Question

Case study level 2 – Urinary tract infection (UTI)
Learning outcomes Level 2 case study: You will be able to: interpret relevant lab and clinical data identify monitoring and referral criteria explain treatment choices describe goals of therapy, including monitoring and the role of the pharmacist/clinician describe issues – counselling points, adverse drug reactions, drug interactions, complementary/alternative therapies and lifestyle advice.
Scenario

A 27-year-old woman presents a prescription for nitrofurantoin tablets 50 mg q.d.s. for 3 days and asks to speak to the pharmacist. She explains that her GP has checked her urine with a ‘coloured strip’ and diagnosed a urinary tract infection (UTI). She is suffering considerable discomfort on urination due to a burning/stinging sensation and her GP has suggested she purchase some Effercitrate over the counter. A friend has recommended she also purchase cranberry extract tablets and the patient would like your advice.

Questions
1 What are the symptoms and signs of a UTI and what is the role of dipstick testing?
2a When can a patient with cystitis be safely treated with over-the-counter products and when should they be referred to their GP?
2b When is antibiotic treatment indicated for UTI?
3a What are the typical UTI pathogens and what are the treatment choices for lower UTI in a non-pregnant woman?
3b What are the treatment choices for lower UTI in a pregnant woman?
4a What should be considered by the pharmacist when dispensing nitrofurantoin?
5a What alternative therapies are available for cystitis and how effective are they?
5b What lifestyle advice can be offered to patients with cystitis?

Answer 1

1. Symptoms and signs of UTI

• Burning sensation while urinating
• Dysuria
• Urgency and frequent urination
• Discomfort / pain in the lower abdomen
• Stingy, cloudy or bloody urine
• Flank pain
• Fever,chills and tiredness
• Cramping pain in pelvis or pubic bone,seen in women.

Role of dipstick testing

Urine dipsticks are the most appropriate method for checking the presence of blood in a fresh urine sample.They also detects white blood cells and bacteria in the urine.

2.a. Over - the- counter products can be used in case of mild cystitis,which can be cleared within few days.See a GP when:

• symptoms are not relieved within 3 days of medication
• presence of blood in urine is detected.

2.b. When Urine culture shows the presence of specific bacteria causing UTI, antibiotics should be started.Some physicians prescribe antibiotics as soon as UTI is diagnosed but the use of antibiotic frequently lead to developing resistance by bacteria to the antibiotics.So it would be better to start antibiotics only if UTI is complicated and is not relieved by other measures.

3.a. The typical UTI pathogens are:

• Escherichia coli
• Staphylococcus epidermis
• Staphylococcus aureus
• Klebsiella pneumoniae

Treatment choices for lower UTI in a non-pregnant woman

• Trimethoprim - sulfamethoxazole BD X 3 days
• Ciprofloxacin 250 mg BD X 3 days
• Nitrofurantoin natural crystals 50- 100 mg 4 times daily X 7 days

3.b Treatment choices for lower UTI in a pregnant woman

• Nitrofurantoin 100 mg BD x 7 days
• Amoxicillin 500 mg TDS
• Fosfomycin 3g stat PO
• Co-amoxiclav 625 mg TDS PO X 7 days
• Cefuroxime axetil 500 mg BD po x 7 days
• Cephalexin 500 mg BD PO X 7 days

4.a.Pharmacist should educate the person to

-keep nitrofurantoin at a temperature between 20-25 degree centigrade,

-place the medication away from light

-not to keep the medication in moist areas.

-take the medication with food to improve the absorption of the drug

-not to take antacid preparations along with nitrofurantoin

- contact the physician if there is watery or bloody stools

5.a. Alternative therapies for cystitis

• Dietary modifications including avoidance of bladder irritating food, alkalizing urine with baking soda, improving hydration status,elimination of alcoholic beverages,carbonated drinks,caffeine etc
• herbal treatments consisting of use of chinese herbal tea
• Bladder training in which voiding interval is prolonged by stopping the urgency.
• Physical therapies including exercise,electrical stimulation,yoga etc

Lifestyle advice

• Avoid citrus juices,caffeine and alcoholic beverages.
• Take lot of oral fluids to improve hydration.
• Sitz bath can be taken at home for 15 -20 minutes to relieve pain.
• Use of hot water bag to relieve discomfort.