treat if symptoms are severe
or consider delayed antibiotic
prescription, and
(iii): send for urine culture
A negative nitrite, leucocyte and
blood result, or negative nitrite
and leucocyte test but positive
blood or protein result, indicates
that an alternative diagnosis
should be considered.
Management of UTI
in elderly patients
The diagnosis of UTI is particularly
difficult in elderly patients, who are
more likely to have asymptomatic
bacteriuria as they get older. This may
be due to changes in the structure
of the urinary tract or the existence
of co-morbidities, such as type 2
The prevalence of bacteriuria
may be so high that urine culture
ceases to be a diagnostic test —
this is particularly true for elderly
institutionalised patients because of
the close proximity of other patients/
residents and the possibility of cross-
infection (SIGN, 2012).
There is no evidence that
treatment of asymptomatic
bacteriuria in the elderly reduces
the risk of symptomatic episodes
or mortality — in fact, the evidence
actually shows that antibiotic
treatment significantly increases
the risk of adverse events, such as
rashes and gastrointestinal symptoms
(SIGN, 2012).
In elderly patients, the use of
urine dipstick testing is not routinely
recommended. However, if patients
exhibit two or more of the common
signs and symptoms of UTI,
diagnosis should be guided using
urine dipstick testing, as described
above (HPA, 2010). For elderly
patients with swallowing difficulties,
or patients of any age with
dysphagia due to comorbidities such
as recent stroke, both nitrofurantoin
and trimethoprim are available in
liquid formulations.
Furthermore, there may be
high levels of antibiotic resistance
Answer the following questions
about this, either to test the new
knowledge you have gained or to
form part of your ongoing practice
development portfolio.
1 – What is a urinary tract infection
2 – Name some of the main symptoms
of a UTI.
3 – What are some of the diagnostic
testing techniques for a UTI?
4 – Name some of the causes of a UTI.
5 – Can you outline some of the main
treatments for UTI?
Five-minute test
‘The diagnosis of UTI is
particularly difficult in elderly
patients, who are more
likely to have asymptomatic
bacteriuria as they get older’
If a patient presents with mild
symptoms, or at least two of the
common signs and symptoms
described earlier, a urine specimen
should be sought. If the specimen is
not cloudy, then a diagnosis other
than UTI should be considered. If
the urine is cloudy, the clinician
should perform a urine dipstick test
(in those under the age of 65 years).
Possible results and treatment
recommendations are as follows
(HPA, 2010):
A positive nitrite test, with or
without a positive leucocyte
result, indicates a probable UTI.
Based on this result the HPA
recommends antibiotic treatment
with either trimethoprim 200mg
twice-daily or nitrofurantoin
100mg modified release twice-
daily (HPA and British Infection
Association, 2010)
A negative nitrite but positive
leucocyte result indicates
that UTI or other diagnoses,
such as diabetes mellitus,
glomerulonephritis, or
coagulation disorders, are
equally likely. In such situations
the clinician should:
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