The discomfort and pain experienced by patients, coupled with the severe consequences if left untreated, means that urinary tract infections are a complex target for healthcare professionals. NIHR talks to Geraldine Conlon-Bingham,  Antimicrobial Pharmacist at the Southern Health & Social Care Trust, about the different presentations of the condition.

What are the Ramifications of Delayed Treatment for Urinary Tract Infections (UTIs), or the Absence of Any Treatment at all?

Any untreated infection can lead to sepsis, which is an organ malfunction due to infection which may be life-threatening.

UTIs in particular are one of the main causes of gram-negative bacteraemia. This is a bloodstream infection with gram-negative organisms, which are commonly implicated in UTIs. Over the past number of years we have seen a rise in this infection, and across health trusts in the UK, the government have issued targets to reduce the incidence of healthcare-acquired gram-negative bacteraemia by 50 per cent by 2024.

That being said, patients should only be treated for a UTI if they display signs and symptoms of infection, such as dysuria, increased frequency, urgency, and flank pain. Urine dipstick tests are no longer recommended in patients > 65 years as these patients commonly have asymptomatic bacteriuria, which does not require treatment with antibiotics.

Unnecessary antibiotic exposure increases the risk of side-effects of antibiotics and of healthare-acquired infections. In addition, there is an increased risk of development and spread of antibiotic resistance, which will negatively impact the future management of infection.

What are the Characteristics and Differences Between Complicated UTIs and Uncomplicated UTIs?

A simple UTI is an infection that is confined to the bladder, and presents with dysuria, increased frequency, urgency, and haematuria.

A complicated UTI extends beyond the bladder and will present with systemic signs of infection, such as temperature spikes, delirium, rigors, and suprapubic tenderness. Catheterised patients commonly develop asymptomatic bacteriuria which should not be treated unless the patient is pregnant or has urology procedures planned.

How do Treatment Options for the Conditions Differ?

The key to successfully treating a UTI is to identify the causative organism and antibiotics to which it is sensitive. Therefore a urine sample should be obtained and sent to the laboratory in patients presenting with signs and symptoms of a UTI. Generally, for a simple UTI, oral antibiotic treatment is sufficient, such as nitrofurantoin, pivmecillinam, trimethoprim and oral fosfomycin. Treatment for three days for females and seven days for males is sufficient. Catheter-associated-UTIs require treatment for seven days regardless of whether the patient is male or female.

For patients with signs of sepsis, IV antibiotics may be required, such as gentamicin or piperacillin / tazobactam, for a period of 48 hours before stepping down to an oral agent. Also depending on the urine culture results, the patient may require IV antibiotics as the isolated organism may not be sensitive to any oral agent.

In Which Scenarios and Groups of Patients are IV Antibiotics most Commonly Utilised?

In patients presenting with signs of sepsis, such as delirium, hypotension, tachycardia, tachypnoea, decreased oxygen saturation, rash mottled skin or decreased urine output, it is imperative that IV antibiotics should be administered within one hour of onset of symptoms. IV antibiotics are generally administered for a period of 48 hours, after which, step down to oral therapy should be considered. However, increasingly there is evidence to suggest that the use of highly bioavailable oral agents are as effective as IV agents in the management of complicated UTIs.