By Elizabeth Si and Certina Ho
Urinary Tract Infections
Urinary tract infections (UTIs), which can generally be classified into several categories (Table 1), are one of the most common conditions seen in the community for which patients seek medical care and are often prescribed with antibiotics. UTI is one of the main potential causes of inappropriate antimicrobial prescribing, which may lead to adverse events and/or secondary complications.
Table 1: Urinary Tract Infections (UTIs)
(*Note: This is not a comprehensive list of the different types of UTIs.)
| General Types of UTIs * | What does this mean? |
| Cystitis | Lower UTI or bladder infection |
| Acute Pyelonephritis | Upper UTI or kidney infection |
| Complicated UTIs |
UTIs are relatively more common in women, infant boys, and older men. Women are prone to having UTIs, mainly due to estrogen related issues and structurally having a shorter urethra (than men). UTIs in older men are often associated with prostate enlargement, which may back up the flow of urine and potentially allow more bacterial growth. Taking certain medications may also increase the risk of having UTIs. For example, sodium-glucose cotransporter-2 (SGLT2) inhibitors (e.g., canagliflozin, dapagliflozin, empagliflozin), one of the newer class of drugs for treatment of type 2 diabetes, has been associated with increased incidence of UTIs in patients, as they work by increasing the amount of glucose released or excreted into urine. Healthcare providers should monitor and evaluate patients who are taking SGLT2 inhibitors for UTIs, treat if required, and counsel on how they can recognize signs and symptoms of UTIs (Table 2). (As an aside, Health Canada has issued a safety review summary of SGLT2 inhibitors in 2016. Refer to their website for further information.)
Burning sensation when urinating is a common symptom of UTI, and this is known as dysuria. Although dysuria most often indicates a UTI, this is a symptom that can also be related to many other potential causes or diagnoses. Therefore, it is important to recognize the signs and symptoms of UTI and eliminate other causes, which may have similar symptoms (Table 3). Inappropriate differential diagnoses will lead to inappropriate antibiotic prescribing.
Table 2: Urinary Tract Infections (UTIs): Signs and Symptoms
| UTIs | Signs and Symptoms |
| Cystitis (bladder infection) | urinary urgency, dysuria, urinary frequency, pain or burning on urination, cloudy or foul-smelling urine, pain in suprapubic area and hematuria |
| Pyelonephritis (kidney infection) | fever, chills, flank pain, nausea and vomiting and cystitis symptoms |
Table 3: Differential Diagnoses Pointing to Other Causes
(+Note: This is not a comprehensive list of differential diagnoses.)
| Differential Diagnoses + | What are the common symptoms? |
| Vaginal Candidiasis | Vaginal itching and soreness, burning or pain when urinating, pain during sexual intercourse, vaginal discharge that is thick, white, and clumpy |
| Prostatitis | Pain in the lower pelvic area, high fever, urinary frequency with burning sensation |
Safe medication use
Before prescribing the agent of choice for UTI, it is imperative to take many factors into consideration. For example, asymptomatic bacteriuria, which is the presence of bacteria in urine but with no clinical symptoms, (in most cases) should not be treated with antibiotics, as this could lead to inappropriate UTI prescribing and contribute to antimicrobial resistance. Careful prescribing and judicious use of antibiotics are recommended for all prescribers. During a clinical consultation, healthcare providers should conduct a comprehensive medication review with patient (e.g., best possible medication history (BPMH), which includes asking patient about any antibiotic exposure or use within the last three months. This question is asked to prevent potential antimicrobial resistance and reduce unnecessary prescribing or use of antibiotics. Additionally, during the BPMH process, healthcare providers can check for drug allergies, identify (and prevent) potential drug interactions before safely prescribing the drug of choice (if needed). On the other hand, some patients may have recurrent UTIs, that is, experiencing two or more UTIs within six months, or three or more UTIs in a year. In this case, prophylactic antibiotics may be recommended. Although prophylactic antibiotics have demonstrated a positive effect in preventing UTIs, there may be increased adverse events associated with antibiotic use. Therefore, patient preferences should always be taken into consideration, while risks and benefits associated with prophylactic antibiotic use must also be discussed with patients prior to prescribing and dispensing.
Prevention and self-care options
Healthcare providers should advise patients on preventative measures to reduce risk of recurrent UTIs. Although studies have not shown a correlation between behavioural modifications and reducing recurrences of UTIs, some self-care options (e.g., stay hydrated, urinate regularly, and avoid tight-fitting pants) may be considered. The Bladder Infection Fact Sheet (https://www.toronto.ca/community-people/health-wellness-care/diseases-medications-vaccines/bladder-infection-fact-sheet/), prepared by the City of Toronto, provides some quick tips and resources on UTIs for patients.
Elizabeth Si is a PharmD for Pharmacists Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto.