Urinary tract infection
From WardWiki - Foundation Doctor Helper
Urinary tract infection is a common infection, responsible for acute admissions of right iliac fossa pain, confusion and dysuria. It is disinct from bacteruria that is asymptomptomatic, although this is of special significance in pregnancy. It should be suspected in all cases of unexplained sepsis, confusion or general malaise such as being "off legs". An indwelling urinary catheter only serves to heighten such suspicion; don't remove it unless agreed by a senior as reintroducing one when it is needed could be difficult.
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Immediate management for all unwell patients
Assess the patency and protection of the airway. Take baseline observations, viewing them on a chart using an early warning system.
If evidence of airway compromise, contact anaesthetist and your seniour colleague.
If there is a raised or reduced respiratory rate, listen to the chest and give high flow oxygen via a non-rebeathe mask
If there is a tachycardia, low blood pressure or evidence of dehydration establish IV access and give a fluid challenge. Consider now placing a urinary catheter. Send off FBC, U&E, CRP, Group and Save, and any special relevant blood tests
If there is pyrexia equal to or above 38 or less than or equal to 35 degrees, take blood cultures. If SIRS is confirmed or sepsis suspected consider the Severe Sepsis Resuscitation Bundle.
If patient meets these criteria and does not respond well to initial management contact a senior team member, and a member of critical care who can see the patient or give advice immediately. Always cross match at least two units a patient in extremis. It is time consuming and distressing to attempt(pointlessly so) to rush the blood bank to dispense blood later on.
Note a urinary catheter is therapeutic only in cases where an empty bladder is desired (including transfer to theatre for surgery). It is important not to miss out resusitation and diagnostics steps in the first hour in an effort to set up equipment that measures a patient only hourly. Your initial fluid challenges will, by definition, not be affected by your promptly placed urinary catheter.
History
Site: Hypogastric tenderness, renal angles in pyelonephritis.
Onset: Very vaiable, may have a history of recurrent infections
Character: Constant dull or burning ache
Radiation: Classically none.
Aassociated with: Nausea and pyrexia are common. Dysuria and offensive urine are classical but not universal
Timing: Constant and worsening.
Exacerbation: Micurition. Pyrexia can be sudden and extreme in pyelonephritis
Severity: Can be very painful in pyelonephritis. Ensure adequate analgesia AND antiemetics.
Examination
Listen to the chest and examine the abdomen in all surgical admissions. Patient looks to be in pain, nauseated and mailaised Look for sweating, tachypnoea and note the observation chart. Pulse will be raised and may be bounding late on, although maybe thready due to dehydration early on. Palpation reveals hypogastric or renal angle tenderness. It is unwise, unpleasant and unwarranted to percuss over a point that is very tender on palpation. It is useful to more confidently exclude generalised peritonitis.
Same day investigations
FBC, U&E, CRP are essential. Group and save when SIRS persists despite fluids and analgesia. Clotting screen only truly warranted in severe sepsis or when urostomy is planned.
Urine dipstick for MC+S is mandatory. Blood in the urine may indicate a ureteric calculus but is commonly seen in UTI. A KUB Xray looks for a ureteric stone.
Next day investigations
Ultrasound abdomen is first line imaging for the renal tract for recurrent UTI in women or even a first UTI in men and is done during normal working hours. It should'nt delay antibiotics being given if they are indicated. It can be arraged overnight is patient is septic and ureteric obstruction is suspected. A normal creatinine does not exlude this but senior advice must be sought before arranging out of hours raiology.
Treatment
Antiemetics and analgesia prescribed. IV fluids can be prescribed as most patients have poor oral intake. Ciprofloxacin is a first line antibiotic although trimethoprim can be used for cystitis in the abscence of sepsis. Beta-lactam antibiotics are often prescribed in the community. In cases of sepsis gentamicin may be used but ensure renal function is normal and the patient hydrated. Ensure venous thromboprophylaxis is given. Arrange the ultrasound for the next day.
Duration of treatment vaires between consultants; always check with them.
