Note: Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat asymptomatic bacteriuria; it occurs in 25% of women and 10% of men and is not associated with increased morbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely.
Uncomplicated UTI ie no fever or flank pain:
Use urine dipstick to exclude UTI. In women with uncomplicated UTI, the negative predictive value when nitrite, leucocytes, and blood are ALL negative ~ 76%. The positive predictive value for having nitrite and EITHER blood or leucocytes ~ 92%. Preferably avoid Trimethoprim in the first trimester of pregnancy.
Trimethoprim 200mg BD (females for 3 days, males for 7 days) OR Co-Amoxiclav 375-625mg TDS
2nd line: depends on susceptibility of organism isolated eg nitrofurantoin. For infections due to resistant coliforms including ESBL, oral options are very limited but may include nitrofurantoin. Clinical Microbiology will advise if oral fosfomycin is indicated.
UTI in pregnancy:
Send MSU for culture. Preferably avoid Trimethoprim in first trimester of pregnancy
Cefalexin 500mg TDS for 7 days
Prophylaxis for Recurrent UTI in women (3 or more in 12 months; positive MSU or dipstick with positive history):
If abdominal ultrasound abnormal refer to urology. If abdominal ultrasound normal, offer lifestyle advice, consider topical oestrogens for atrophic vaginitis; and prophylaxis at intercourse if sexually provoked.
Offer 6 month trial of low-dose continuous antibiotic treatment: trimethoprim 100 mg every night, or nitrofurantoin (immediate-release) 50–100 mg every night. Stop after 6 months and evaluate.
For breakthrough infection, change antibiotics according to sensitivities, treat for 14 days and continue prophylaxis.
Lower UTI in patients with an indwelling catheter:
Do not treat asymptomatic bacteriuria. Considerable clinical judgement is required to diagnose UTI in patients with an indwelling urinary catheter.
Treatment may be indicated if there are signs of local infection eg suprapubic pain.
If symptoms are severe (eg confusion, tachypnoea, tachycardia, hypotension, reduced urine output), admit to hospital as intravenous antibiotics may be required.
Check that the catheter is correctly positioned and not blocked. If the catheter has been in place for more than a week, consider changing it before starting antibiotic treatment. The need for an indwelling catheter should be reviewed according to individual catheter life (documentation should be on the patient’s Indwelling Urinary Catheterisation Record).
If there is fever, or loin pain, or both, manage as upper UTI (acute pyelonephritis). Otherwise, treat for lower UTI: Relieve symptoms with paracetamol or ibuprofen. Send urine for culture and microscopy before starting antibiotic treatment. If symptoms are moderate or severe, empirically prescribe an antibiotic. Follow up after 48 hours (or according to the clinical situation) to check response to treatment and the result of urine culture.
Acute pyelonephritis:
Co-Amoxiclav until sensitivity results are available. Then treat according to sensitivity results.
If no organism isolated Co-amoxiclav. If no response within 48 hrs consider referral.
Co-Amoxiclav 625mg TDS for 10 days
If penicillin allergic seek microbiology advice.
Acute epididymitis:
Take specimen. Check sexual history.
Ofloxacin 200mg BD for 14 days
If gonorrhoea suspected, refer to GU.
Catheter associated bacteriuria:
If asymptomatic, no antibiotics. Don’t swab catheters.
MRSA:
If in doubt contact Clinical Microbiology
Depending on sensitivity, Doxycycline 100mg BD for 5-7 days OR Trimethoprim 200mg BD for 5-7 days