Any person, 16 years and over, presenting with urinary symptoms suggestive of a urinary tract infection.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Pain assessment – PQRST
- Urinary or bowel incontinence
- Known pregnancy
- Pre-hospital treatment
- Past admissions
- Medical and surgical history, including spinal injury, recurrent UTI or genitourinary/prostate/renal history
- Urinary catheter present
- When was the catheter last changed
- Time of last bag emptying and amount
- Sexual activity
- Current medications
- Known allergies
Signs and symptoms
- Abdominal or loin pain
- Localised genitourinary pain
- Urinary frequency
- Dysuria
- Changes to continence
- Haematuria
- Pungent smelling urine
- Fever
- Acute delirium in 65 years and over
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Kidney disease or a single kidney
- Recent abdominal or urological surgery
- Immunocompromised or steroid therapy
- Pregnancy
- Recent instrumentation to the urethra
- Sexual or domestic assault
Clinical
- Signs of urinary sepsis – switch to sepsis (suspected) protocol
- Confusion or delirium
- Urinary retention
- Haematuria with frank blood or clots
- Vaginal or urethral purulent discharge
Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Position of comfort |
Airway
Assessment | Intervention |
---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and effort Oxygen saturations (SpO2) Auscultate chest (breath sounds) | Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Disability
Assessment | Intervention |
---|---|
ACVPU | If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated |
Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
Assessment | Intervention |
---|---|
Temperature | Measure temperature |
Skin inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
Assessment | Intervention |
---|---|
Hydration status: last ate, drank, bowels opened, passed urine or vomited | Commence fluid balance chart, as required |
Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Genitourinary | Inspect any urinary devices and look for blockages, kinks, clamps, blood clots or sedimentation Inspect catheter insertion point for signs of infection or obstruction Ask patient about blood loss, urethral, penile or vaginal discharge |
Glucose
Assessment | Intervention |
---|---|
BGL | Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete abdominal focused assessment.
Precautions and notes
- Avoid using sodium citrotartrate, e.g. Ural, in patients recently, or currently, using quinolones due to the risk of crystalluria.
- 75% of patients with pyelonephritis will have had a UTI previously and may require hospitalisation for intravenous antibiotics.
- UTI and urosepsis can be more difficult to identify in older adults, they can manifest acute illness with atypical signs and symptoms.
- If the patient meets sepsis criteria, switch to sepsis (suspected) protocol immediately.
Interventions and diagnostics
Specific treatment
- For symptom relief of dysuria, give 2 sachets of sodium citrotartate, e.g. Ural, orally once only.
- If concerned for urinary retention, assess bladder with a bedside bladder scanner, if available.
Analgesia
Select pain score:
Pain score 1–3 (mild)
Give paracetamol 1000 mg orally once only
and/or ibuprofen 400 mg orally once only
Pain score 4–6 (moderate)
Give:
oxycodone (immediate release):
- 16–65 years: 5 mg orally and, if required, repeat once after 30 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg orally and, if required, repeat once after 30 minutes, maximum dose 5 mg
and/or paracetamol 1000 mg orally once only
and/or ibuprofen 400 mg orally once only
Pain score 7–10 (severe)
Give one of:
Fentanyl intranasal
- 16–65 years: 50 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 100 microg. Dose to be divided between nostrils
- 65 years and over: 25 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 50 microg. Dose to be divided between nostrils
Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device
Fentanyl IV
- 16–65 years: 50 microg IV and, if required, repeat once after 5 minutes, maximum dose 100 microg
- 65 years and over: 25 microg IV and, if required, repeat once after 5 minutes, maximum dose 50 microg
Morphine IV
- 16–65 years: 5 mg IV and, if required, repeat once after 5 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg IV and, if required, repeat once after 5 minutes, maximum dose 5 mg
Morphine IM
- 16–65 years: 5 mg IM and, if required, repeat once after 60 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg IM and, if required, repeat once after 60 minutes, maximum dose 5 mg
and/or paracetamol 1000 mg orally once only
and/or ibuprofen 400 mg orally once only
If pain does not improve with medication, escalate as per local CERS protocol.
Nausea and/or vomiting
If nausea and/or vomiting is present, give:
- metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
- or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
- or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only
Choice of antiemetic should be determined by cause of symptoms.
Radiology
Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.
Pathology
- Urinalysis: mid-stream (preferred), clean catch or catheter urine. Send for MC&S. Keep sample refrigerated if transport delayed
- Suspected pyelonephritis: FBC, EUC
- Temp less than 35°C or 38.5°C and over: take two sets of blood cultures from two separate sites
- Female of childbearing age: urine βHCG. If positive and within the first trimester, send serum βHCG for quantitative analysis
Medications
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
Fentanyl H, R | 16–65 years: 65 years and over: | IV/intranasal | Pain score 7–10 Repeat once if required after 5 minutes to maximum dose |
Ibuprofen H, R | 400 mg | Oral | Pain score 1–10
Once only |
Over 20 years: | Oral/IV/IM | Once only | |
Morphine H, R | 16–65 years:
65 years and over: | Pain score 7–10 | |
IV | Repeat once if required after 5 minutes | ||
IM | Repeat once if required after 60 minutes | ||
4 mg Maximum dose 8 mg | Oral/IV/IM | Repeat once if required after 60 minutes | |
16–65 years:
65 years and over: | Oral | Pain score 4–6 Repeat once if required after 30 minutes to maximum dose | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
1000 mg | Oral | Pain score 1–10 Once only | |
5 mg | Oral | Once only | |
OR | |||
12.5 mg | IV/IM | Once only | |
250 mL Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved | |
Sodium citrotartate/urinary alkaliniser (Ural) H, R | 2 sachets | Oral | Once only |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Agency for Clinical Innovation. Bladder scanning (non-realtime) - Adult: Clinical Guideline. NSW, Australia: NSW Health; 2014 [cited 20 February 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0019/191062/ACI-Bladder-scanning-adult.pdf
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
- Benton T. Urinary tract infections in men. BMJ Best Practice: BMJ Publishing Group; 2022 [cited 20 February 2023]. Available from: https://bestpractice.bmj.com/topics/en-us/76
- Clinical Excellence Commission. Deteriorating Patient Program -Sepsis. NSW, Australia: NSW Ministry of Health; 2022 [cited 20 Feb 2023]. Available from: https://www.cec.health.nsw.gov.au/keep-patients-safe/sepsis
- Desai D, Gilbert B, McBride C. Paediatric urinary tract infections: Diagnosis and treatment. Australia: The Royal Australian College of General Practitioners, Australian Family Physician; 2016 [cited 20 Feb 2023]. Available from: https://www.racgp.org.au/afp/2016/august/paediatric-urinary-tract-infections-diagnosis-and-treatment/
- Gupta K. Acute complicated urinary tract infection (including pyelonephritis) in adults. UpToDate: Wolters Kluwer; 2022 [cited 20 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/acute-complicated-urinary-tract-infection-including-pyelonephritis-in-adults
- Lee U. Urinary tract infections in women. BMJ Best Practice: BMJ Publishing Group; 2022 [cited 20 February 2023]. Available from: https://bestpractice.bmj.com/topics/en-us/77
- Lyn-Li L, Noleen B. Improving management of urinary tract infections in residential aged care facilities. Australian Journal of General Practice. 2022;51(8):551-7.
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- NSW Emergency Care Institute. Management of Pyelonephritis in Adults. NSW, Australia: Agency for Clinical Innovation; 2023 [cited 20 Feb 2023]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/renal/pyelonephritis
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- Therapeutic Guidelines. Antiemetic drugs in adults. Australia: Therapeutic Guidelines Limited; 2022 [cited 15 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/topicTeaser?guidelinePage=Gastrointestinal&etgAccess=true#
Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
Currency | Due for review: Jan 2026. Based on a regular review cycle. |
Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/urinary-tract-infection