Who to refer and red flags

The PGD for nitrofurantoin for this condition in the Pharmacy First scheme gives specific inclusion and exclusion criteria. The following is intended to give some pragmatic guidance on how these might be followed – it is not intended to be all-inclusive or definitive. 

Most of the people who attend a pharmacy with cystitis will have pain but are not severely ill. A few patients may attend who have symptoms suggesting more severe illness or who are at risk of severe illness.

The most important requirement is to recognise severely ill patients and ensure they get urgent care. This might be facilitated by discussing with local GP practices in advance how best Pharmacy First patients can access urgent assessment, if required.

Some patients may seek assessment by a pharmacist but do not meet the inclusion criteria for the PGD. These patients will need referral to their GP practice (or to urgent care, if required). The main complication of lower UTIs is ascending infection, which can lead to pyelonephritis and renal damage.

Emergency or GP referral — direct referral to A&E if severely ill

Same day

• Kidney pain/tenderness in back, under ribs
• New/different myalgia/flu-like illness
• Shaking chills (rigors) or temperature 37.9˚C or above
• Nausea/vomiting
• Confusion/altered mental state/very drowsy
• No urine passed all day
• Visible blood in urine
• Pregnant women
• Patient is immunosuppressed.

Less urgent referral (if obviously unwell/distressed may need same day)

• Children under 16 years of age
• Women 65 years or above
• Recurrent urinary tract infections (two episodes in last six months or three episodes in last 12 months
• Vaginal discharge
• Possible sexually transmitted infection – refer to sexual health clinic
• Urethritis: inflammation post sexual intercourse, irritants
• Menopause genitourinary syndrome 
  (vulvovaginal atrophy)
• Men