1. No category

SUSPECTED URINARY TRACT INFECTION (UTI) - NURSE PRACTITIONER
SCOPE OF PRACTICE (SEE SUMMARY OF MANAGEMENT OF UNCOMPLICATED UTI IN ADULTS – PAGE 11)
Practitioner
Scope
Outcomes
Nurse Practitioner
(NP)
Symptoms suggestive of uncomplicated UTI.
Clients not suitable for NP management include:
Male with suspected UTI.
Persons requiring parenteral antibiotics for management of UTI.
Children under 16 years old.
Co-existing medical condition requiring hospital admission or complex
multiple co-morbidities (eg Diabetes and or Renal Failure). Particularly
in age >65 years.
Immuno-compromised person.
o
Evidence of impending septic shock (fever>38.5 C or hypotension or
tachycardia) (1).
Active Intravenous drug user.
Suspected or confirmed penicillin immediate hypersensitivity reaction.
Suspected or confirmed cephalosporin delayed or immediate
hypersensitivity reaction.
Pregnancy.
Previously treated UTI not responsive to antibiotics.
Known renal tract abnormalities (including long term indwelling
catheter, ureteric stents obstructive uropathy, neurogenic bladder).
Suspected Prostatitis.
Signs and symptoms consistent with renal colic/calculi.
Acute delirium.
Social support structure inadequate for support of the client at home.
Mental Health condition not stabilised on treatment (2).
Identify clients suitable for Silver Chain Nurse Practitioner (NP).
Medical
Practitioner
Management of clients not suitable for NP scope of practice (as per above).
Identify client not suitable for NP and refer to Medical
Governance Doctor of Silver Chain or Emergency Department
(ED) of Western Australian Hospital. Joint management by
Medical Governance Doctor of Silver Chain and NP may be
deemed to be appropriate.
CC-NG-002
Review Date: 160410
Page 1 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
CLIENT ASSESSMENT
Activity
Presenting
History
Assessment
Outcome
Relevant past medical history including: Recent or present
instrumentation: catheter, cystoscopy, urodynamics, and history of
prostatic or other genitourinary disease.
Allergy and immunization status (1).
Medication usage (prescribed, over the counter and
herbal/complimentary).
Alcohol, cigarette and illicit drug use profile- ascertain if current
intravenous drug user.
Social and work related status.
Onset and duration of symptoms.
Sexual history.
Treatment to date.
Identify patients not suitable for NP and refer to Medical
Governance Doctor of Silver Chain or ED of Western Australian
Hospital.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
Clinical
Examination
Conduct primary survey: Airway, breathing, circulation, disability, if evidence
of potential system compromise exit clinical practice guideline (1).
Conduct physical examination of genitourinary system include
assessment of body temperature, heart rate, blood pressure and
respiratory rate.
Determine principal differential diagnosis is urinary tract infection; if
findings inconsistent collaborate and if necessary refer to Medical
Governance Dr of Silver Chain.
Female clients with evidence of vaginal itch or discharge are
recommended to undergo visual examination of external genitalia and
vaginal examination (2).
Male clients are recommended to undergo visual examination of
external genitalia and digital rectal examination if an enlarged prostate
is suspected (2).
Clinical examination finding consistent with diagnosis of UTI.
Ongoing care to be provided by NP. Identify patients not
suitable for NP and refer to Medical Governance Doctor of
Silver Chain or ED of Western Australian Hospital.
Exit clinical practice guideline if evidence of abnormal primary
survey.
Male clients with evidence of prostatic hypertrophy and female
clients with evidence of vaginitis will be referred to Medical
Governance Doctor of Silver Chain.
Clinical examination findings inconsistent with diagnosis of UTI
will initiate collaboration with Medical Governance Doctor. Joint
management by Medical Governance Doctor of Silver Chain and
NP may be deemed to be appropriate.
Pain Assessment
Determine intensity of pain (refer to Symptom Assessment Scale Manual
Entry Form HCS-FRM-054) and location, duration and characteristics of
pain.
Determines need and type of pain relief modalities required.
Can guide the NP in determining alternative differential
diagnosis.
CC-NG-002
Review Date: 160410
Page 2 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
Activity
Assessment
Outcome
Nausea and
Vomiting
Assessment
Determine severity of nausea (refer to Symptom Assessment Scale
Manual Entry Form HCS-FRM-054).
Assess for precipitating factors, frequency and duration of nausea and
vomiting.
Determines need for antiemetics.
Imaging
Renal tract ultrasound (includes upper and lower tract - bladder).
Plain abdominal x-ray.
Renal status, obstruction, dilatation, bladder emptying capacity
demonstrated. Abdominal x-ray will help to identify radioopaque renal tract calculi. Radiological identification of renal
tract pathology will initiate referral to Medical Governance
Doctor, joint management by Medical Governance Doctor and
NP of Silver Chain may be deemed to be appropriate.
Pathology
Urine for microscopy, culture and sensitivity (MSU).
Full blood picture and urea and electrolytes if evidence of pyelonephritis
or client acutely unwell (3).
Qualitative beta human chorionic gonadotropin (B HCG) if female and
of child bearing years.
Blood cultures if temperature >38.5, rigors or toxic clinical picture (3).
Random plasma glucose level via finger prick (for client with known
Diabetes Mellitus or high risk for Diabetes Mellitus).
Macroscopic urinalysis (dipstick) (4).
Gentamicin trough level if duration of therapy >3 days (5).
Gentamicin dosing >3 days should be avoided because of risk of
nephro and or oto-toxicity.
Identify causative organisms and susceptibility of organisms to
antibiotic treatment.
Provide further evidence to suggest systemic inflammation.
Identify any end organ involvement (renal).
Assist in identification of undiagnosed or exacerbation of known
Diabetes Mellitus.
Macroscopic urinalysis results will provide further evidence for
presence of UTI.
Gentamicin level monitoring to identify potential drug toxicity.
CC-NG-002
Review Date: 160410
Page 3 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
INTERPRETATION OF RESULTS AND MANAGEMENT DECISIONS
Investigation
Interpretation
Outcomes
Elevated Plasma
Glucose Level
Random plasma glucose level >8.0mmol/l in non diabetic client
warrants further investigation for evidence of undiagnosed Diabetes
Mellitus-referral to client’s General Practitioner for follow up (6).
Loss of glycaemic control in a well controlled type 1 and 2 Diabetes
Mellitus warrants collaboration with Medical Governance Doctor of
Silver Chain and if deemed necessary transferred back to care of
Medical Governance Doctor of Silver Chain or ED of WA public
hospital.
General Practitioner referral for further investigation of
unrecognized hyperglycaemia.
Collaboration with Medical Governance of Silver Chain re
management of poor glycaemic control in known type 1 or 2
Diabetes Mellitus client.
Transfer of care back to Medical Governance Doctor of
Silver Chain or ED of WA public hospital.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
Leucocytosis and
Neutrophilia
Leucocytosis and neutrophilia is a common finding in pyelonephritisabsence of, warrants consideration of alternative diagnosis and
collaboration and possible referral to Medical Governance Doctor of
Silver Chain (3).
Alternative diagnosis considered.
Initiates collaboration and possible referral to Medical
Governance Doctor of Silver Chain.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
Positive Urine
Culture
Identification of organism will guide Practitioner in antibiotic therapy.
Evidence of atypical or multi-resistant organism will initiate collaboration
and possible referral to Infectious Diseases Specialist.
Identification of positive blood cultures requires collaboration and
possible referral to Infectious Diseases Specialist.
Antibiotic regime adjusted to reflect susceptibility results.
Atypical or multi-resistant organism initiates collaboration and
possible referral to Infectious Diseases Specialist.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
Positive blood cultures initiates collaboration and possible
referral to Infectious Diseases Specialist.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
Deranged Renal
Function Tests
Biochemical evidence of acute deterioration in renal function tests
(serum creatinine >110micromol/L) necessitates collaboration and
possible referral with Medical Governance Doctor of Silver Chain to
reconsider severity of UTI or alternative diagnosis (3).
Abnormal renal function initiates collaboration and possible
referral to Medical Governance Doctor of Silver Chain.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
CC-NG-002
Review Date: 160410
Page 4 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
Investigation
Interpretation
Outcomes
Positive
Macroscopic
Result (dipstick)
Presence of blood, nitrites or leucocytes strengthens diagnosis of UTI
(4).
Presence of microscopic or macroscopic haematuria in male client
warrants collaboration and referral to Medical Governance Doctor of
Silver Chain (2).
Assists in diagnosis of UTI.
Presence of haematuria in male initiates collaboration and
referral to Medical Governance Doctor of Silver Chain.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
Elevated
Gentamicin
Trough Level
Elevated trough level warrants dose readjustment (5).
Potential drug toxicity will be identified and treated.
CLIENT SUPPORT
Topic
Action
Outcomes
Certificates
Absence from work certificates will be provided as appropriate.
Workers compensation and Motor Vehicle Insurance Trust certificates
will be provided as appropriate.
Referral letters.
Correspondence with client’s GP.
Follow Up
Review in 3 days.
Follow up pathology results.
Persistent fever and or loin pain warrants further investigation: MSU,
renal tract ultrasound and collaboration/referral with Medical
Governance Dr of Silver Chain.
Client Education
Hygiene and prevention strategies.
The client will demonstrate an understanding of strategies to
reduce the risk of UTI.
Referrals
Health Care Practitioners for issues that lie outside NP Scope of
Practice.
Issues that lie outside NP Scope of Practice will be referred onto
appropriate Health Care Practitioners.
CC-NG-002
Review Date: 160410
Page 5 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
PHARMACOLOGY INFORMATION
Drug Group
General
Information
Drug Formulary
Outcomes
Client will be educated re medication usage, potential adverse effects and
course of action to take in event of adverse effect.
Anaphylaxis will be managed as per Silver Chain policy FP4-OA (33)
Anaphylaxis emergency management in the home.
Client will use the medication in an effective and safe manner.
Prescribing NP will be informed of significant adverse effects of
medication.
Analgesia Mild
pain
(unscheduled-S2)
(7&8)
Adults and children > 12yrs old: Paracetamol PO 0.5 to 1.0g 4-6hrly not
to exceed 4g in 24 hours.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Analgesia requirements determined by ongoing assessment of
pain.
Analgesia
Moderate Pain
(S2-S4) (7&8)
ADD to paracetamol if still in pain
Adults: Ibuprofen: PO 200-400mg TDS or QID up to maximum dose of
2400mg per 24 hours.
If pain poorly managed with above regime or client not suitable for non
steroidal anti-inflammatory drugs add Panadeine Forte (in lieu of
paracetamol): 1-2 tablets,4-6 hourly, maximum of 8 tablets in 24 hours
(only suitable for adults).
If non steroidal anti-inflammatory drugs and Panadeine forte not
suitable or pain poorly controlled refer back to Medical Governance
Doctor of Silver Chain.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Use ibuprofen with caution in clients with evidence of renal
impairment and in the elderly.
Analgesia requirements determined by ongoing assessment of
pain.
Severe pain warrants consideration of severity of UTI or
alternative differential diagnosis.
Inadequate pain relief initiates referral to Medical Governance
Doctor of Silver Chain.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
CC-NG-002
Review Date: 160410
Page 6 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
Drug Group
Drug Formulary
Outcomes
Antiemetics
S4 (8&9)
Ondansetron
4-8 mg IV/IM/subling or PO BD.
Metoclopramide
Adult (>20yrs old) Total daily dose should not normally exceed
0.5 mg/kg. Give orally, IV or IM as needed.
>60 kg, 10 mg 3 times daily.
30–59 kg, 5 mg 3 times daily.
Generally a dose of 5mg TDS is better tolerated due to less adverse
effects of drowsiness.
Adult: Oral, initially 20 mg, then 10 mg 2 hours later; if still needed,
Prochlorperazine
PO: 5–10 mg tds, IM/IV: 12.5 mg every 8 hours as needed, .Rectal:
25 mg followed by oral medication (if possible) 6 hours later.
Enteric administration route will be the route of choice- a parental route
will be utilized if the enteric route is unsuitable.
Uncontrolled nausea and vomiting warrants collaboration and possible
referral to Medical Governance Doctor of Silver Chain for further
assessment and management.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Referral to Medical Governance Doctor of Silver Chain for poorly
controlled nausea and vomiting.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
Antibiotics
S4 (5&8)
Antibiotic therapy as per drug formulary below.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Collaboration with Infectious Diseases Specialist or Medical
Governance Doctor of Silver Chain for patient showing no
improvement after ~ 72 hours of antibiotics or worsening illness
severity.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
CC-NG-002
Review Date: 160410
Page 7 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
ANTIBIOTIC DRUG FORMULARY
Indication (2,5&8)
Drug (2,5&8)
UTI in Women
Mild lower UTI in non-pregnant woman
Mild lower UTI as an alternative to Trimethoprim in non-pregnant woman
Mild lower UTI as an alternative to Trimethoprim or Cephalexin in nonpregnant woman
Mild lower UTI as an alternative to Trimethoprim, Cephalexin and
Amoxycillan+clavulanate in non-pregnant woman
If resistance to above drugs is present or if the organism is identified as
Pseudomonas aeruginosa in non-pregnant woman
UTI in Men
Mild UTI men
Mild UTI as an alternative to Trimethoprin
Mild UTI as an alternative to Trimethoprim or Cephalexin
Mild UTI as an alternative to Trimethoprim, Cephalexin,
Amoxycillan+clavulanate
Men and Women
Mild acute pyelonephritis (low grade, fever and no nausea or vomiting)
Mild acute pyelonephritis (low grade, fever and no nausea or vomiting) as
an alternative Cephalexin
Mild acute pyelonephritis (low grade, fever and no nausea or vomiting) as
an alternative to Cephalexin or Amoxycillan+clavulanate
Mild acute pyelonephritis (low grade, fever and no nausea or vomiting) as
an alternative Cephalexin or Amoxycillan+clavulanate or Trimethoprim
Mild acute pyelonephritis (low grade fever and no nausea or vomiting) and
if resistance to above drugs is present or if the organism is identified as
Pseudomonas aeruginosa
As an alternative to Norfloxacin in mild acute pyelonephritis (low grade,
fever and no nausea or vomiting) and if resistance to above drugs is
present or if the organism is identified as Pseudomonas aeruginosa
CC-NG-002
Dosage
Duration of Drug Therapy
Trimethoprim
Cephalexin
Amoxycillan + clavulanate
300mg PO daily
500mg PO BD
500+125mg PO BD
3 days
5 days
5 days
Nitrofurantoin
50mg PO QID
5 days
Norfloxacin
400mg PO BD
3 days
Trimethoprim
Cephalexin
Amoxycillan+clavulanate
Nitrofurantoin
300mg PO daily
500mg PO BD
500+125mg PO BD
50mg PO QID
14 days
14 days
14 days
14 days
Cephalexin
500mg PO 6-hourly
Amoxycillan+clavulanate
875+125mg PO BD
Trimethoprim
300mg daily PO
Trimethoprim+
sulfamethoxazole
Norfloxacin
160+800mg PO BD
10 days for women,
14 days for men
10 days for women,
14 days for men
10 days for women,
14 days for men
10 days for women,
14 days for men
10 days for women,
14 days for men
Ciprofloxacin
500mg PO BD
Review Date: 160410
400mg PO BD
10 days for women,
14 days for men
Page 8 of 11
Suspected Urinary Tract Infection (UTI) - Nurse Practitioner
Drug Group
Drug Formulary
Outcomes
Adrenaline
S3 (8,10&11)
Indicated for use in patients experiencing anaphylaxis.
Dosage-for adults and children >12yrs old with spontaneous circulation:
300ug (epipen) or 500ug (adrenaline 1:1000) IM-lateral thigh repeated
every 5 minutes if inadequate resolution of symptoms.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Cetirizine
S2 (8,10&11)
Indicated for use in patients experiencing cutaneous changes only
associated with drug hypersensitivity reaction.
Dosage for adults and children> 12 years old: 10mg daily.
Route: Oral.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Sodium Chloride
0.9% IV fluid
(8,10,11&12)
Unscheduled
Indicated for use in patients with evidence of hypovolaemia due to
hypovolaemic or septic shock or anaphylaxis.
Route: IV.
Dosage for adult (18yrs or older) 250-1000ml STAT.
Dosage for children (<18yrs old) 20ml/Kg STAT.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Oxygen Therapy
Oxygen therapy will be guided by measured oxygen saturation levels
(SaO2).
Patients with no history/evidence of chronic lung disease aim for SaO2
> 94%.
Oxygen delivery device will be either nasal prongs or face mask.
Patients with history of chronic lung disease aim for Sao2 via oxygen
delivery device equivalent to baseline SaO2 (if known) otherwise aim for
SaO2 >90%.
Authorization for use of oxygen therapy to seek to maintain
SaO2 > 90%.
Transferral of care to Medical Governance Doctor of
Silver Chain or ED of WA public hospital.
Joint management by Medical Governance Doctor of
Silver Chain and NP may be deemed to be appropriate.
CC-NG-002
Review Date: 160410
Page 9 of 11
Suspected Urinary Tract Infection (UTI) Nurse Practitioner
PURPOSE:
Summary of Management of Uncomplicated UTI in Adults (excluding pregnant
females by HATH Nurse Practitioner)
SCOPE:
PROCESS
Obtain patient history:

Dysuria, frequency

Suprapubic/flank pain

Fever

Antibiotic allergies
Conduct physical assessment
Conduct Urine dipstick analysis:

Leucocyte

Nitrites
Consider differential diagnosis:

(Collaborate with Medical
Governance Doctor as need
arises)

Renal Colic/Calculi
Male:

Prostatitis

Epididyorchitis

Urethritis
Female:

Pelvic Inflammatory Disease

Vaginitis
Conduct Investigations:
MSU for MC&S.
If pyelonephritis suspected: U&E,
FBP, BC
If pregnancy suspected: beta-HCG
Suitable for NP HATH:

Cystitis

Mild uncomplicated
Pyelonephritis
Determine if
suitable for NP
HATH
management
No
Yes
Unsuitable for NP HATH:

Evidence of complicated UTI

Severe illness:

Male with UTI

Parental antibiotics required

Pregnancy

Acute onset

Delirium

Temp> 38.50C

Hypotension

Oliguria

Renal tract abnormality:

IDC/SPC/ureteric stent insitu,

Obstruction, neurogenic
bladder

Renal failure

Presence of unstable comorbiditity (eg diabetes,
decompensated heart failure)
Suitable for oral
antibiotics?
Yes

Commence oral Trimethoprim
300mg daily or amoxycillin
500mg+clavulanate acid 125mg BD.
14 days for males
5 days for females uncomplicated
cystitis or 10 days for pyelonephritis.




No
Refer to Medical
Governance Doctor or
Emergency
Department
Referral to Medical
Governance Doctor or
Emergency Department
Review in 2 days with MSU
result (CC: GP)
Further investigations by GP for
all male UTIs and females with
recurrent/complicated UTI
MAC-CPG-002
Review Date: 070210
Page 10 of 11
Suspected Urinary Tract Infection (UTI) Nurse Practitioner
REFERENCES
1
Lee F. Clinical practice guideline and protocol urinart tract infection [Online]. 2007 Aug [cited 2009 Feb
28]; Available from:
URL:http://www.ocno.health.wa.gov.au/practitioner/docs/urology_continence/NPCG_UTI.pdf
2
Scottish Intercollegiate Guideline Network. Management of suspected bacterial urinary tract infection
in adults; A national clinical guideline. [Online] 2006 [cited 2009 Mar 9]; Available from:
http://www.sign.ac.uk/pdf/sign88.pdf.
3
Nicolle L. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol
Clin N Am [serial online] 2008 Feb [cited 2009 Feb 24]; 35:1-12. Avalable from: URL:
http://www.mdconsult.com.rplibresources.health.wa.gov.au/das/article/body/1250392653/jorg=journal&source=MI&sp=20186587&sid=814689937/N/620000/s0094014307000894.pdf?SEQN
O=1&issn=0094-0143
4
St John A, Boyd J, Lowes A, Price C. The use of urinary dipstick tests to exclude urinary tract
infection-a systematic review of the literature. Am J Clin Pathol 2006;126: 428-436.
5
eTG complete 2008. Urinary tract infections.Therapeutic Guidelines limited. [Online]. 2008 Nov [cited
2009 Feb 24]. Available from: URL:http://etg.tg.com.au.rplibresources.health.wa.gov.au/ip/
6
Australian Centre for Diabetes Strategies Prince of Wales Hospital, Sydney. National Evidence Based
Guidelines for the management of type 2 diabetes mellitus. [Online]. 2001 updated 2005 [cited 2009
Feb 22]; Available from: National Health and Medical Research Council
http://www.nhmrc.gov.au.rplibresources.health.wa.gov.au/PUBLICATIONS/synopses/_files/di9.pdf
7
eTG complete 2008. Analgesics.Therapeutic Guidelines limited. [Online]. 2008 Nov [cited 2009 Feb
24]. Available from: URL:http://etg.tg.com.au.rplibresources.health.wa.gov.au/ip/
8
Australian Medicines Handbook. [Online]. 2009 Jan [cited 2009 Feb 22]. Available from: URL:
http://www.amh.net.au.rplibresources.health.wa.gov.au/online/view.php?page=index.html
9
eTG complete 2008. Nausea and vomiting.Therapeutic Guidelines limited. [Online]. 2008 Nov [cited
2009 Feb 24]. Available from: URL:http://etg.tg.com.au.rplibresources.health.wa.gov.au/ip/
10
Australian Resuscitation Council. Cardiopulmonary resuscitation for advanced life support providers.
Melbourne : Australian Resuscitation Council, 2007.
11
Working group of the Resuscitation Council (UK). Emergency treatment of anaphylactic reactionsguidelines for healthcare providers. Resus 2008 77: 473-483.
12
Burridge N, editor. Australian Injectable Drugs Handbook-The Society of Hospital Pharmacists of
th
Australia. 4 ed. Melbourne: SHPA Publications. 2008.
MAC-CPG-002
Review Date: 070210
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