Pharmacy First

Most UTIs are lower urinary tract or uncomplicated infections which can be managed with self care or antibiotics, although these are not always needed.

The good news for patients presenting with UTI symptoms in the pharmacy, is that one of the seven Pharmacy First pathways is a service to diagnose and treat uncomplicated urinary tract infection for women aged 16-64 years with suspected lower UTIs. However, there are still some exclusions, with the service not covering pregnant individuals, those with a urinary catheter, or people who have had a recurrent UTI (two episodes in the last six months, or three episodes in last 12 months).

If a woman appears to fit the initial inclusion criteria, then the pharmacist will take them through the Pharmacy First consultation for Uncomplicated UTI. The first step is to consider the risk of deterioration or serious illness. If this is suspected, the pharmacist will signpost the patient to A&E or call 999 in a life-threatening emergency.

If these risks are not present, the pharmacist will then check the patient for any new signs or symptoms of kidney infection (pyelonephritis), such as:

• Kidney pain or tenderness under the ribs
• New or different muscle aches and pains (myalgia) or flu-like illness
• Shaking chills (rigors) or temperature of 37.9°C or above
• Nausea or vomiting.

If the patient is displaying any of these, the pharmacist will initiate an urgent same day referral to the person’s GP, or the relevant Out Of Hours (OOH) service.

If these symptoms are not present the pharmacist will next ask the person about missed or lighter periods – and carry out a pregnancy test if there is a chance they might be pregnant. They will also ascertain if the person is experiencing vulvovaginal atrophy (a genitourinary syndrome of menopause), or if they are immunosuppressed. If the answer to any of these points is ‘yes’ then the pharmacist will organise onward referral to the person’s GP, a sexual health clinic, or other provider as appropriate.

If the person is not experiencing any of these health scenarios then this is the gateway point for the Pharmacy First uncomplicated UTI service. At this point the pharmacist will determine if the patient has any of the three key diagnostic signs/symptoms of uncomplicated UTI, which are:

• Dysuria (burning pain when passing urine)
• New nocturia (needing to pass urine in the night)
• Urine cloudy to the naked eye.

If they have none of these symptoms, the pharmacist will go on to check if there are other urinary symptoms of urgency, frequency, visible haematuria, or suprapubic pain or tenderness. If yes, this means the pathway considers UTI equally likely to other diagnosis, and the patient will be referred on to the GP, a sexual health clinic, or other appropriate healthcare provider.

If there are no other urinary symptoms then the pathway considers UTI less likely and the patient will be advised on self care and pain relief. Similarly, if they only have one of the symptoms of urgency, frequency, visible haematuria, or suprapubic pain or tenderness, then this means the pathway considers UTI equally likely to other diagnosis, and the patient will be referred to their GP, a sexual health clinic, or other healthcare provider.

However, if they have two or more of these symptoms the pharmacist will go through the shared decision-making approach with the patient using the TARGET UTI resources, which help explain what treatment options are available and why – supporting recommendations in the NICE guidelines on processes for antimicrobial stewardship.

Women who describe their symptoms as mild will be encouraged to consider pain relief and self care as first line treatment, with the pharmacist asking them to return to the pharmacy for pharmacist reassessment if they don’t see any improvement within 48 hours.

People with moderate to severe symptoms, will be offered the antibiotic nitrofurantoin for three days, plus self care advice.

All patients will be advised that if their symptoms worsen rapidly or significantly at any time, or do not improve in 48 hours of taking antibiotics they can get an onward referral to their GP or other provider as appropriate. All patients will also be given self care and safety-netting advice using the TARGET UTI leaflet.