MSOP 1010 - Clinical Decision Making, Renal Health - PDF

MSOP 1010 Professional Practice & Prescribing Clinical Decision Making – Renal Health Dr. Suky Bhamra  Lecture Overview Renal health, differential diagnosis: Urinary tract infections = Differential diagnosis with:...

MSOP 1010 Professional Practice & Prescribing Clinical Decision Making – Renal Health Dr. Suky Bhamra  Lecture Overview Renal health, differential diagnosis: Urinary tract infections = Differential diagnosis with: Vaginal thrush Cystitis Bacterial Vaginosis (BV) Kidney Infection = Pyelonephritis Trichomoniasis Kidney stones  Urinary-tract infections Urinary-tract infections (UTIs) are common infections that can affect any part of the urinary tract. UTIs are associated with inflammation of the bladder (cystitis) and urethra (urethritis). In some patients infection can spread to an upper UTI. Upper UTIs affect the proximal part of the ureters (pyelitis) or the proximal part of the ureters and the kidneys (pyelonephritis), and can cause renal scarring, abscess or failure, and sepsis. The most common signs and symptoms of lower UTIs are dysuria, increased urinary frequency and urgency, urine that is strong smelling, cloudy or contains blood, and persistent lower abdominal pain. Upper UTIs usually present with accompanying loin pain and fever.  Cystitis Cystitis = inflammation of the bladder Cause: = a urinary tract infection (UTI) usually caused by bacteria from the GI tract - Most commonly caused by Escherichia coli - Can be casued by Staphylococcus species, Proteus mirabilis, and enterococci - Candida albicans rarely causes UTI - may occur in hospitalised patients who are immunocompromised or have a catheter. Bacteria get to the bladder by: - Females wiping from back to front after going to the toilet - After having sexual intercourse - Using a diaphragm for contraception  Cystitis Epidemiology: - More common in women than men = anus closer to urethra in women and urethra is much shorter Risk of cystitis increased by: - Not emptying bladder fully - If there is a blockage - During pregnancy pressure on the bladder - Enlarged prostate in men - Menopause = lining of urethra shrinks and becomes thinner because of a lack of the hormone oestrogen & balance of bacteria in the vagina may also change - Diabetes = high levels of sugar in urine = a good environment for bacteria to multiply - Chemical irritants e.g. soap/ bubble bath or perfumes  Cystitis Signs and symptoms: - Need to urinate more often and urgently than normal - Feel like you need to urinate soon after going - Dysuria = pain/ discomfort during urination - Burning or stinging during urination - Urine is dark, cloudy or strong smelling - Blood in urine - Lower abdominal ache - Feeling generally unwell, achy, sick and tired - If fever or loin (lower back) pain in adults – might be a kidney infection (upper UTI) Symptoms in children: - Fever = 38 ⁰C or above - Weak/tired - Irritable - Reduced appetite - Vomiting  Cystitis Differential diagnosis: - Kidney infection - cystitis doesn't usually cause a fever in adults. If temperature of 38⁰C or above and pain in lower back or sides could be kidney infection - Drug-induced cystitis - cyclophosphamide or allopurinol - Threadworms - if urination causes discomfort outside the bladder and urethra, especially if there is peri-anal or peri-vaginal itching - Vaginitis - if dysuria is associated with vaginal discharge - Bladder cancer - recurrent or persistent UTIs associated with haematuria  Referral: Cystitis - Symptoms for the first time - Persistent/ frequent cystitis - Male or child reporting symptoms of cystitis - Symptoms of fever, vomiting or vaginal discharge associated - Blood in urine - Pregnant women - Frequent symptoms associated with increased thirst, weight loss and thrush = undiagnosed/ uncontrolled diabetes - Patient with high blood pressure/ heart disease shouldn’t take potassium/ sodium containing medicines without doctor knowing - OTC treatment failure  Cystitis Treatment: over the counter… – Potassium and sodium salts = make urine more alkaline and render conditions less favourable for bacteria e.g. Canesten Oasis = Sodium citrate sachets Cystopurin = Potassium citrate sachets – Cranberry juice = stops bacteria sticking to walls of bladder (little evidence -suggests it is good for prevention rather than treatment) – Analgesia = pain relief/ fever e.g. paracetamol/ ibuprofen – Prescription for antibioticas = – 1st line = Nitrofurantoin 100 mg twice daily for 3 days (7 days in males and pregnant women) / Trimethoprim 200 mg twice daily for 3 days (7 days in males). – 2nd line = Nitrofurantoin (if not used first line), or amoxicillin (high rate of resistance, so only use if culture susceptible).  Cystitis General advice: A hot water bottle can help with pain/ discomfort OTC pain relief for pain and fever (paracetamol/ ibuprofen) Drink lots of water = may help flush out the bladder Avoid sexual intercourse until feeling better = can make condition worse Use personal lubricants as repeated trauma in genital area can cause cystitis Avoid toiletries containing perfumes = cause irritation Females = wipe front to back Avoid tight fitting clothes and underwear = encourage bacterial growth Avoid caffeine and alcohol intake Avoid acidic drinks and spicy food as these can irritate the bladder Pharmacy First  Introduction and background to Pharmacy first Community Pharmacy England made a proposal to the Department of Health and Social Care and NHS England for a Pharmacy First service back in March 2022. Government have invested £645 million into community pharmacies in England. The Pharmacy First service, which commenced on 31st January 2024, is a crucial first step in recognising and properly funding the enormous amount of healthcare advice that community pharmacies provide to the public every day and in establishing and funding community pharmacy as the first port of call for healthcare advice. Consultations for these seven clinical pathways can be provided to patients presenting to the pharmacy as well as those referred by NHS 111, general practices and others. The service also incorporates the elements of the Community Pharmacist Consultation Service, i.e. minor illness consultations with a pharmacist and the supply of urgent medicines (and appliances), both following a referral from NHS 111, general practices (urgent supply referrals are not allowed from general practices) and other authorised healthcare providers (i.e. patients are not able to present to the pharmacy without a referral). Q. What happened to the Community Pharmacist Consultation Service (CPCS)? The CPCS ended on 30th January 2024 and the Pharmacy First service started on 31st January 2024, encompassing the minor illness and urgent repeat medicines elements of the CPCS. In the clinical pathway consultations with a pharmacist, people with symptoms suggestive of the seven conditions will be provided with advice and will be supplied, where clinically necessary, with a prescription-only treatment under a Patient Group Direction (PGD) or in one pathway, an over-the-counter medicine (supplied under a clinical protocol), all at NHS expense. In the future, we hope that independent prescribers will be able to use their skills to complete episodes of care within the service, without the need for a PGD. However, for the time being, all pharmacists providing the service must use the PGDs and clinical protocol.  What does the service involve? The Advanced service involves pharmacists providing advice and NHS-funded treatment, where clinically appropriate, for seven common conditions: Sinusitis Sore throat Will be examined Acute otitis media in year 3 Infected insect bite Impetigo Shingles Uncomplicated urinary tract infections in women. Service start date 31st January 2024  The Pharmacy First Service Pharmacy is a new Advanced service that will include seven new clinical pathways and will replace the Community Pharmacist Consultation Service (CPCS) The service will consist of three elements Seven conditions Medicines that can be prescribed The Pharmacy First Service Distance Selling Pharmacies (DSPs)  Service objectives The objectives of the Pharmacy First advanced service are: To offer patients who contact either: o NHS 111 (by telephone or on-line), or o 999 service, or o their own GP practice, or o a primary care out-of-hours service, or o an urgent and emergency care (UEC) setting (e.g.an ED, UTC, UCC), the opportunity to access appropriate urgent care services in a convenient and easily accessible community pharmacy setting. To free up clinician capacity in the above settings, for the treatment of patients with higher acuity conditions. To identify ways that individual patients can self-manage their health more effectively with the support of community pharmacists and to recommend solutions that could prevent inappropriate use of UEC services in the future. To provide urgent access to patients who are not registered with a GP for treatment of low acuity minor illnesses, and to ensure equity of access to the emergency supply provision, regardless of the patient’s ability to pay for the cost of the medicine requested. To further utilise the clinical skills of community pharmacy teams to complete episodes of care for patients and improve access, displacing activity from general practice and urgent care settings.  Referrals for low acuity, minor illnesses Referrals for low acuity, minor illnesses The pharmacist will ensure that any relevant 'Red Flags' such as symptoms associated with sepsis, meningitis or cancer are recognised and responded to as part of the consultation process. The pharmacist will identify any concurrent medication or medical conditions, which may affect the treatment of the patient. The outcome of the referral received in relation to low acuity/minor illness may include: Self-care advice to the patient. Self-care advice and the sale of an OTC medicine. Any of the clinical pathway outcomes for the seven conditions. Referral to a separately commissioned pharmacy service delivered in the pharmacy. Referral to the patient’s GP or relevant out of hours service for an urgent appointment. Routine referral to other appropriate services (including other health professionals). With the patient’s consent, their GP record, using GP Connect Access Record, their National Care Record or an alternative clinical record must be consulted. If it is known that a patient has used the service more than twice within a month, with the same symptoms and there is no indication for urgent referral, the pharmacist should consider referring the patient to their general practice. Any outcome would need to be recorded and supported with a post event message.  Prescription charges The normal prescription charge rules apply to medicines or appliances supplied under the service, whether via the urgent medicines supply part of the service or the seven clinical pathways. The Pharmacy First IT system will print off a FP10DT EPS dispensing token and the patient should complete the relevant parts of the reverse of the form to claim exemption from the prescription charge or to indicate they have paid the NHS prescription charge. Uncomplicated UTI in women aged 16-64 years Can prescribe Nitrofurantoin for 3 days  Kidney Infection = Pyelonephritis Kidney infection is usually caused by cystitis (i.e. a UTI) – but not everyone with cystitis will get a kidney infection. When the infection spreads an upper UTI may occur i.e. pyelonephritis. Causes: Same as UTI = E.coli – the bacteria travel up from the bladder (cystitis) to the kidneys. Kidney infection can sometimes develop without a bladder infection, i.e. kidney stones, diabetes or a weakened immune system. Risks = women more at risk (shorter urethra), sexually active women have a higher risk, wiping back to front. Symptoms = same as for a UTI but lower back pain indicates infection could have spread to the kidneys. Fever, chills nausea and vomiting would indicate a potential kidney infection. Treatment Antibiotics = Oral first line: Cefalexin, or ciprofloxacin If sensitivity known: co-amoxiclav, or trimethoprim =200 mg twice daily for 14 days.  Kidney stones A kidney stone is a solid, pebble-like piece of material that can form in one or both of the kidneys when high levels of certain minerals (e.g. calcium) are in urine. They can be as small as a grain of sand or — rarely — larger than a golf ball. Kidney stones rarely cause permanent damage if treated appropriately.​ Can be found in the kidneys or ureter. Most stones pass out of the body in urine on their own, but they can be very painful as they move through.  Kidney stones Causes: Urine contains minerals, acids and other substances, like calcium, sodium, oxalate and uric acid. If these accumulate or are too high, they can start to stick together, forming crystals or stones. Types of stones: Calcium stones, form when you eat high-oxalate or low-calcium foods and aren’t drinking enough fluids. Calcium-oxalate stones are the most common type of kidney stones. Struvite stones, usually caused by an infection, e.g. a urine infection Uric acid stones, usually caused by a large amount of acid in your urine = linked to eating animal proteins (beef, poultry, pork, eggs and fish) Cystine stones. = an inherited condition causes cystine stones. Cystine is a substance made of two cysteine amino acids bound together.  Kidney stones Risk factors (increase chance of recurrent kidney stones): Don’t drink enough fluids Eat a high-protein, low-fibre diet Eat foods high in sodium or sugars (sucrose and fructose) Vitamin C supplements Have a family history of kidney stones Have had several kidney or urinary infections Have had a kidney stone before, particularly if it was before they were 25 years old Inactive or bed-bound Medicines can increase risk of developing recurrent kidney stones: aspirin, antacids, diuretics (used to reduce fluid build-up), antibiotics, antiretroviral medicines (used to treat HIV), anti-epileptic medicines Differential diagnosis? Kidney infection  Kidney stones Symptoms: Pain in the side of abdomen or groin – men may have pain in their testicles High temperature Feeling sweaty/ chills Severe pain that comes and goes Feeling sick or vomiting Pain while urinating Blood in your urine (haematuria) Cloudy/ smelly urine Urine infection Small stones may not cause any symptoms Treatment: Relax the ureter to help stones pass. – tamsulosin is commonly prescribed Manage nausea and vomiting using anti-sickness medicines Manage pain = analgesics e.g. NSAIDs Surgery if stones don’t pass alone/ if causing a blockage  Recommended Reading FASTtrack: Managing Symptoms in the Pharmacy - Alan Nathan Community Pharmacy, 3rd Edition - Symptoms, Diagnosis and Treatment - Paul Rutter Symptoms in the Pharmacy: A Guide to the Management of Common Illness -Wiley-Blackwell