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Adult Treatment - Urinary Tract Infections

refer to PHE UTI guidance for diagnosis information. Note: As antimicrobial resistance and Eschericia coli bacteraemia is increasing, use nitrofurantoin first line. ALWAYS give safety net and self-care advice, and consider risks for resistance1 C. Give TARGET UTI leaflet.

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. Take sample if new onset of delirium, or two or more symptoms of UTI.

Acute pyelonephritis

NICE-CKS

If admission not needed, send MSU for culture & sensitivities and start antibiotics 1 C
If no response within 24 hours, seek advice2 C

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

Medicine Calendar

co-amoxiclav 4 C

500/125mg TDS

7 days5 A+

OR ciprofloxacin 3 A-

500mg BD

7 days 5 A+

If lab report shows sensitive
trimethoprim3 A

200mg BD

14 days5 A+

UTI in adults (lower)

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

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

All patients first line antibiotic: nitrofurantoin if GFR >45ml/min 24-5 ; if GFR 30-45 ml/min only use if resistant to other antibiotics and there is no alternative.

Women mild/or ≤ 2 symptoms. Pain relief and consider back-up/delayed antibiotic. If urine NOT cloudy 97% negative predictive value of no UTI. If urine cloud use dipstick to guide treatment. Nitrite, leucocytes, blood all negative 76% negative predictive value. Nitrite plus blood or leucocytes 92% positive predictive value of UTI. 4A-

Men: Consider prostatitis and send pre-treatment MSU 1,5C OR if symptoms mild/non-specific, use negative dipstick to exclude UTI 6C

Over 65 years: treat if fever equal to over 38oC or 1.5oC above baseline twice in 12 hours AND dysuria OR equal to or more than 2 other symptoms.

If treatment failure: always perform culture.

Low risk of resistance: younger women with acute UTI and no resistance risks.

*Risk factors for increased resistance include: care home resident, recurrent UTI (2 in six months; equal to or greater than 3 in twelve months), hospitalisation for more than 7 days in the last six months, unresolving urinary symptoms, recent travel to a country with increased resistance, previous UTI resistant to trimethoprim, cephalosporins, or quinolones.

**If risk of resistance": send urine for culture and susceptibilities and always safety net.

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 risk of resistance: send culture for susceptibility testing & give safety net advice.

Medicine Calendar

1st line: nitrofurantoin8B+,9C,10B+

100mg m/r BD11C

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

alternative 1st line if low risk of resistance: trimethoprim 7B+

200mg BD

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

if 1st line options unsuitable: pivmecillinam 13,21,22,29, 30A

400mg stat then 200mg TDS

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

if high risk of resistance: fosfomycin

women 3g stat; men 3g stat followed by 3g three days later (unlicensed)

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 in all patients with significant bacteriuria, even if asymptomatic 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

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

First line: Advise simple measures, including hydration and analgesia 6 . Cranberry products work for some women but good evidence is lacking 4 A+,5 A+

Second line: Standby3 B+ or post-coital antibiotics 1,2 B+.

Third line: antibiotic prophylaxis. Consider methenamine if no renal or hepatic impairment.

Medicine Calendar

First line: nitrofurantoin

100 mg at night1 A+, OR Post coital stat (off-label) 2 B+,3 C

3-6 months; review recurrence rate and need4

Second line: pivmecillinam

200mg at night1 A+, OR Post coital stat (off-label) 2 B+,3 C

3-6 months; review recurrence rate and need4

If recent culture sensitive: trimethoprim

200mg at night1 A+, OR Post coital stat (off-label) 2 B+,3 C

3-6 months; review recurrence rate and need4

Third line: Methenamine hippurate

1g BD

6 months

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

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).