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Adult Treatment - Urinary Tract Infections

refer to PHE UTI guidance for diagnosis information
As E. coli bacteraemia in the community is increasing ALWAYS safety net and consider risks for resistance1 C

People >65 years; do not treat asymptomatic bacteriuria: it is common but is not associated with increased morbidity1 B+

Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria: only treat if systemically unwell or pyelonephritis likely2 B+
Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma3 B (NICE & SIGN guidance).

UTI in adults (no fever or flank pain)

PHE Urine
SIGN
CKS Women
CKS Men
RCGP UTI Clinical Module
SAPG UTI

Treat women with severe/or ≥ 3 symptoms1,2A,3C

Women mild/or ≤ 2 symptoms AND
a) Urine NOT cloudy 97% negative predictive value,
do not treat unless other risk factors for infection.
b) If cloudy urine use dipstick to guide treatment.
Nitrite plus blood or leucocytes has 92% positive
predictive value; nitrite, leucocytes, blood all negative 76% NPV 4A-
c) Consider a back-up / delayed antibiotic option 20A

Men: Consider prostatitis and send pre-treatment MSU 1,5C OR if symptoms mild/non-specific, use negative dipstick to exclude UTI 6C
Always safety net.
First line: nitrofurantoin if GFR over 45ml/min 24-5

GFR 30-45ml/min: only use if resistance & no alternative
In Treatment failure: perform culture in all 1B

Use nitrofurantoin first line as general resistance and community multi-resistant Extended-spectrum Beta-lactamase E. coli are increasing. Trimethoprim (if low risk of resistance) and pivmecillinam are alternative first line agents.

Risk factors for increased resistance include:
-care home resident,
-recurrent UTI,
-hospitalisation >7d in the last 6 months,
-unresolving urinary symptoms,
-recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related,
-previous known UTI resistant to trimethoprim, cephalosporins or quinolones 19

If increased resistance risk, send culture for susceptibility testing & give safety net advice.
If GFR<45 ml/min or elderly, consider pivmecillinam 21-3,28 or fosfomycin (3g stat in women 15,16B, 17A plus 2nd 3g dose in men 3 days later 18)

Medicine Calendar

nitrofurantoin8B+,9C,10B+

100mg m/r BD11C

Women all ages 3 days2,12,13A Men 7 days1,5C

trimethoprim 7B+

200mg BD

Women all ages 3 days2,12,13A Men 7 days1,5C

pivmecillinam 13,21,22,29, 30A

200mg TDS (400mg TDS if resistance risk)

Women all ages 3 days2,12,13A Men 7 days1,5C

If organism susceptible, amoxicillin14B+

500mg TDS

Women all ages 3 days2,12,13A Men 7 days1,5C

UTI in pregnancy

PHE Urine
NICE-CKS

Send MSU for culture and start antibiotics 1 A.
Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus 2 C.
Avoid trimethoprim if low folate status 3 or on folate antagonist (e.g. antiepileptic or proguanil) 2

Medicine Calendar

First line: nitrofurantoin

100mg m/r BD

7 days 6 C

if susceptible, amoxicillin

500mg TDS

7 days 6 C

Second line: trimethoprim Give folate if first trimester

200mg BD (off-label)

7 days 6 C

Third line: cefalexin 4 C,5 B-

500mg BD

7 days 6 C

Acute prostatitis

BASHH
NICE-CKS

Send MSU for culture and start antibiotics 1 C.
4-wk course may prevent chronic prostatitis 1 C
Quinolones achieve higher prostate levels 2

Medicine Calendar

ciprofloxacin 1 C

500 mg BD

28 days 1 C

OR ofloxacin 1 C

200 mg BD

28 days 1 C

2nd line: trimethoprim 1 C

200 mg BD

28 days 1 C

Acute pyelonephritis

NICE-CKS

If admission not needed, send MSU for culture & sensitivities and start antibiotics 1 C
If no response within 24 hours, admit 2 C

If ESBL risk, with microbiology advice consider IV antibiotics via outpatients (OPAT)6 C

Medicine Calendar

ciprofloxacin 3 A-

500mg BD

7 days 5 A+

Or co-amoxiclav 4 C

500/125mg TDS

7 days5 A+

If lab report shows sensitive
trimethoprim3 A

200mg BD

14 days5 A+

Recurrent UTI in non-pregnant women ≥ 3 UTIs/year

To reduce recurrence first advise simple measures6 including hydration, cranberry products, 4 A+,5 A+
Then standby3 B+ or post-coital antibiotics 1,2 B+ may reduce recurrence.

Nightly prophylaxis reduces UTIs but adverse effects and long term compliance poor 1 A+

Medicine Calendar

Antibiotics: nitrofurantoin

50–100 mg

Post coital stat (off-label) 2 B+,3 C
Prophylaxis OD at night 1 A+, review at 6 months 4

OR trimethoprim

100mg

Post coital stat (off-label) 2 B+,3 C
Prophylaxis OD at night 1 A+, review at 6 months 4

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).