Health Care Guideline:
Uncomplicated Urinary Tract Infection in Women
Copyright © 1998 by Institute for Clinical Systems Integration
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Work Group Leader
Margaret Houston, MD, Mayo Clinic
Family Practice
Lesley Atwood, MD, Allina Medical Group East
Margaret Houston, MD, Mayo Clinic
Rosa Marroquin, MD, HealthSystem Minnesota
Ann Lowe, MD, HealthPartners
Internal Medicine
Nancy Grubbs, MD, Mayo Clinic
Nursing
Pat Dahlman, RN, HealthSystem Minnesota
Infectious Disease
David Strike, MD, HealthPartners
Ob/Gyn
Elisabeth Heefner, MD, HealthPartners
Health Education
Janet Williams, HealthPartners
Measurement Advisor
Diane Jacobsen, MPH, ICSI
Buyers Health Care Action Group Representative
Pat Drury, BHCAG
Facilitator
Margaret White, RN, MS, Central Minnesota Group Health
Plan
Women age 18-65 with uncomplicated urinary tract infection.
1. Decrease use of urine culture as a guide in therapy of uncomplicated UTI.
Possible measures of accomplishing this aim:
a. Percentage of women with uncomplicated UTI with urine culture performed
at initial
encounter.
2. Increase use of short course therapy in women with uncomplicated UTI.
Possible measures of accomplishing this aim:
a. Percentage of women treated with recommended therapy.
3. Increase patient satisfaction with management of uncomplicated UTI.
Possible measures of accomplishing this aim:
a. Percentage of women with positive response to satisfaction survey.
Clinical Algorithms & Annotations
1. Classic Symptoms
2. Complicating Factors Present?
3. Urinalysis/Hold
for Urine Culture
4. Provider Visit
5. Symptoms
of or Risk for Other Genitourinary Disease
6. Provider Visit
8. Short
Course Therapy & Patient Education
9. UA and Patient Education
10. Pyuria Present?
11. Provider Review
The classic symptoms of urinary tract infection (UTI) in women are dysuria, frequency, and urgency. One or more of these symptoms can trigger the initiation of the UTI guideline. Hematuria is not a classic uncomplicated UTI symptom. There is concern the presence of hematuria may be a sign of more significant disease.
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2. Complicating Factors Present?
History taking is essential in differentiating uncomplicated from complicated urinary infection. Women should be screened for the presence of complicating factors when presenting or calling with symptoms of UTI. Depending upon which complicating factor is present, short course therapy may or may not be appropriate:
Symptoms for which short course therapy is not appropriate:
Factors for which short course therapy may be appropriate at physician discretion:
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Instructions on collecting a clean-catch, midstream urine specimen should be given to the patient. Education should also be given to the patient regarding urinary tract infection and prevention.
The laboratory should be instructed to perform a urinalysis with microscopy and hold for possible urine culture. Urine specimens that are marked "Hold for UC" should be refrigerated.
The final decision about culturing should be left to the care provider.
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Women with a complicated history should be seen and evaluated by a health care provider. The provider (physician or paraprofessional) will determine if a UC is necessary.
Complicating factors are listed in detail on the algorithm page (box 2), and include the following categories:
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Genitourinary symptoms
Women with the following characteristics are at greater risk of a sexually transmitted disease:
Chlamydia risk factors
or
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Women with the symptoms and risk factors listed in Annotation #5 are at high risk for STD and should receive closer evaluation. These patients should be scheduled for a provider (physician or paraprofessional) visit and should receive a pelvic exam.
Finding an STD does not rule out concomitant UTI, which could be treated with short course therapy.
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A. Short Course Therapy
Once the presence of pyuria is established, adult female patients with uncomplicated UTIs can be prescribed treatment over the phone if preferred by both the provider and the patient, or can receive treatment at a clinic visit with a medical provider.
The drugs recommended for short course therapy are as follows:
If allergic to Sulfa or on Warfarin:
B. Over the Phone Treatment
Symptomatic women without complicating factors who prefer to receive treatment without a clinic visit may be treated over the phone at physician discretion.
C. Patient education should be provided over the phone, handed out at the pharmacy or mailed to the patient, and should include information about the following:
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Obtain a urine sample and give the patient education about urinary tract infections and prevention.
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"The most commonly used method for measuring pyuria, determining cells per microscopic high power field in a centrifuged urine specimen, does not correlate well with either the leukocyte excretion rate or the hemocytometer chamber technique." (Stamm 1983) However, most practices do not use a hemocytometer for measurement of white blood cells in urine; therefore, defining a level of wbc's/hpf which is abnormal is a matter of sensitivity and specificity. There is agreement that > 6 wbc/hpf reflects a real UTI, but it is also known that UTI's can occur in symptomatic women with < 6 wbc's/hpf.
While microscopy is strongly supported by the literature, a positive leukocyte esterase may also be acceptable. However, a dipstick leukocyte esterase may not be sensitive enough to detect the pyuria associated with UTI.
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Symptomatic women with a negative urinalysis should receive further evaluation as clinically indicated.
Within our population there may be some patients who do not appear to have a UTI by laboratory tests who will nonetheless respond to a trial of antibiotics. In addition, there may be patients who are well known to our physicians and who are known to be accurate historians who may not be able to come in for laboratory testing. In both cases, it may be reasonable to treat based on history without laboratory support.
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Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.
Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal (but not on a randomized, controlled trial):
Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):
Guidelines obtained from the Agency for Health Care Policy and Research (AHCPR) or other sources, position statements, panel consensus statements from the National Institutes of Health (NIH) or elsewhere, review articles, and textbook chapters that cite primary evidence are not assigned a grade because they are not primary evidence. The individual studies cited in such secondary sources can be graded according to the categories presented above.
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