Urinary tract infections

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

• Care home resident
• Hospitalised in the last six months
• Recurrent treated UTI
• Previous known resistance to trimethoprim, co-amoxiclav or quinolones or ESBL

See below for treatment advice for fosfomycin or pivmecillinam if there are any of the above risk factors

Nitrofurantoin

• 100mg modified release every 12 hours for 3 days in women and 7 days in men
• For short-term use only
• Use nitrofurantoin first-line as general resistance and community multi-resistant Extended-spectrum Beta-lactamase E. coli are increasing
• MHRA Drug Safety Update (September 2014):
  • Nitrofurantoin should be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 45 mL/min
  • Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection or suspected upper urinary tract infections
  • A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min (but see below). 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
  • Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment.

Trimethoprim

• 200mg every 12 hours for 3 days in women and 7 days in men
• General resistance and community multi-resistant Extended-spectrum Beta-lactamase (ESBL) E. coli are increasing; use trimethoprim only if low risk of resistance.

If GFR <45mL/min

Pivmecillinam

• Consider pivmecillinam if eGFR less than 45mL/min
• 400mg single dose on day one then 200mg every 8 hours for 3 days in women, 7 days in men
• This is an extended-spectrum penicillin antibiotic

If high risk of resistance

Fosfomycin

• Consider fosfomycin if high risk of resistance to first line options
• Prescribe as Monuril^® brand
• Female: 3g sachet as a single dose
  
• Male: 3g sachet initial dose and repeat after 3 days; unlicensed but in line with PHE guidance
  
• Doses should be taken preferably before bedtime and after emptying the bladder

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.

If GFR <45mL/min

Pivmecillinam

• Consider pivmecillinam if eGFR less than 45mL/min
• 400mg single dose on day one then 200mg every 8 hours for 3 days in women, 7 days in men
• This is an extended-spectrum penicillin antibiotic

If high risk of resistance

Fosfomycin

• Consider fosfomycin if high risk of resistance to first line options
• Prescribe as Monuril® brand
• Female: 3g sachet as a single dose
  
• Male: 3g sachet initial dose and repeat after 3 days; unlicensed but in line with PHE guidance
  
• Doses should be taken preferably before bedtime and after emptying the bladder

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.

Ciprofloxacin

• 500mg every 12 hours for 28 days

Notes

1. MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
2. MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects

Refer to 5.1.12 Quinolones for further details

Trimethoprim

• 200mg every 12 hours for 28 days

See section: 5.1.8 Sulfonamides and trimethoprim, 5.1.12 Quinolones

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.

Nitrofurantoin

• 100mg modified release every 12 hours for 7 days
• Nitrofurantoin can be used throughout until the last 2 weeks of pregnancy (risk of neonatal haemolysis at term). Not suitable if there is evidence of upper tract infection e.g. loin pain.
• The Public Health England advice is that short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus.

Trimethoprim

• 200mg every 12 hours for 7 days (off label)
• Public Health England recommends avoiding trimethoprim if patient has low folate status or is on a folate antagonist (e.g. antiepileptic or proguanil)
• The BNF states that there may be a teratogenic risk in first trimester and the manufacturer's advice is to avoid.
• Give high dose folic acid (5mg daily) until week 12 of pregnancy

Cefalexin

• 500mg every 12 hours for 7 days

If susceptible

Amoxicillin

• 500mg every 8 hours for 7 days
• Use amoxicillin only if susceptible

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.

Lower UTI

Trimethoprim

• See BNFc for dose (duration: 3 days)

Nitrofurantoin

• See BNFc for dose (duration: 3 days)

Cefalexin

• See BNFc for dose (duration: 7 days)

Upper UTI

Co-amoxiclav

• See BNFc for dose (duration 10 days)

Cefixime

• See BNFc for dose (duration 10 days)

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.

Co-amoxiclav

• 625mg every 8 hours for 7 days

Ciprofloxacin

• 500mg every 12 hours for 7 days

Notes

1. MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
2. MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects

Refer to 5.1.12 Quinolones for further details

Trimethoprim

• 200mg every 12 hours for 14 days
• Suitable if laboratory testing demonstrates sensitivity
• Patient is stable and does not require admission
• The offending organism is not an enterococcus

Pregnant women who do not require admission

Cefalexin

• 500mg every 12 hours for 14 days

See section: 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim,5.1.12 Quinolones

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

• 100mg modified release single dose post coital (off label) or once daily at night

Nitrofurantoin should be avoided in patients with CrCl less than 45mL/min. Where there is no other suitable alternative treatment- discuss with Microbiology.

Trimethoprim

• 100mg single dose post coital (off label) or once daily at night