723036. research-article2017.

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2 9 8 C P J / R P C • S e p t e m b e r / O c t O b e r 2 0 1 7 • V O L 1 5 0 , N O 5
© The Author(s) 2017
DOI: 10.1177/1715163517723036
Practice guidelines PeeR-ReViewed
Practice guidelines * Peer-reviewed
723036CPHXXX10.1177/1715163517723036C P J / R P C C P J / R P C
research-article2017
The assessment and management
of urinary tract infections in adults:
Guidelines for pharmacists
Nathan P. Beahm, BSP, PharmD; Lindsay E. Nicolle, MD, FRCPC; Alistair Bursey,
BScPharm; Daniel J. Smyth, MD, FRCPC; Ross T. Tsuyuki, BSc(Pharm), PharmD, M
FCSHP, FACC
Introduction
Urinary tract infection (UTI) is one of the most
common indications for which antimicrobials are
initiated.1-3 UTIs cause symptoms that are often
distressing for patients and can lead to serious
complications. They are also often overscreened
by means of obtaining urine cultures when not
clinically indicated and, especially in the case of
asymptomatic bacteriuria (ASB), overtreated.3,4
In this era of increasing antimicrobial resistance,
antimicrobial stewardship has become a highly
important measure in the struggle to preserve
the effectiveness of available antimicrobials. The
Infectious Diseases Society of America (IDSA)
definesantimicrobialstewardshipas coordi-
nated interventions designed to improve and
measure the appropriate use of antimicrobials,
with the goal of achieving best clinical outcomes
while minimizingtoxicityand otheradverse
events, thereby decreasing the selective pressure
for antimicrobial-resistantstrains.5 Although
antimicrobial stewardship programs and initia-
tives have largely been localized to hospitals and
other institutions, community-based health care
professionals have an important role to play in
antimicrobial stewardship as well.
Pharmacists,with increasingpresencesin
the community, hospital and ambulatory care
settings, are well positioned to have important
rolesin the assessmentand managementof
UTIs. In some provinces, pharmacists already
have the authority to manage UTIs, to varying
degrees. In New Brunswick, uncomplicated UTI
is one of the conditions on the list of ambulatory
conditionsfor which pharmacistshave the
authority to prescribe.6 In Quebec, pharmacists
can prescribe for UTI in females if there h
been a diagnosis of UTI and a resulting prescr
tion to treat it in the past year.7 In Saskatchewan,
prescribing for UTI in females has been pr
posed, but is not yet approved.8 And in Alberta,
pharmacists who have Additional Prescribin
Authorization are able to prescribe for UTI if it
is within their scope of practice and if, through
their own assessmentor collaborativelywith
another health professional, it is determined t
treatment is appropriate.9 Regardless of whether
the pharmacist is taking responsibility for
tiation of therapy for a UTI, the pharmacist ca
play an important role in the assessment of U
and, when indicated, ensuring that antimic
bial treatment is appropriate. Pharmacists oft
receive prescriptions suggesting a diagnosi
UTI or are referred patients from other he
care providers with a suspected UTI. These ar
valuableopportunitiesfor the pharmacistto
assess the appropriateness of treatment. In ad
tion, the pharmacist has an important role in t
education of other health care providers on th
appropriate use of antimicrobials.
The purpose of this document is to serve as
guideline for pharmacists to address the asse
ment and management of UTI in adults in vari
ous settings.
Methods
A literature search was conducted in PubM
Scopus and the Cochrane Library to identi

C P J / R P C • S e p t e m b e r / O c t O b e r 2 0 1 7 • V O L 1 5 0 , N O 5 2 9 9
Practice guidelines
publications relating to the treatment of UTI.
Articles were limited to those published in the
English language. Additional articles were iden-
tified from bibliographicreviewsof relevant
publications. Preference was given to guideline
and review articles. From these, a guideline for
pharmacists was created reflecting these best
practice documents.
Results
Step 0: Know the difference between UTI and ASB
UTI is defined as a bacterial infection of the uri-
nary tract and can involve both the lower (cys-
titis) and upper (pyelonephritis) urinary tract.
Cystitis typically presents with symptoms such
as dysuria with or without frequency, urgency,
suprapubic pain or hematuria. Symptoms sug-
gestive of pyelonephritis include fever, chills,
flank pain or tenderness, with or without the
typical symptoms of cystitis above.2 Characteris-
tics of the urine itself, such as being malodorous
or smelly, or being cloudy, milky or turbid, are
not valid indicators of UTI by themselves.4,10,11
ASB is the presence of bacteria in the urine
without symptoms attributable to the urinary
tract. Only pregnant patients and patients who
will be undergoing a genitourinary procedure
with mucosal breach, such as a transurethral
resection of the prostate, require treatment of
ASB. In other populations, ASB may be very
common;but treatingASB in thesepopula-
tions has not been shown to improve morbid-
ity or mortality, and some studies indicate that
treatment produces more harmful effects than
good.3,10,12 Exposingpatientsto unnecessary
antimicrobial therapy may select for and lead
to subsequentinfectionwith antimicrobial-
resistantorganisms(AROs), causesecondary
infections (including Clostridium difficile) and is
associated with increased risk of adverse effects
and increased costs to the patient and health
care system.3,11,12
Step 1: Assessing for UTI
If a patient presents to a pharmacist complain-
ing of symptoms of UTI, the pharmacist should
further assess to confirm the symptoms that the
patient is experiencing. If a patient has been
prescribed an antibiotic for a presumed UTI,
the pharmacist should also assess here to con-
firm the appropriateness of treatment. Patients
should be asked about symptoms such as dysuria,
frequency,urgency,suprapubicpain, flank
pain or tenderness, fever, or hematuria in non-
catheterized patients. In catheterized patients,
symptoms suggestive of UTI include fever, rig-
ors, flank pain or tenderness, acute hematuria,
purulent discharge from catheter site and new
or worsening mental status (in the presence of
leukocytosis)with no identifiablealternative
cause.13-15If the patient has had a urinalysis or
urine dipstick showing pyuria, or a urine culture
with a significantamountof uropathogen(s)
present, in the absence of symptoms, this would
be consistent with ASB (see Step 0).
Elderly patients can be more difficult to assess
for UTI for several reasons. Some may have
baseline cognitive impairment that limits their
ability to recall or communicate their symptoms.
They may have concurrent illnesses that pres-
ent with nonspecific symptoms, such as urinary
incontinence, that can interfere with the ability
to assess for acute symptoms.14-16See Table 1 for
criteria for UTI diagnosis in elderly patients who
have significantmedicalcomorbidities.14,15,17
For elderly patients with nonspecific symptoms,
such as worsening mental or functional status;
increased confusion, delirium or agitation; or
new or more frequent falls, if their medical sta-
tus is not rapidly declining and they are not on
a fluid restriction, it is preferable to hold anti-
biotics, ensure adequate hydration and observe.
Often this will be sufficient for symptoms to
resolve. If typical UTI symptoms develop, then
treatment as for a UTI is warranted. If nonspe-
cific symptoms continue without the develop-
ment of typical symptoms, assessing for other
causes of the nonspecific symptoms, such as
recent medication changes, uncontrolled pain,
dehydration, hypoxia or other alternate causes,
should be undertaken. If nonspecific symptoms
resolve without the development of typical symp-
toms, no further intervention is necessary.4,14,17
In women with dysuria, if there is also vaginal
discharge or odour, pruritis, painful intercourse,
and no urinary frequency or urgency, vaginitis
becomes more likely than UTI.18
Step 2: Assess for presence of complicating factors
Once it has been determined that the patient has
symptoms consistent with UTI, evaluation for
complicating factors is essential. UTIs are con-
sidered complicated when they are associated
with structural, functional or metabolic condi-
tions that promote UTI. These patients have an

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increased likelihood of resistant pathogens and
may be more likely to experience treatment fail-
ure.2,11Examples of complicating factors include
UTIs in males, chronic obstruction, nephroli-
thiasis, poorly controlled diabetes, indwelling
urinary catheter,chronicrenal insufficiency,
pregnancy and immunosuppression (see Box 1
for examples of complicating factors).
Instances where patients should be referred
for physician assessment include likely upper
UTI (pyelonephritis), patients who appear sys-
temically unwell or septic, suspicion of obstruc-
tion requiring urologic investigation, patients
with a history of recurrent UTI and an increase
in the frequency or severity of symptoms, preg-
nancy, recent urologic intervention or surgery,
or if other aspects of the patient’s presentation
are felt to be beyond the ability of the individ-
ual pharmacist to assess. Isolated epididymitis/
orchitis should be assessed by a physician to rule
out other conditions, such as sexually transmit-
ted infection. Isolated testicular pain and swell-
ing should also be assessed by a physician to
exclude torsion, which is a medical emergency.
Step 3: Considerations for laboratory assessment
If the patient does not have symptoms indicative
of UTI, sending a urine culture is not recom-
mended. If a culture is performed on an asymp-
tomatic patient and results in the presence of
bacteria that is not attributable to contamination,
this is consistent with ASB. Screening for and
treatment of ASB is not recommended, unless
the patient is pregnant or going to be undergo
ing an invasive genitourinary procedure, as ou
lined above.3,12 However, some clinicians have
difficulty ignoring a positive urine culture, eve
when the patient is asymptomatic. One study
hospitalized patients showed that by not routi
reporting urine culture results in noncathet
ized patients, the rates of inappropriate treatm
of ASB were reduced from 48% to 12%.20 There-
fore, one should avoid sending a urine culture
the absence of symptoms to limit the pressure
treat (should the culture result be positive).
If the patienthas an uncomplicatedUTI,
sending a urine culture is usually not nece
sary. Escherichia coli is the most likely pathog
Table 1Criteria for symptomatic UTI in elderly patients with comorbidities
Noncatheterized Catheterized
Minimum criteria include 1 of the following:
• Acute dysuria or acute pain, swelling or tenderness of
testes, epididymis or prostate
OR
• Fever (≥38°C or increase of at least 1.1°C above baseline),
rigors or leukocytosis and at least 1 of the following
symptoms (see below)
OR
• At least 2 of the following symptoms:
• New or increased frequency
• New or increased urgency
• New or increased incontinence
• Suprapubic pain
• Acute flank pain or tenderness
• Gross hematuria
Minimum criteria include no alternative diagnosis AND 1 of
the following:
• Fever (≥38°C or 1.1°C above baseline), rigors or new-onset
hypotension
• Leukocytosis and either an acute change in mental statu
or acute functional decline
• New-onset flank or suprapubic pain or tenderness
• Purulent discharge from catheter site
• Acute pain, swelling or tenderness of testes, epididymis o
prostate
bOX 1 Examples of complicating
factors2,11,19
• Male sex
• Chronic obstruction
• Nephrolithiasis
• Poorly controlled diabetes
• Indwelling urinary catheter
• Indwelling urinary stent or
nephrostomy tube
• Chronic renal insufficiency
• Pregnancy
• Immunosuppression (e.g., chronic high-
dose corticosteroid use, use of other
immunosuppressives, neutropenia, etc.)

C P J / R P C • S e p t e m b e r / O c t O b e r 2 0 1 7 • V O L 1 5 0 , N O 5 3 0 1
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causing up to 95% of uncomplicated UTIs.1,2 The
reliability of the clinical diagnosis, coupled with
the limited interpretability of quantitative urine
cultures in uncomplicated UTI and the predict-
able microbiology,makesempirictreatment
without a culture reasonable.2,21Also, studies of
placebo for uncomplicated UTI have shown that
clinical cure can occur in up to 42% of women
who are either untreated or are treated with
an agent that does not possess in vitro activity
against the isolated pathogen.1,22 Instances in
which a urine culture is more strongly indicated
in uncomplicated UTI include if there is early
recurrence of infection, if presentation is atypi-
cal, or when pyelonephritis is a consideration.21
In cases of complicated UTI or pyelonephritis,
a urine culture should always be sent. This is due
to the broader range of pathogens that are likely
to be causative and the higher likelihood of these
pathogens being more resistant.11,19If the patient
has a urinary catheter that has been in place for
2 weeks or longer, it should be discontinued or
changed before collection of the specimen.4,13
The reason for this is that when catheters have
been in place for this amount of time, there is a
very high likelihood of bacterial biofilm produc-
tion. Biofilms are problematic in that urine cul-
tures taken from these catheters may reflect the
bacteria in the biofilm and not what is actually
in the bladder, as well as the fact that these bio-
films protect uropathogens from antimicrobials.
In addition, urinary catheters that have been in
place for this amount of time will virtually always
result in a positive culture—in the absence of
symptoms, this would be consistent with ASB.
Pharmacists who are unable to order urine
cultures should advocate for or make recom-
mendations to have them done when they are
appropriate and should discourage the sending
of urine cultures when they are not indicated.
Pyuria(leukocytesin the urine)identified
by urinalysis or urine dipstick does not identify
symptomatic infection, as it is also present in the
majority of patients with ASB. It does, however,
provide a high negative predictive value; there-
fore, the absence of pyuria may be used to exclude
symptomatic infection.11,13
This negative predic-
tive value is higher in elderly patients than in
younger patients with symptoms strongly sugges-
tive of acute uncomplicated UTI.2,14,21
Therefore,
for uncomplicated UTI in younger patients, a uri-
nalysis or urine dipstick should not be obtained,
and patients should be treated on the basis of the
presence of symptoms alone. For elderly patients,
in the absence of pyuria, urine culture or treat-
ment should not be pursued. In pregnant women,
screening for pyuria alone should not be done, as
a high proportion of patients will be negative for
pyuria but still have ASB.10
Blood cultures should be considered if the
patient is febrile, hemodynamically unstable, if
pyelonephritis is suspected or if the patient is
immunocompromised.21,23
Step 4: Considerations for treatment
If a urine culture is to be sent, the specimen
should be collected before the initiation of anti-
biotics. While the results of the urine culture are
pending, the initiation of antibiotics should be
delayed until the results of the culture are avail-
able, if possible. This way, therapy can be directed
at the specific pathogen(s).2,11 When antibiotics
are started empirically, the choice of agent should
be reevaluated once culture results are available.
In the case of uncomplicated UTI, the IDSA
stressesthe importanceof considering“col-
lateraldamage”when selectingantimicrobial
agents, that is, the ecological adverse effects,
such as selection of AROs.1 They propose that
the preserved in vitro susceptibility of E. coli to
nitrofurantoin and fosfomycin over the years
may suggest that these agents cause only minor
collateral damage, possibly because of negligible
effects on fecal flora. Agents such as the fluoroqui-
nolones are known to affect fecal flora to a larger
extent and have been associated with increased
rates of antimicrobial resistance and C. difficile
infection. This, coupled with the high rate of
spontaneous resolution of symptoms in uncom-
plicated UTI, makes keeping collateral damage
to a minimum by avoiding agents such as fluo-
roquinolones desirable and achievable. Also, the
Food and Drug Administration recently issued
a warning stating that the risk of serious side
effects of fluoroquinolones outweighs the ben-
efits in uncomplicated UTI and that they should
be avoided for this indication.24 Therefore, fluo-
roquinolones should not be used as first-line
agents in uncomplicated UTI.1 See Table 2 for
suggested empiric first-line agents.1,11,23,25
Phar-
macists should also familiarize themselves with
the local antibiogram, as this will assist in the
selection of empiric therapy. They should keep
in mind, however, that resistance rates portrayed
in hospitalantibiogramsmay not be repre-
sentative of the expected resistance patterns of

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uncomplicated infections, as these antibiograms
are often heavily influenced by patients with
complicated and nosocomial infections, which
tend to be more resistant in nature.1,2 Because
of increasing fluoroquinolone resistance26 and
the need to reserve these agents for more severe
infections, fluoroquinolones should also be con-
sidered as alternatives for complicated infections
and not first-line therapy, in areas where there is
a high rate of resistance to them (i.e., resistance of
E. coli exceeding 10%). Nitrofurantoin and fos-
fomycin are not indicated for upper UTI.1,11
Additionalconsiderationsthat shouldfac-
tor into the treatment decision include patient
allergies, recent antibiotic exposure, recent prior
urine culture results, drug interactions, contra-
indications, cost and other patient factors, such
as renal status.
Pharmacists who are able to perform thera-
peutic substitutions may choose to do so, if appro-
priate, to optimize antimicrobial therapy based on
their assessment and/or once culture results are
available. Pharmacists who are not able to do this
should advocate for changes, when indicated.
Step 5: Follow-up
If a urine culture was sent, these results need
to be followed up. Most urine cultures have a
turnaround time of about 24 to 72 hours. If anti-
microbial therapy was delayed in symptomatic
patients, the results of the urine culture should
direct therapy. If therapy was started empiri-
cally, the urine culture results should be checked
to ensure that the regimen covers the offending
pathogen and then adjust, including narrowing
the spectrum to minimize collateral damage, if
appropriate.1,11,23Pharmacists who have access
to electronic health records should easily be able
to follow up on these results. Others may need
to be more creative, such as having the r
faxed to them.
Patients can usually expect to have improv
ment in symptoms within 48 to 72 hours
treatment2,11,21
; therefore, changing agents du
to lack of response before this time shoul
avoided (unless urine cultures suggest the ne
for a change). If there has been no improveme
in the patient’s symptoms beyond this time, t
patient should be reevaluated for missing
microbial coverage, alternate sources of in
tion and other factors, such as poor adherenc
to therapy. Patients with complicated UTI who
do not respond in this time and in whom
lack of response is not attributable to the afor
mentioned factors should be assessed prompt
by a physician to exclude urinary obstruct
abscess or other abnormalities that may requ
source control.11 Red flag symptoms, including
fever, rigors, flank pain and significant nausea
vomiting, should be evaluated at all follow
encountersand promptemergencymedical
assessment, if present.
Patients who have early recurrence of infec
tion after completion of therapy should ha
urine culture sent. Recurrence within 1 mont
of completion of therapy is usually conside
a relapse, for which the same organism is
most likely cause. Relapse may require urolog
investigation, depending on the individual cas
If the culture shows a resistant pathogen,
treatmentwith an appropriateantimicrobial
would be indicated. If the organism is not resi
tant to the previously used antimicrobial,
referral to a physician to identify a reason
recurrence would be warranted, as ongoing cu
ture of the same organism raises the possibili
Table 2Recommended first-line empiric treatment of urinary tract infection
Uncomplicated* Complicated, nonsevere Severe/septic/pyelonephritis†
• Nitrofurantoin PO × 5 days
• TMP/SMX PO × 3 days
• TMP PO × 3 days
• Fosfomycin tromethamine PO × 1
dose
• Cefixime PO × 7-10 days
• Amoxicillin-clavulanate PO × 7-10
days
• TMP/SMX PO × 7-10 days
• Fluoroquinolones‡ PO × 7-10 days
• Ceftriaxone IV ± ampicillin IV
• Gentamicin IV ± ampicillin IV
If clinically appropriate, may step down
to PO therapy to complete 7-14 day
course
PO, orally; TMP, trimethoprim; SMX, sulfamethoxazole; IV, intravenously.
*Longer durations should be considered if relapse (recurrent infection within 4 weeks of treatment completion).
†The decision of which antibiotic to use should always be based on knowledge of local antimicrobial resistance of Escherichia col
negative organisms
‡Resistance to fluoroquinolones is increasing and has reached unacceptable levels in some regions. Fluoroquinolones should be
alternatives, rather than first-line, in areas where resistance is high.

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of a complicating factor that requires investi-
gation (i.e., prostatitis, infected stone, abscess).
Recurrenceafter1 monthof completionof
therapy is usually a reinfection, which is due to
a different organism or strain than the original
infection. Reinfection in patients with uncom-
plicated UTI usually does not require urologic
investigation.2,21,23
Sending a urine culture following comple-
tion of antibiotics is not necessary if symptoms
have resolved.2,21,23
Doing so may create pressure
for the treatment of ASB, if bacteria turn up in
the urine of a patient who no longer has symp-
toms. An exception to this is pregnant patients,
for whom ongoing screening and treatment of
ASB is recommended, as untreated ASB in this
population is associated with higher rates of
pyelonephritis and adverse fetal outcomes.2,23
Discussion
This document is intended to act as a general
guideline for pharmacists to enhance their abil-
ity to appropriatelyassessand manageUTI.
To our knowledge, there are no existing guide-
lines intended specifically for pharmacists for
the assessment and management of UTI. This
guideline is applicable to primary care pharma-
cists in various practice settings, such as com-
munity and ambulatory care settings, as well as
to hospital practice. It can be used by a pharma-
cist assessing and managing a UTI themselves
or by a pharmacist entering a patient’s care after
FigUre 1Proposed algorithm for assessment and management of urinary tract
infection
*See text for assessment considerations.

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an assessment has already been performed by
another health care provider. It could also be
used by a pharmacist after initial assessment and
treatment have already been initiated by another
health care provider.
There are several important areas of UTI
management that are beyond the scope of this
document. The management of UTI in preg-
nancy is not covered here in great detail, as
this is an area that is typically managed during
prenatal care. Other areas beyond the scope of
this document include long-term prophylaxis
of UTI, acute or chronic prostatitis and UTI
in pediatric patients. Interpretation of micro-
biologic colony counts is not included in this
document,as manymicrobiologylabs typi-
cally report the significance of the counts with
their reports. Also, in the empiric treatment
recommendations, specific doses/dosing int
vals are not provided, just the agents and dur
tions. This is to leave it open to the pharmacis
select the appropriate regimen based on patie
specific factors. This guide is not intended
replace clinical judgment.
To our knowledge, there are no publishe
studies on the impact of the management
UTI by pharmacists other than studies of
effect of educational interventions. This co
be a good area for future pharmacy pract
research. We look forward to the results of the
RxOUTMAP study (Outcomes of Urinary Tract
Infection Management by Pharmacists), a t
of pharmacist prescribing and care of unco
plicated UTI in New Brunswick (ClinicalTria
.gov - NCT03184818), scheduled for completio
in early 2018.■
From the Faculties of Pharmacy and Pharmaceutical Sciences (Beahm) and Medicine an
(Tsuyuki), University of Alberta, Edmonton, Alberta; Departments of Internal Medicine a
Microbiology (Nicolle), Health Sciences Centre, University of Manitoba, Winnipeg, Manito
PJC Briggs Drugs (Bursey), Fredericton, New Brunswick; Division of Infectious Diseases (
Department of Internal Medicine, Dalhousie University, Halifax, Nova Scotia and The Mo
Hospital, Moncton, New Brunswick. Contact: [e-mail].
Author Contributions: N.P. Beahm initiated the project, wrote the initial draft of the m
edited subsequent drafts of the manuscript. L.E. Nicolle and A. Bursey reviewed and edi
the manuscript. D.J. Smyth reviewed and edited late drafts of the manuscript. R.T. Tsuy
edited early and late drafts of the manuscript. All authors approved the final draft of the
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of
respect to the research, authorship and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship and/o
this article.
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