Assess and manage children <5 years of age with a lower UTI and fever as per NICE Guideline NG143: Fever in under 5s: assessment and initial management (November 2019).

Children under 3 months of age

Infants and children under 3 months with a possible UTI should be referred to a paediatric specialist.

Children over 3 months of age

Offer an immediate antibiotic prescription for children and young people under 16 years with lower UTI, taking into account the considerations when prescribing antibiotics.

Obtain a urine sample from children and young people 3 months or older with suspected lower UTI before antibiotics are taken, and dipstick test or send for culture and susceptibility testing, in line with NICE CG54 Urinary tract infection in under 16s: diagnosis and management (August 2007 [updated October 2018]).

When results are available:

• review antibiotic choice and
• change antibiotic if bacteria resistant and symptoms not improving

Trimethoprim

• Children and young people aged 3 months and over (doses given twice daily for 3 days):
  • 3 to 5 months: 4 mg/kg (maximum 200mg per dose) or 25mg
  • 6 months to 5 years: 4 mg/kg (maximum 200mg per dose) or 50mg
  • 6 to 11 years: 4 mg/kg (maximum 200mg per dose) or 100mg
  • 12 to 15 years: 200mg

Notes

• Nitrofurantoin is advocated if trimethoprim has been used in the past 3 months, previous urine culture suggests not susceptible, or if patient is not responding

OR

Nitrofurantoin

• Children and young people aged 3 months and over:
  • 3 months to 11 years: 750micrograms/kg four times a day for 3 days
  • 12 to 15 years: 50mg four times a day or 100mg modified-release twice a day for 3 days

Notes

• Nitrofurantoin suspension is significantly more expensive than tablets and capsules, and should be avoided unless other options are not appropriate
• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin
• An alternative agent to nitrofurantoin should be used if symptoms of upper urinary tract infection or systemic infection (loin pain, fever, rigors) are present, as nitrofurantoin lacks systemic activity.
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice first-line option taken for at least 2 days, try alternative first-line option before considering second-line options below:

Cefalexin

• Children and young people aged 3 months and over:
  • 3 to 11 months: 12.5mg/kg or 125mg twice a day for 3 days
  • 1 to 4 years: 12.5mg/kg twice a day or 125mg three times a day for 3 days
  • 5 to 11 years: 12.5mg/kg twice a day or 250mg three times a day for 3 days
  • 12 to 15 years: 500mg twice a day for 3 days

If worsening of symptoms on second choice treatment options, taken for at least 2 days, consult local microbiologist.

Refer to Urinary tract infection (UTI) - suspected referral guideline

See 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim, and 5.1.13 Urinary-tract infections

Best Use of Medicines in Pregnancy (BUMPS); provided by the UK Teratology Information Service (UKTIS), contains useful information on prescribing in pregnancy.

Offer immediate antibiotic prescription to pregnant women with lower UTI, taking into account the considerations when prescribing antibiotics.

Send midstream urine for culture and susceptibility before antibiotics are taken and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant

Nitrofurantoin

• 100mg modified-release twice daily for 7 days
• Avoid at term in pregnancy; may produce neonatal haemolysis

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• An alternative agent to nitrofurantoin should be used if symptoms of upper urinary tract infection or systemic infection (loin pain, fever, rigors) are present, as nitrofurantoin lacks systemic activity.
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice taken for at least 2 days or when first choice not suitable:

Amoxicillin

• 500mg three times a day for 7 days
• Use only if culture results available and susceptible

OR

Cefalexin

• 500mg twice daily for 7 days
• Use with caution in non-severe penicillin allergy

If worsening of symptoms on second choice treatment options, taken for at least 2 days, consult local microbiologist.

Refer to Urinary Tract Infections in females Clinical Referral Guidelines:

• West Devon
• South Devon

See 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.13 Urinary-tract infections

Consider a 3-day prescription (delayed for 2 days) for patients presenting with symptoms which do not start to improve within the next 2 days or worsen at any time, or an immediate antibiotic prescription for women with lower UTI who are not pregnant, taking into account the considerations when prescribing antibiotics.

If urine sent for culture and susceptibility, and antibiotic given:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Nitrofurantoin

• 100mg modified-release twice daily for 3 days

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• An alternative agent to nitrofurantoin should be used if symptoms of upper urinary tract infection or systemic infection (loin pain, fever, rigors) are present, as nitrofurantoin lacks systemic activity.
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice option taken for at least 2 days or when first choice option not suitable:

Pivmecillinam

• 400mg initial dose, then 200mg three times day for a total of 3 days
• This is an extended-spectrum penicillin antibiotic

OR

Fosfomycin

• 3g as a single dose sachet dissolved into a glass of water
  
• Take on an empty stomach, preferably before bedtime and after emptying the bladder

If worsening of symptoms on second choice treatment options, taken for at least 2 days, consult local microbiologist.

Refer to Urinary Tract Infections in females Clinical Referral Guidelines:

• West Devon
• South Devon

See 5.1.1 Penicillins and 5.1.13 Urinary-tract infections

Offer immediate antibiotic prescription to men with lower UTI, taking into account the considerations when prescribing antibiotics.

Send midstream urine for culture and susceptibility before antibiotics are taken and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Nitrofurantoin

• 100mg modified-release twice daily for 7 days
• Nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• An alternative agent to nitrofurantoin should be used if symptoms of upper urinary tract infection or systemic infection (loin pain, fever, rigors) are present, as nitrofurantoin lacks systemic activity.
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice taken for at least 2 days or when first choice not suitable:

Consider alternative diagnoses, such as urethritis / STI, pyelonephritis (acute) or prostatitis in men presenting with cystitis symptoms that are recurrent or are accompanied by pelvic or perineal pain, or fever, or the presence of obstructive symptoms such as dribbling and hesitancy.

Please see pyelonephritis (acute) or prostatitis (acute) for further helpful information.

Where the diagnosis remains lower UTI, local microbiologists suggest considering Pivmecillinam and Fosfomycin as reasonable second line empirical options for those patients.

Pivmecillinam

• 400mg initial dose, then 200mg three times day for a total of 3 days
• This is an extended-spectrum penicillin antibiotic

OR

Fosfomycin

• 3g as a single dose sachet initially, dissolved into a glass of water, then repeated after 3 days (unlicensed)
  
• Take on an empty stomach, preferably before bedtime and after emptying the bladder

Refer to Urinary Tract Infections in males Clinical Referral Guidelines:

• West Devon
• South Devon

See 5.1.1 Penicillins and 5.1.13 Urinary-tract infections

Do not perform urine dipsticks

Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults will have bacteria present in the bladder/urine without an infection.

This asymptomatic bacteriuria is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm.

Check for signs/ symptoms of sepsis or pyelonephritis, and consider alternative diagnoses and causes of delirium, according to the Public Health England (PHE) quick reference diagnostic toolkit for patients over 65 years.

Please see pyelonephritis (acute) or prostatitis (acute) for further helpful information.

If signs/ symptoms suggest UTI, always send urine culture if feasible, as greater resistance in older adults.

Consider a 3-day antibiotic prescription (delayed for 2 days) in women with mild symptoms without catheters and low risk of complications or an immediate antibiotic prescription for patients with lower UTI, taking into account the considerations when prescribing antibiotics.

When urine culture results are available:

• review antibiotic choice and
• change antibiotic if bacteria resistant and symptoms not improving

For antibiotic choice please see the appropriate sliders above; Non-pregnant women ≥16 years with UTI (lower) or Men ≥16 years with UTI (lower).

Please see Catheter-associated urinary tract infections (CA-UTI) for formulary guidance if patient has an indwelling urinary catheter.

If worsening signs or symptoms, consider admission or start/change antibiotic