Pharmacy First: Tips for diagnosing and treating uncomplicated UTI in women

CLINICAL UPDATE

How are you getting on with Pharmacy First? GP Dr Toni Hazell presents useful tips for diagnosing and treating uncomplicated UTI in women

Most community pharmacies in England are now running the Pharmacy First service which enables them to diagnose and treat seven specific conditions. Under the service, pharmacists can prescribe set medications where appropriate, without recourse to a GP. This will hopefully reduce some of the current pressures on general practice.

This series of guides assumes that pharmacists are familiar with the clinical pathways and requirements for Pharmacy First. The articles explore some key aspects of each service to support and enhance pharmacists’ knowledge. Here, GP Dr Toni Hazell offers ten tips on managing uncomplicated urinary tract infection (UTI) in adult women in line with the Pharmacy First service.

Uncomplicated UTI

A lower UTI (also known as uncomplicated UTI) is an infection in the bladder. It is usually caused when bacteria are transferred from the bowel to the urethra, and is more common in women than men due to the anatomy making this transfer more likely.

Various studies show a lifetime risk of UTI of up to 37%, with nearly half of all women who have had one UTI having a recurrence at some point. For most women the symptoms are easily treated with antibiotics, but complications can include pyelonephritis (when the infection ascends to the kidneys), kidney abscess, renal failure or life-threatening sepsis.

Here are ten tips on how to assess and manage presentations of suspected uncomplicated UTI in women appropriately and in line with the new Pharmacy First service.

1. No need for dipsticks – but consider a urine sample

Based on research into uncomplicated UTIs in women, it is reasonable to assume that antibiotics are required if the following four criteria are met:

1. Cloudy urine
2. Offensive smell
3. Pain on passing urine (dysuria) and
4. Passing urine at night (nocturia)

The positive predictive value (PPV), ie, the likelihood that a person with these symptoms has a UTI, can be calculated as follows:²

For this reason, the clinical pathway algorithm for UTI recommends considering treatment for patients with two or more symptoms, as over three-quarters of this cohort will have a UTI. Note that a urine dipstick does not significantly change this probability and is therefore not needed, although if the patient doesn’t know whether their urine is cloudy, the pharmacist might want to look at a sample.

2. Don’t rely on NEWS2 – use your intuition

Before getting to that point, however, other pathologies need to be ruled out. The NHSE clinical pathway starts by suggesting that the pharmacist considers calculating a National Early Warning Score (NEWS)2, an early warning score for sepsis. Be aware that NEWS2 is not validated for use in primary care;^3,4

NHS England recommends its use in ambulance and secondary care services, and it may be helpful to provide a NEWS2 score to an emergency clinician – unlikely though that scenario is in this context. However, pharmacists should not rely solely on NEWS2 to make a judgement, nor wait to calculate a score if that might delay a sick patient being directed to the emergency department.

It is important to develop a feeling for when a patient looks unwell, backed up by physiological measurements. I would be concerned if a patient looks sweaty or feels dizzy, is tachycardic or has a low blood pressure. Developing this clinical antenna or ‘Spidey sense’ is key for any healthcare professional who wishes to see unwell patients.

3. Focus on ‘new, severe’ pain to rule out kidney problems

Assuming that the patient is not septic and needing admission, pyelonephritis (infection in the upper part of the urinary tract) should next be ruled out, by asking about pain or tenderness in the kidney area, flu-like symptoms, chills, nausea or vomiting.

If I had £10 for every patient with back pain who tells me that they have ‘pain in their kidneys’ then I’d be on my tropical island instead of writing this, so it’s important to take a careful history and differentiate new and severe pain in the upper back from chronic lower back pain (which is felt by up to 60% of the population at some point).⁵

4. Ensure the patient can speak freely

Other differentials of UTI symptoms include a sexually transmitted infection (STI) and vulvovaginal atrophy due to genitourinary syndrome of the menopause (GSM) and complications.

The next step in the pathway is to ask questions about these possibilities, and to consider whether the patient may be pregnant. It’s important at this point to see the patient alone, even if they initially came with a friend, partner or parent – questions about discharge and sexual history may not be answered honestly if someone else is there.

In my experience, a woman who is having regular unprotected sex will often answer ‘no’ to the question ‘might you be pregnant?’, so it’s important to check the date of the last menstrual period and advise a pregnancy test if needed.

5. Always refer if STI, GSM or pregnancy

Positive answers to any questions when considering these differentials should prompt the pharmacist to refer on appropriately, either to the GP, to a sexual health clinic, or to ‘other provider as appropriate’.

Women who have a UTI in pregnancy need to have a sample sent for microscopy, culture and sensitivities (MC&S) and to have a longer course of treatment (seven days) and so should be referred to a GP, or another healthcare professional who can do this.

If their urinary symptoms are accompanied by lower abdominal pain, and they have not yet had a scan to confirm that the pregnancy is intrauterine, the possibility of an ectopic pregnancy also needs to be considered.

6. Take a full medical and drug history

Women who are immunosuppressed either by disease (eg, untreated HIV, leukaemia, lymphoma or a primary immunodeficiency) or by drug (medication used for conditions such as rheumatoid arthritis, or post-transplant) should always be referred to the GP – the pharmacist therefore needs to take a full medical and drug history at some point in the assessment, or check medications on the spine if possible.

7. Remember to check if symptoms are new, or have recently changed

Once other differentials have been ruled out, the three key diagnostic symptoms should be considered:

1. Dysuria (pain, burning, discomfort, tingling or stinging when passing urine).
2. New nocturia (waking at least once per night to pass urine).
3. Cloudy urine.

If two or three of these symptoms are present then pharmacists are expected to discuss with the patient to decide whether the symptoms are mild and manageable with self-care, or moderate-to-severe and requiring treatment with antibiotics.

Taking a good history is often described as an art, and determining the significance and severity of symptoms is key here. It is important to establish what represents a change in symptoms for the person, and whether their symptoms are indeed new.

Clearly there is an element of common sense – needing to pass urine every half an hour during the night is obviously more severe than needing to urinate every few hours and being able to hold on if needed. However, in more nuanced cases it may be hard to judge so it’s important to ask about usual habits and explore the pattern and any changes in symptoms. People don’t always volunteer clear information about their symptoms so be prepared to ask follow-up questions if needed.

Also with Pharmacy First being publicised widely, it’s possible that someone may present with, for example, established nocturia, not realising that it is only significant if they are needing to pass urine in the night more often than usual (see Case study 1).

The following four symptoms should be considered if there is no or only one key UTI diagnostic symptom – the presence of any of these should then prompt onward referral:

1. Urgency (a strong desire to pass urine, which may lead to incontinence if a toilet is not accessible).
2. Frequency (passing urine more often than normal).
3. Visible blood in the urine (haematuria).
4. Pain above the pubic bone (suprapubic pain).

Case study 1

Mary gets up once or twice every night because she has an autistic child who sleeps badly. On the way back from her child’s bedroom to her own she often goes to the toilet to pass urine, to avoid another night-time wake. When her child is in respite, she rarely gets up to go to the toilet in the night.

Hearing about the Pharmacy First service from a friend, who explained symptoms can include going to the toilet at night, Mary makes an appointment with her local pharmacy. When she is seen by the pharmacist and a careful history is taken, it’s clear that she does not have new nocturia, and she has no other urinary symptoms. As she doesn’t need pain relief, she is therefore reassured that no action is needed.

7. Don’t be caught out by common symptoms

Symptoms of UTI – in particular pain or discomfort on passing urine – are common to several other conditions so it is vital to keep this in mind when taking a history.

As outlined above you should always rule out possible STI or GSM (see point 4) but some causes may be less obvious such as chemical urethritis (eg, from bubble bath or perfumed soap) or thrush (see Case study 2).

Case study 2

Jeanette has just finished a course of antibiotics for an exacerbation of her asthma. She has developed thrush as an adverse effect of these, which is making it very uncomfortable for her to pass urine, causing burning and stinging every time that she goes. She has seen an advert for Pharmacy First and come to enquire about whether she has a UTI and needs antibiotics. On being taken through the screening questions, it is noticed that she has a recent onset of vaginal discharge which is white, itchy and thicker than usual. The pharmacist then asks about recent antibiotics and realises Jeanette may well have thrush. They suggest treating this over the counter and seeing the GP if things do not improve. If the pharmacist had not taken such a clear and full history, Jeanette might have been referred on for her initial, single presenting symptom – delaying access to treatment for her thrush.

8. Explain self-care ‘dos and don’ts’

Make sure to explain self-care clearly to patients, as outlined in box 1. Offer patients information leaflets to take away (see patient resources below) and always safety net with advice to return if symptoms do not improve (see Case study 3).

Box 1: Self-care advice for women with symptoms that may indicate a UTI

• Drink enough fluids to stop you feeling thirsty – ideally 6-8 glasses per day.
• Use regular paracetamol or ibuprofen, unless there is a reason not to (eg, previous side-effects).
• In future, wipe from front to back after using the toilet, pass urine as soon as you need to rather than waiting, pass urine after sex and consider washing the genitals before and after sex to wash away any bacteria.
• Avoid alcohol, fizzy drinks and caffeine as these can exacerbate symptoms.
• There is no clear evidence for use of cranberry products or over-the-counter cystitis.⁶

Case study 3

Shazia attends a Pharmacy First appointment as she has noticed a burning sensation when she passes urine for the past few days and is having to get up at night to pass urine. She has brought a sample with her which is cloudy to the naked eye. She has read online about UTIs and has tried to drink lots of water over the last day – she thinks that her symptoms are improving a bit, and they seem quite mild. After discussion with the pharmacist, and going through the TARGET UTI resources, she agrees to carry on with self-help. An appointment is made for 48 hours later, which she can cancel if her symptoms have continued to improve or gone completely, and she doesn’t feel that she needs a review. If Shazia had felt her symptoms were more severe, or were worsening, it would have been reasonable to treat her with antibiotics.

9. Always check for recent nitrofurantoin use

At the point of prescribing antibiotics, a pharmacist who is not an independent prescriber would need to be aware of the patient group direction (PGD) for this.⁷ It is important that anyone who will be using the PGD reads it in full, but key points are in box 2.

If antibiotic treatment is needed but there is an exclusion according to the PGD then the patient will need to be signposted to a prescriber – local pathways might dictate whether this is to their GP, or other prescriber.

Box 2: Extracts from the PGD for nitrofurantoin use

• Check no nitrofurantoin use in the last three months (repeated use risks generating antibiotic resistance).
• Exclude pregnancy, breastfeeding, immunosuppression, allergy to nitrofurantoin, the use of prophylactic antibiotics for recurrent UTI and previous use of nitrofurantoin for UTI which didn’t work.
• Exclude key co-morbidities including diabetes, anaemia, B12/folate deficiency, chronic kidney disease at stage 3b or worse and admission to hospital in the UK for over seven days in the last six months, or abroad at any point in the last three months.
• Exclude recurrent UTI (two in the last six months or three in the last 12 months) – this will require referral for a urine culture and GP review.

10. Be prepared to decline antibiotics

For women with two or three of the key diagnostic symptoms, antibiotics will usually be appropriate. However, there may be cases in which a patient has a very clear expectation of antibiotics when they are not actually indicated. For example, a patient who only has one symptom but tells the pharmacist that she has had a UTI before, and she’d like some antibiotics in case it gets worse. Or a patient who should be referred on, but would like antibiotics in the meantime.

It’s important that any pharmacist who is consulting under Pharmacy First is prepared to decline to prescribe antibiotics when they are not indicated (see Case study 4).

Case study 4

Amelie has presented to Pharmacy First with a one-week history of dysuria. She has no other symptoms, which means that a UTI is equally likely to another diagnosis. As there is nothing in the history to direct her to a specific provider, such as a sexual health clinic, she is advised to see her GP. She is about to travel with work for a week and is not happy with this advice, as it isn’t convenient – she asks if she can just have some antibiotics instead. The pharmacist explains that this isn’t a good idea – treating her under Pharmacy First when she doesn’t clearly have a UTI might delay the diagnosis of whatever is causing her symptoms, and if she uses antibiotics when they aren’t needed, she could develop resistance to the antibiotics so they do not work when she does need them in the future. She reluctantly accepts this advice and says that she will try to see her GP.

This is the first in a new series of articles on aspects of Pharmacy First from The Pharmacist.  

Author: Dr Toni Hazell is a GP in north London.