UTIs: New PHE

recommendations for
Primary Care

{ Muhammad Ibrahim Foondun

 Developing a UTI tool for primary care

 In November 2018, Primary Care England (PHE)

published Diagnosis of urinary tract infections: quick
reference tool for primary care.

 The tool contains new diagnostic flowcharts and

recommendations based on the latest available
evidence, and has been endorsed by NICE.
 The new diagnostic flowcharts and diagnostic points
include:
1. women aged under 65 years (see Figure 1)
2. men aged under 65 years
3. older people aged over 65 years (see Figure 2)
4. infants and children aged under 16 years with suspected UTI
Key changes with the new PHE Guidance
 for women aged <65 years, 3 specific indicators to increase
diagnostic certainty of a UTI :
1. dysuria
2. new nocturia
3. cloudy urine

 for men and women aged >65 years:

• do not perform a urine dipstick test!!!
• use PINCH ME to exclude other causes of delirium

 Always exclude vaginal & urethral causes of urinary symptoms,

(incl. urethritis and genitourinary syndrome of menopause.)
Figure 1: Flowchart for
women aged under 65
years, with suspected
UTI
Diagnostic points for men aged under 65 years
1. Asymptomatic bacteriuria is rare in men <65 years!!

2. Consider other genitourinary causes of urinary symptoms

• check for sexual history (?STIs e.g chlamydia, gonorrhoea)
• Urethritis due to urethral inflammation post sexual intercourse,
irritants, or STIs

3. Check for pyelonephritis, prostatitis, systemic infection, or suspected

sepsis using local policy
• Urinary symptoms + fever or systemic symptoms in men
= prostatic involvement, or pyelonephritis
• Acute prostatitis (check symptoms)
• Recurrent or relapsing UTI in men  referral to urology for Ix

4. Always send a mid-stream urine sample for culture, collected before

antibiotics are given

If suspected UTI, offer immediate treatment according to NICE/PHE

guideline on Lower UTI: antimicrobial prescribing and review choice of
antibiotic with pre-treatment culture results
 Figure 2: Flowchart
for men and women
aged over 65 years
with suspected UTI

• Difficult diagnosis
due to prevalence of
dementia and
asymptomatic
bacteriuria.

• ‘asymptomatic
bacteriuria’ will test
positive on a urine
dipstick !!

• But is not harmful

and Abx are not
beneficial and will
contribute to
increasing antibiotic
resistance
Treatment options
Difficult balance between the clinical, empirical management of UTIs using
broad-spectrum antibiotics, and the development of antibiotic resistance in the
community.

. Trimethoprim resistance in is now at 28.6% of E. coli urine isolates, compared

with only 2% for nitrofurantoin, and 6% for pivmecillinam.

Nitrofurantoin is therefore a first-line antibiotic to consider in all

patients (except women who are pregnant at term)

NICE and PHE now recommend cefalexin as a first-line treatment for

oral treatment of pyelonephritis in the community
When to send urine for culture:
Send a urine for culture in:

• over 65 year olds if symptomatic and Abx given

• pregnancy: for routine tests or if symptomatic

• suspected pyelonephritis or sepsis

• suspected UTI in men

• failed Abx treatment or persistent symptoms

• recurrent UTI (= 2 episodes in 6 months, or 3 in 12 months)

References
• www.gov.uk/government/publications/urinary-tract-infection-
diagnosis.

• https://assets.publishing.service.gov.uk/government/uploads/syst
em/uploads/attachment_data/file/829723/Diagnosis_of_urinary_tr
act_infections_UTI_diagnostic_flowchart.docx

• www.rcgp.org.uk/TARGETantibiotics.