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For comprehensive details on the diagnosis of urinary tract infections please refer to the algorithms and diagnosis guidelines from Public Health England (formerly HPA).
Asymptomatic bacteriuria in patients aged over 65 years does not require treatment. It is common but not associated with increased morbidity.
Note: In line with NICE CKS asymptomatic bacteriuria in pregnancy should always be confirmed with a second sample and if persisting then treated.
For mild UTI symptoms with no fever or flank pain, advise patient to drink plenty of fluids, take analgesia and only use antibiotics if symptoms do not improve after 48 hours. Consider a back-up / delayed antibiotic option
Always send a urine culture in treatment failures and always check past microbiology results for a history of resistance and sensitivities.
Recurrent urinary tract infections in men, consider prostatitis.
Consider chlamydia if symptoms of UTI but negative cultures.
Refer to Public Health England guidelines to decide whether antibiotic treatment is appropriate.
Nitrofurantoin is recommended as first line followed by trimethoprim if there is low risk of resistance.
Risk factors for Multi Drug Resistant UTI
See below for treatment advice for fosfomycin or pivmecillinam if there are any of the above risk factors
The Patient UTI Information leaflet has been designed to be used during consultation with women who are experiencing uncomplicated UTIs. It is a useful tool for clinicians to use where the clinician feels that the patient does not require an antibiotic prescription. It includes information on illness duration, self-care advice, prevention advice and advice on when to re-consult.
Diagnosis of catheter associated urinary tract infection (CA-UTI) is based on clinical signs. Asymptomatic catheterised patients with cloudy or crystalline urine, debris in urine, discomfort or bypassing of the catheter do not require treatment for infection.
Patients with indwelling urinary catheters almost invariably have abnormalities on dipstick testing including nitrite, leucocyte esterase, blood and protein. Similarly bacteriuria is present in most patients with urinary catheters. Only send a CSU if patient has symptoms of systemic infection such as fever, new onset of confusion, supra-pubic tenderness.
When a sample for culture is indicated, include clinical details.
Only consider antibiotic prophylaxis when changing or removing a catheter if previous history of sepsis following catheter change or where the change is likely to be technically difficult.
Send MSU for culture and start antibiotics. Quinolones achieve higher prostate levels.
4 weeks treatment may prevent chronic infection. Review treatment after 14 days and consider accuracy of original diagnosis if no improvement.
For more information on drugs in pregnancy refer to the UKTIS maternal exposure summary documents
Take an MSU for culture & sensitivities. Immediately start antibiotics then review when results are known.
Test urine culture 7 days after completion to confirm cure.
Child younger than 3 months: refer urgently for assessment. Refer any child with features of upper UTI / pyelonephritis.
Child 3 months or older: use positive nitrite to start antibiotics. Send pre-treatment MSU for all.
Imaging: only refer if child under 6 months old, recurrent or atypical UTI
Asymptomatic bacteriuria in infants and children should not be treated with antibiotics. This advice may not apply to children and infants with underlying medical and Urological conditions. Refer to
NICE CG54: urinary tract infection in under 16s: diagnosis and management, for further information.
Send MSU for culture and then empirical treatment initiated. Be guided by previous MSUs (if available) for evidence of resistance.
Review treatment choices with antibiotic sensitivities.
Depending on severity / systemic symptoms consider referral to hospital. Also, if no response within 24 hours consider referral.
A recurrent urinary tract infection is where a woman has 3 or more infections in 12 months.
Recurrent urinary tract infections require investigation, always send an MSU.
Nightly prophylaxis reduces UTIs but adverse effects and long term compliance is poor
To reduce recurrence, first advise simple measures including hydration, cranberry products, and then standby or post-coital antibiotics. Nightly prophylaxis reduces UTIs but adverse effects and long term compliance poor, review after 6 months.
Cranberry products: frequent ingestion of high strength cranberry products (not cranberry juice) has not been shown to be more effective than antibiotics but may have some effect and avoid use of antibiotics. These products are a reasonable first line in preventing recurrent UTIS. Not suitable for those on warfarin. Many of these products are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet
Nitrofurantoin should be avoided in patients with CrCl less than 45mL/min. Where there is no other suitable alternative treatment- discuss with Microbiology.