Urinary Tract Infection

Appropriate assessment to identify cause and severity of symptoms

Explanation to patient and family

Correct reversible factors

Consider disease-specific palliative therapy

Institute non-pharmacological interventions

Prescribe appropriate first-line treatment

Consider adjuvant/second-line treatment

Review assessment and management

At all stages of management

Appropriate assessment to identify cause and severity of symptoms 

Differentiate between complicated and uncomplicated UTI. In palliative care most UTIs will be complicated as the following risk factors are often associated: indwelling catheter, diabetes, structural abnormalities (congenital, tumour, fistula), low output (dehydration), immune impairment, spinal cord injury, previous urologic surgery, atrophic vaginitis, renal calculi 

The clinical picture may vary from asymptomatic to severe symptoms to septicaemia. 

History: dysuria, frequency, incontinence, urinary retention, pyuria, haematuria, supra-pubic pain, loin pain, fever (PUO), rigours 

Examination: pyrexia, confusion, tender supra pubic area, loin area 

Investigation: bedside test for urinary blood, protein, leucocytes, nitrates (any or all may be positive) 

MCS for men, children, complicated cases, structural abnormalities, upper UTIs (e.g. pyelonephritis) 

If dipstix is negative, but UTI symptoms are present, consider yeasts (candida) 

Explanation to patient and family 

UTI can cause considerable morbidity in terminal disease and should therefore be managed with the necessary empathy and rapid response to needs. 

Relieve anxiety around urinary incontinence and request support from family members. 

The patient will be helped by; 

• close proximity to the toilet 
• ready availability of a commode, urinal or bottle 
• a rapid response for help by family members 

Correct reversible factors 

• Rehydrate if appropriate (especially in hypercalcaemia, septicaemia) 
• Check on catheter hygiene – do not treat asymptomatic bacteriological colonisation in catheterised patients 
• Local oestrogen therapy for severe atrophic vaginitis 
• Distinguish and treat related symptoms due to STI infections such as gonorrhoea, Chlamydia or genital herpes 

Consider disease-specific palliative therapy

UTIs are most commonly caused by E Coli/ other gram neg. Bacilli – resistance common and increasing, therefore: 

• Acute, uncomplicated bacterial cystitis 
  • Trimethoprim-sulphamethoxazole (160mg trimethoprim-800mg sulphamethoxazole i.e 1 DS or 2 SS tablets) or trimethoprim 200mg twice daily for 3 days; 
  • Ciprofloxacin 250 – 500 mg twice daily for 3 days 
  • Nitrofurantoin 50-100mg 4 times daily for 7 days/nitrofurantoin monohydrate 100mg twice daily for 7 days 
  • Cefuroxime 250 – 500mg bd 

More severe cases 

• Cefuroxime 750 mg IVI 8 hourly ( Zinacef ) 
• Ceftiraxone ( Rocephin) 1-2 g daily IMI/IVI 
• Gentamycin 80 mg IVI/IMI daily 

• Extend to 7 days if diabetic, symptoms > 7 days, >65 years old or change regime according to MSU result which should be taken in any complicated UTI prior to starting antibiotics; 
• If UTI is due to a fungal infection found upon culture of a midstream specimen, it is usually a systemic infection (yeasts - candida sp) Rx: Fluconazole 400mg/day X14 days . Exclude asymptomatic commensal from the GIT tract, which does not require treatment; 
• For frequent recurrences of lower UTI, prophylaxis required with once daily treatment Trimethoprim 200mg, or Nitrfurantoin 50 – 100 mg 

Institute non-pharmacological interventions 

General: 

• Supporting the patient with adequate fluid intake, especially cranberry/blueberry juice 180 ml bd could be beneficial as a preventative measure in recurrent infections. The juice contains a large polymer which inhibits bacterial adherence to the bladder mucosa. Avoid if on Warfarin. 
• Abstaining from caffeine and alcohol is beneficial 
• Regular voiding – every 3 hours. 

Catheterised patients: 

• bladder washouts with 100mls 0,9% Saline or with continuous bladder irrigation; 
• change indwelling catheter – ensure that antibiotics are given for 48 hours prior to de-catheterisation; 
• revert to intermittent catheterisation 4-6 hourly 

Prescribe appropriate first-line treatment 

Treat the infection with the necessary antibiotic and provide antibiotic-prophylaxis in recurrent infections as above. 

Consider adjuvant/second-line treatment 

• Treat bladder spasms and pain symptomatically with the following treatment  options: 
  • Hyoscine Butylbromide 10-20 mg po, IVI, IMI or S/C tds. Maximum of 100mg per day 
  • WHO pain ladder 
  • Intravesical morphine and bupivacaine tds (morphine 10-20mg and 0.5% bupivacane 10ml diluted in 0.9% salineto 20 ml), instil through an indwelling catheter and clamp for 30 min. 
  • Spinal analgesia, e.g. epidural morphine and 0,5% bupivacaine 
• Treatment of urgency and frequency 
  • Tricyclic antidepressants ( Amitryptaline and imipramine 25-50 mg nocte) for nocturnal enuresis 
  • Anti-inflammatories (NSAID) such as Naproxen 250-500 mg bd 
  • Desmopressin Oxybutinin 5mg bd/tds 200-400ųg po or spray 20-40ųg intranasally as a last resort for refractory troublesome nocturia 

Review assessment and management 

It is mandatory that refractory treatment and resistance to antibiotics causing unabated symptoms need careful review of antibiotic regime. Consider prophylactic antibiotics where successful treatment of UTI is followed by repeated infections. 

At all stages of management consider: 

Involvement of interdisciplinary team – ensure that appropriate treatment regimes for pain management are adhered to and involve the nursing staff to assist in adherence support. 

Referral to appropriate service/more experienced clinician – refer to Urologists where necessary for additional interventions such as dilatation of urinary stricture, retention, complicated pyelonephritis and enlarged prostate. The following tests may be required to confirm diagnosis:  MSU, Ultrasound, CT scan and MRI if contrast contra-indicated.