Urinary tract infection (UTI)

Prescribing Notes:

Guidance on first line choices:

• First choice is trimethoprim, however if one of the following is present then use nitrofurantoin:
  
  • Hospital inpatient in previous 12 months
  • Nursing/Care home resident
  • Patient >65 years
  • Received trimethoprim in past 3 months
  • Trimethoprim resistant organism in any of the last 3 urine culture (up to 12 months ago)
• If renal function prevents use of nitrofurantoin, then use cephalexin or pivmecillinam.
• If a urine culture has shown an organism resistant to trimethoprim, nitrofurantoin and cefalexin in the last three months and the patient presents with new symptoms, then send a repeat urine culture and consider using one of the antibiotics listed on the microbiology report to which the organism was sensitive.
• In frail patients, when 1st line options are not suitable, pivmecillinam may be considered. Pivmecillinam is a narrow spectrum antibiotic. 
• If a patient remains symptomatic despite initial antibiotics send a urine culture (consider starting one of the alternatives if severe symptoms whilst awaiting the result) if culture negative stop antibiotics and re-assess.

Other prescribing notes:

• Asymptomatic bacteriuria does not require treatment, except in pregnancy.
• A short course of antibiotics, for women with severe/>3 symptoms (dysuria, urgency, frequency, polyuria, suprapubic tenderness), is usually sufficient for uncomplicated UTIs in women.
• Give TARGET UTI leaflet.
• Women with mild/≤2 symptoms; give pain relief and consider delayed antibiotic.
• See the following SAPG link for more information on alternative management of lower urinary tract infection in non-pregnant women.
• 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.
• Trimethoprim should be used with caution in patients with eGFR less than 30mL/min/1.73m², refer to BNF for dose adjustments in renal impairment.
• A transient increase in serum creatinine may occur with trimethoprim treatment.
• Pivmecillinam can be dosed as in normal renal function when eGFR <10mL/min, for normal course lengths.
• See BNF for dosing instructions for other antibiotics in renal impairment.
• Do not use dipstick urine testing in the diagnosis of UTI in older people.  See SAPG guidance for diagnosis and management of suspected UTI in people aged 65 years and over.

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 nitrofurantoin (avoid at term), amoxicillin or cefalexin 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.
• Send urine for culture before starting antibiotics; and another 7 days after completion of antibiotics to check for cure.
• Contact microbiology for advice if the formulary choices are unsuitable.

Prescribing Notes:

• Give TARGET UTI leaflet.
• Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
• Resistance to trimethoprim may be more likely if used in the past 3 months or if previous urine culture suggests resistance.
• 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.
• Trimethoprim should be used with caution in patients with eGFR less than 30mL/min/1.73m², refer to BNF for dose adjustments in renal impairment.
• A transient increase in serum creatinine may occur with trimethoprim treatment.
• Pivmecillinam can be dosed as in normal renal function when eGFR <10mL/min, for normal course lengths. 
• See BNF for dosing instructions for other antibiotics in renal impairment.
• 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.
• Do not use dipstick urine testing in the diagnosis of UTI in older people.  See SAPG guidance for diagnosis and management of suspected UTI in people aged 65 years and over.

Prescribing Notes:

• A recurrent UTI is defined as two positive MSU in last 6 months or three positive MSU in last 12 months. If MSU is not possible then ALL of the symptoms (frequency, dysuria, urgency +/- bladder pain and prompt resolution with antibiotics).
• 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.
• NHS Lothian RefHelp has a useful page with guidance on recurrent UTIs.
• 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.

Additional steps

• For postmenopausal women with risk factors such as atrophic vaginitis, consider prescribing topical oestrogen, review in 12 months.
• Non pregnant women may wish to purchase and try D-mannose (if E.coli UTI) or cranberry products, note the sugar content of these products.
• Methenamine tablets 1g twice daily and over the counter high dose vitamin C 1000mg can be tried for a period of 6 months.
• For non-pregnant women, if no improvement, consider single-dose antibiotic prophylaxis for exposure to a trigger (review within 6 months) or alternatively self-start antibiotics – a 3-day course of antibiotic as per recent sensitivities, depending on patient’s circumstances.
• For non-pregnant women (if no improvement or no identifiable trigger) or with specialist advice for pregnant women and men, consider a trial of daily antibiotic prophylaxis (review within 6 months).
• If there is evidence that the organisms have developed resistance to the agent being used for prophylaxis it should be stopped.
• Nitrofurantoin should not be used for long term treatments; it has been associated with serious lung and liver adverse effects.

Prescribing Notes:

• Refer to important safety information for all quinolones prior to prescribing.
• See MHRA Drug Safety Update January 2024: Fluoroquinolones must only be used in situations when other antibiotics, that are commonly recommended for the infection, are inappropriate such as:  
  • there is resistance to other first-line antibiotics recommended for the infection 
  • other first-line antibiotics are contraindicated in an individual patient 
  • other first-line antibiotics have caused side effects in the patient requiring treatment to be stopped 
  • treatment with other first-line antibiotics has failed 
• 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:

• Refer to NICE guideline NG113: Urinary tract infection (catheter- associated): antimicrobial prescribing.
• Dipstick urinalysis is of no diagnostic value in determining if a catheterised patient has a urine infection.
• In catheterised patients, pyuria and bacteriuria are common and do not merit antibiotics. Bladder spasm and dysuria are usually catheter associated.
• Signs and symptoms compatible with catheter-associated UTI include new onset or worsening of fever, rigors, new onset delirium, flank pain; costo-vertebral angle tenderness; acute haematuria; and pelvic discomfort.
• 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.
• For alternative choices of antibiotic refer to the NICE UTI (catheter): antimicrobial prescribing visual summary.
• Obtain a urine sample before antibiotics are taken. Take the sample from the catheter via a sampling port if provided (using aseptic technique). If the catheter has been changed take the sample from the new catheter. If the catheter has been removed obtain a midstream specimen of urine.
• Remove or change the catheter if it has been in place for more than 7 days. But do not delay antibiotic treatment.
• Check CSU result to ensure appropriate antibiotics are being given. If a change of antibiotic is required, ideally change the catheter again.
• Advise adequate fluid intake and paracetamol for pain.
• Gentamicin should not be used routinely when catheters are changed.
• Where patients have developed sepsis related to changing a long-term urinary catheter, prophylaxis may be considered. Previously documented antimicrobial resistance should be considered when choosing an appropriate antimicrobial.

Prescribing Notes:

• If the patient is catheterised, treatment is only indicated if systemically unwell. If antibiotics are commenced, then the catheter should be changed.
• MRSA, like other Staphylococcus aureus strains, may be part of normal colonising flora, for example, on skin, on a leg ulcer, in urine in an asymptomatic catheterised patient. The criteria for treating MRSA are the same as for any other pathogen, i.e. clinical evidence of chest infection, soft tissue infection, or systemic illness in a catheterised patient.
• Most MRSA locally is sensitive to doxycycline.
• If severe infection or no response to monotherapy after 24-48 hours, seek advice from Microbiology.

Prescribing Notes:

• Refer to local board guidance in NHS Fife and NHS Borders for referral criteria.
• In NHS Lothian all children < 3 years old presenting with first UTI should be referred for investigation.
• Child < 3 months: refer urgently for assessment.
• Child > 3 months: use positive nitrite to guide antibiotic use; send pre-treatment MSU.
• Imaging: refer if child < 6 months, or recurrent or atypical UTI.
• Children with high risk of serious illness and/or infants under 6 months of age should usually be treated with intravenous antibiotics.
• Start treatment after urine sent for culture and sensitivity.
• Always review choice of antibiotic with culture result.
• If history of previous confirmed UTI, recheck urine again at day 7.
• The evidence base for the value of prophylactic antibiotics is weak. In NHS Lothian children under 6 months are prescribed prophylaxis based on culture and sensitivity results, while awaiting investigation via paediatrics or paediatric urology/renal. In NHS Fife and Borders seek specialist advice on prophylactic treatment in children under 6 months.
• Consider antibiotic prophylaxis in recurrent UTI after discussion with paediatrics or paediatric urology/renal.
• If reflux (or other risk factor) is demonstrated, the child will require prophylaxis to continue at least until continence is achieved.
• Amoxicillin resistant E. coli are common; amoxicillin should not be used for empirical treatment but reserved for cases where there is proven sensitivity.
• If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost. Some children may also be able to take a tablet or part-tablet, rather than a liquid formulation if the dose is appropriate.
• For more information refer to NICE CKS: Urinary tract infection - children.

Prescribing Notes:

• The evidence base for the value of prophylactic antibiotics is weak. For more information on patients who may warrant antimicrobial prophylaxis refer to NICE CKS: Urinary tract infection - children.
• Consider antibiotic prophylaxis in recurrent UTI after discussion with paediatrics or paediatric urology/renal specialists.
• In NHS Lothian refer patients to the UTI clinic.
• For more information on criteria for UTI prophylaxis in NHS Lothian refer to the Paediatric Guideline for the Management of Acute Urinary Tract Infection (intranet).
• If reflux (or other risk factor) is demonstrated, the child will require prophylaxis to continue at least until continence is achieved.

Prescribing Notes:

• Symptoms normally resolve in 2-4 days.
• Paracetamol or ibuprofen may be taken to ease discomfort.
• There is little evidence to support use of alkalinising products.
• Sodium containing products are contraindicated in patients with hypertension.
• Potassium containing products are best avoided in patients with hyperkalaemia, renal or cardiac impairment and in patients taking potassium sparing diuretics, ACE inhibitors and aldosterone antagonists.
• Young women with symptoms of urinary frequency and dysuria are likely to have a urinary tract infection which will require antibiotic treatment. See urinary tract infection pathway.

Examples of Counselling Points
Patients with cystitis should increase their fluid intake - up to 2 litres of water per day.
Avoid alcohol, tea and coffee as they can irritate the bladder and can increase urinary acidity.
Drinking cranberry juice may help prevent recurrence.
Hot water bottle may help relieve discomfort.

When to advise patient to contact GP
All men and children.
Women aged over 60.
Fever, nausea/vomiting.
Loin pain and tenderness.
Haematuria.
Vaginal discharge.
Duration longer than 2 days.
Pregnancy.
Patients with diabetes.
Recurrent cystitis.
Failed medication.
Patient with hypertension or taking ACE inhibitors, potassium sparing diuretics.