RN First Call Certified Practice
Adult Decision Support Tools: LOWER URINARY TRACT INFECTION (FEMALE)
This decision support tool is based on best practice as of February 2012. For more information or to
provide feedback on this or any other decision support tools, e-mail [email protected]
ADULT (FEMALE) LOWER URINARY TRACT INFECTION (UTI)
DEFINITION
Bacterial infection of the bladder, also known as cystitis, caused by bacteria multiplying in the
urine.
Potential Causes
 Escheria coli (E. coli) is the most common organism in 80-90% of cases
 Staphylococcus saprophyticus
 Other enterobacteria
Predisposing risk factors
 Female gender
 Sexual activity
 Previous Urinary Tract Infections (UTIs)
 Pregnancy
 Use of spermicides, diaphragm
 Infrequent voiding
 Dehydration
 Urinary instrumentation (e.g., catheterization)
 Renal calculi
 Immunocompromise (e.g., Human Immunodeficiency Virus (HIV) infection)
 Diabetes mellitus
 Genito-urinary (GU) tract anomalies (congenital, urethral stricture, neurogenic bladder,
tumour)
Typical findings
 Frequency
 Urgency
 Dysuria
 Mild dehydration
 Afebrile
 Supra pubic discomfort
 Bladder spasm
 Foul smelling urine
 Hematuria
CRNBC monitors and revises the CRNBC certified practice decision support tools (DSTs) every two years and as necessary based
on best practices. The information provided in the DSTs is considered current as of the date of publication. CRNBC-certified nurses
(RN(C)s) are responsible for ensuring they refer to the most current DSTs.
The DSTs are not intended to replace the RN(C)'s professional responsibility to exercise independent clinical judgment and use
evidence to support competent, ethical care. The RN(C) must consult with or refer to a physician or nurse practitioner as
appropriate, or whenever a course of action deviates from the DST.
THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC
© CRNBC May 2012/Pub. 685
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RN First Call Certified Practice
Adult Decision Support Tools: LOWER URINARY TRACT INFECTION (FEMALE)
PHYSICAL ASSESSMENT
Vital Signs
 Temperature
 Pulse
 Respiratory rate
 SpO2
 Blood pressure
General
 Hydration status
 Supra pubic tenderness – may be mild to moderate
 Flank pain if present refer or consult as suggests ascending infection
 Costo-vertebral angle (CVA) percussion - presence of tenderness suggests ascending
infection
Note: In the elderly, symptoms do not always follow the classic triad of urgency, frequency and
dysuria. Look for subtle cognitive changes and predisposing factors.
Female
 Perform a pelvic exam and full Sexually Transmitted Infection (STI) screening if abnormal
vaginal discharge or symptoms suggestive of vaginitis or STI are present
 Use appropriate Decision Support Tool(s) (DSTs) for treatment and follow-up as there may
be more than one condition present (e.g., STI and UTI)
 Diagnostic tests
 Urinalysis
 Dipstick test: blood, protein, nitrites, leukocytes
 Consider microscopic urinalysis: White Blood Cells (WBC), Red Blood Cells (RBC),
bacteria
 Urine Culture and Sensitivity (C&S) is generally not required with uncomplicated UTI –
consider a urine C&S if:
- this is the second presentation of a UTI within a one-year time-frame
- the client presents with fever, chills, rigor, or flank pain (refer or consult)
- dipstick test is negative and symptoms are indicative of a likely UTI
 Offer full STI screening if appropriate – if full STI screening declined obtain a urine
specimen for CT/GC NAAT as indicated
 Consider pregnancy test if indicated
Note: If urinary frequency, urgency or dysuria and dipstick is positive for leukocytes and/or
nitrites may treat as lower UTI.
MANAGEMENT AND INTERVENTIONS
Goals of treatment
 Relieve symptoms
 Prevent ascending infection
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© CRNBC May 2012/Pub. 685
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RN First Call Certified Practice
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Adult Decision Support Tools: LOWER URINARY TRACT INFECTION (FEMALE)
Eradicate infection
Non-pharmacological interventions
Rest, if febrile
Keep hydrated, increase fluids
PHARMACOLOGICAL INTERVENTIONS
Oral antibiotics - Female
First choice
Nitrofurantoin (monohydrate/macrocrystal formulation - Macrobid) 100 mg, po bid for 5-7 days
or
Nitrofurantoin (macrocrystal formulation - Macrodantin) 50-100 mg, po qid for 5-7 days
Second choice
Trimethoprim 160 mg / Sulphamethoxazole 800 mg, 1 tab po bid for 3 to 7 days
Third choice
Cephalexin 250-500 mg po qid for 7 days
Note: Women with bladder outlet obstruction, spinal cord injury, long term catheterization, have
failed short-term treatment previously, or have diabetes and UTI symptoms for a week should be
given 7 to 10 days of treatment.
Oral Antibiotics - Pregnant or Breast Feeding Women
Nitrofurantoin (monohydrate/macrocrystal formulation - Macrobid) 100 mg, po bid for 5-7 days
(do not use in third trimester or labour)
Or
Nitrofurantoin (macrocrystal formulation - Macrodantin) 50-100 mg, po qid for 5-7 days (do not
use in third trimester or labor)
Or
Keflex 250 mg po qid for 7 days
Trimethoprim 160 mg / Sulphamethoxazole 800 mg (do not use in pregnancy)
POTENTIAL COMPLICATIONS
 Ascending infection (pyelonephritis)
 Chronic cystitis
CLIENT EDUCATION AND DISCHARGE INFORMATION
 Advise on condition, timeline of treatment and expected course of disease process
 Return to clinic if fever develops or symptoms do not improve in 48-72 hours
 Counsel client about appropriate use of medications (dose, frequency, side effects, need to
complete entire course of medications)
 Recommend increasing fluid intake to 8-10 glasses per day
 Sitting in a warm tub may relieve symptoms of dysuria
 Advise regarding wiping front to back after a bowel movement
 Do not use douches
THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC
© CRNBC May 2012/Pub. 685
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RN First Call Certified Practice
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Adult Decision Support Tools: LOWER URINARY TRACT INFECTION (FEMALE)
Avoid bubble baths
Advise that voiding after intercourse may be beneficial
Use appropriate cleaning for sex toys and advise against sharing sex toys
MONITORING AND FOLLOW-UP
 If symptoms do not begin to resolve in 48-72 hours or if symptoms progress despite
treatment, client should return to the clinic for reassessment
 Pregnant women who present with symptoms of UTI are recommended to have urinalysisC&S monthly
CONSULTATION AND/OR REFERRAL
 Presence of complicating factors suggestive of upper urinary tract infection (fever (>38◦ C),
chills, flank pain, CVA tenderness, nausea and vomiting)
 Women presenting with a second UTI within one month or more than three in one year
should be referred to a physician or nurse practitioner
DOCUMENTATION
As per agency policy
REFERENCES
Anti-Infective Review Panel (2012). Anti-infective guidelines for community-acquired
infections. Toronto: MUMS Guideline Clearinghouse.
BC Medical Association, BC Ministry of Health Services (2009). Macroscopic and microscopic
urinalysis and the investigation of UTI. Clinical Practice Guidelines. Victoria BC: BC
Ministry of Health Guidelines and Protocols Advisory Committee.
www.bcguidelines.ca/gpac/
Blondel-Hill, E., & Fryters, S. (2006). Bugs and drugs. Edmonton: Capital Health.
www.bugsanddrugs.ca BC Center for Disease Control (2010). Antimicrobial resistance
trends in the province of British Columbia. Retrieved December 7, 2011 from
www.bccdc.ca/NR/rdonlyres/4F04BB9C-A670-4A35-A236CE8F494D51A3/0/2010AntimicrobialResistanceTrendsinBCJuly2011.pdf
Brusch, J. (2011). Urinary tract infections in females. Retrieved December 6, 2011 from
http://emedicine.medscape.com/article/233101-overview
Canadian Pharmacists Association (2011). (6th Ed.) Therapeutic Choices. Ottawa, ON:
Canadian Pharmacists Association.
Car, J. (2006). Urinary tract infections in women: diagnosis and management in primary care.
BMJ, (332), 94-97.
Cash, J. & C. Glass, (Eds.) (2011) Family Practice Guidelines. New York, NY. Springer
Publishing Company, LLC.
Chen, A., & C Tran. (2011). Comprehensive Medical Reference and Review for MCCQE and
USMLE II. Toronto Notes for Medical Students. Toronto, On: Toronto Notes for Medical
Students, Inc.
Christiaens, T., De Meyere, M., Verschraegan, G. Peersman, W., Heytens, S., & De Maeseneer,
J. (2002). Randomised controlled trial of nitrofurantoin versus placebo in the treatment of
uncomplicated urinary tract infection in women. British Journal of General Practice.
September, 729-734.
THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC
© CRNBC May 2012/Pub. 685
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RN First Call Certified Practice
Adult Decision Support Tools: LOWER URINARY TRACT INFECTION (FEMALE)
Colgin, R., & Williams, M. (2011). Diagnosis and treatment of acute uncomplicated cystitis.
Retrieved December 6, 2011 from
www.aafp.org/afp/2011/1001/p771.html#afp20111001p771-t2
Fihn, S. (2003). Acute uncomplicated urinary tract infection in women. The New England
Journal of Medicine, (349), 259-266.
First Nations and Inuit Health Branch (2010). Clinical practice guidelines for primary care
nurses. Adult care. Retrieved December 2011 from http://www.hc-sc.gc.ca/fniahspnia/services/nurs-infirm/clini/adult/index-eng.php
Grude, N., Tveten, Y., Jenkins, A., & Kristiansen, B. (2005). Uncomplicated urinary tract
infections: Bacterial findings and efficacy of empirical antibacterial treatment.
Scandinavian Journal of Primary Health Care, (23) 115-119.
Gupta, K., Hooton T. M., Naber, K. G., Wullt, B., Colgan, R.(2011). Infectious Diseases Society
of America, European Society for Microbiology and Infectious Diseases. International
clinical practice guidelines for the treatment of acute uncomplicated cystitis and
Pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America
and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis.
Mar; 52(5), 103-20. Retrieved December 7, 2011 from
http://www.guideline.gov/content.aspx?id=25652&search=international+clinical+practic
e+guidelines+for+the+and+cystitis
Jackson, M. (2007). Evidence-based practice for evaluation and management of female urinary
tract infection. Urologic Nursing, (27)2, 133-136.
Jensen, B., & Regier, L. (2008). The Rx Files Drug Comparison Charts (7th Ed).
www.rxfiles.ca
Johnson, E. (2011). Urinary tract infections in pregnancy. Retrieved December 6, 2011 from
http://emedicine.medscape.com/article/452604-overview#aw2aab6b2
Katchman, M., Christiaens, T., Baerheim, A., & Leibovici, L. (2009). Duration of antibacterial
treatment for uncomplicated urinary tract infection in women. Cochrane Database of
Systematic Reviews 2005, Issue 2. Art. No.: CD004682. DOI:
10.1002/14651858.CD004682.pub2.
Nicolle, L., Anderson, P., Conly, J., Mainprize, T., Meuser, J. (2006). Uncomplicated urinary
tract infection in women. Canadian Family Physician (52), 612-618.
Rx Files. (2011). Urinary Tract Infections (Adult). Retrieved January 30, 2012 from
http://www.rxfiles.ca/rxfiles/uploads/documents/members/CHT-UTI-Tx.pdf
THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC
© CRNBC May 2012/Pub. 685
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