Uncomplicated urinary−tract infection
- Asymptomatic bacteriuria does not require treatment, except in pregnancy.
- A short course of antibiotics, for women with sever/>3 symptoms (dysuria, urgency, frequency, polyuria, suprapubic tenderness, fever, flank or back pain), is usually sufficient for uncomplicated UTIs in women; longer courses may be needed for more complicated infections.
- It is always necessary to strive to establish the cause of male UTIs. An MSSU should always be obtained prior to treatment but treatment need not be deferred pending the result.
- Nitrofurantoin should not be prescribed in patients with renal impairment (eGFR <60ml/min), as adequate levels in urine will not be achieved and increased risk of peripheral neuropathy.
- See BNF for dosing instructions for other antibiotics in renal impairment.
- Cephalexin and co-amoxiclav are less effective than trimethoprim
Multi-antibiotic resistant enterobacteriaceae lower urinary tract infections
- Fosfomycin and pivmecillinam are both approved for the treatment of confirmed multi-antibiotic resistant enterobacteriaceae lower urinary tract infections. Refer to this flowchart for appropriate choice of agent.
- Norfloxacin is no longer recommended.
- Complicated UTI refers to patients with systemic toxicity; haematuria alone does not constitute a complicated UTI.
- If admission to hospital not required, send MSU for culture and sensitivities and start antibiotics. If no response within 24 hours admit to hospital.
Urinary−tract infections in pregnancy
- Trimethoprim (first trimester) and quinolones should be avoided in pregnancy; UTIs in pregnancy should be treated for 7 days with cefalexin or amoxicillin. See Appendix 7, prescribing in pregnancy.
Prophylaxis of recurrent UTI
- Prophylaxis is not recommended for recurrent UTI or asymptomatic bacteruria.
- Consider investigation for underlying cause. Prophylaxis may be recommended for 6-12 months, only on Specialist advice.
- In younger female patients with symptomatic infection, where recurrence is related to intercourse, consider single dose prophylaxis taken before or soon after intercourse. Antibiotics may reduce the efficacy of combined oral contraceptives.
- In catheterised patients, pyuria and bacteriuria are common and do not merit antibiotics; these should only be used for episodes of systemic toxicity. Bladder spasm and dysuria are usually catheter associated.
- The catheter should be changed prior to obtaining CSU and commencing antibiotics. Check CSU to ensure appropriate antibiotics are being given. If a change of antibiotic is required, ideally change the catheter again.
- Gentamicin should not be used routinely when catheters are changed.