Urinary tract infection (UTI)

Prescribing Notes:

• Do not treat asymptomatic bacteriuria, except in pregnancy.
• Self-management: Advise oral fluid intake >2L/day, and use of NSAIDs. See SAPG guidance for more information.
• Give TARGET UTI leaflet.
• In women with mild symptoms consider non-drug management as above or delayed antibiotic.

Guidance on first line choices

• If a patient remains symptomatic despite initial antibiotics, send a urine culture and consider starting an alternative antibiotic whilst awaiting the results. If culture negative stop antibiotics and re-assess.

Patients with renal impairment

• Cefalexin, pivmecillinam and fosfomycin don’t require dose adjustment.
• eGFR <30: Trimethoprim – use with caution (note that creatinine is transiently increased with trimethoprim use).
• Nitrofurantoin should be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 45mL/min/1.73m². However, a short course (3 to 7 days) may be used with caution in patients with an eGFR of 30 to 44mL/min/1.73m² to treat uncomplicated lower urinary tract infection caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk.

Prescribing Notes:

• Send urine for culture before starting antibiotics; and another 7 days after completion of antibiotics to check for cure.
• Asymptomatic bacteriuria in pregnancy; confirm culture result with second urine culture before treating. Choose from cefalexin, nitrofurantoin (avoid at term) or amoxicillin based on recent culture and susceptibility results.
• Give TARGET UTI leaflet.
• Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
• Nitrofurantoin should be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 45mL/min/1.73m². However, a short course (3 to 7 days) may be used with caution in patients with an eGFR of 30 to 44mL/min/1.73m² to treat uncomplicated lower urinary tract infection caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk.
• See BNF for dosing instructions for other antibiotics in renal impairment.
• Contact microbiology for advice if the formulary choices are unsuitable.

Prescribing Notes:

• 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.
• Non drug management: Advise oral fluid intake >2L/day, and use of NSAIDs. See SAPG guidance for more information.
• Give TARGET UTI leaflet.

Guidance on first line choices

• See NICE Guideline NG109 for advice on antibiotic choice.
• If a patient remains symptomatic despite initial antibiotics, send a urine culture and consider starting an alternative antibiotic whilst awaiting the results. If culture negative stop antibiotics and re-assess.

Patients with renal impairment

• Cefalexin, pivmecillinam and fosfomycin don’t require dose adjustment.
• eGFR <30: Trimethoprim – use with caution (note that creatinine is transiently increased with trimethoprim use).
• Nitrofurantoin should be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 45mL/min/1.73m². However, a short course (3 to 7 days) may be used with caution in patients with an eGFR of 30 to 44mL/min/1.73m² to treat uncomplicated lower urinary tract infection caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk.

Prescribing Notes:

• A recurrent UTI is defined as two symptomatic UTIs in the last 6 months or three in the last 12 months. 
• Refer to NICE guideline NG112: Urinary tract infection (recurrent): antimicrobial prescribing.
• Refer to SAPG guidance for Management of recurrent urinary tract infection in non-pregnant women.
• First advise about behavioural and personal hygiene measures, and self-care to reduce the risk of UTI.
• If antibiotics are prescribed, discontinue at 6 months, unless continuation is clinically indicated.
• Refer or seek specialist advice for men, people with recurrent upper UTI, recurrent upper UTI when the underlying cause is unknown, pregnant women and people with suspected cancer.

Prescribing Notes:

• Complicated UTI refers to patients with systemic toxicity, flank pain and rigors; 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.
• If no oral treatment options are available due to resistance or intolerance, consider IV antibiotics. These may be available via OPAT service.
• Pregnant women with pyelonephritis should be treated in hospital.

Prescribing Notes:

• Clinical features include new onset delirium, suprapubic tenderness, acute haematuria, and pelvic discomfort. Pyuria and bacteriuria are common and should not be used to diagnose CAUTI. Bladder spasm and dysuria are usually catheter associated.
• Refer to NICE Guideline NG113 for prescribing advice.
• Nitrofurantoin should be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 45mL/min/1.73m². However, a short course (3 to 7 days) may be used with caution in patients with an eGFR of 30 to 44mL/min/1.73m² to treat uncomplicated lower urinary tract infection caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk.
• Check CSU result to ensure appropriate antibiotics are being given. If a change of antibiotic is required, ideally change the catheter again.

Non drug management

• Advise oral fluid intake >2L/day, and use of NSAIDs. See SAPG guidance for more information. 
• Review catheter requirement and remove or change the catheter if it has been in place for more than 7 days. But do not delay antibiotic treatment.