Lower Urinary Tract Infection (UTI) in Men in Primary Care

Publication: 30/09/2010  
Last review: 09/07/2019  
Next review: 30/06/2021  
Clinical Guideline
CURRENT 
ID: 2235 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Lower Urinary Tract Infection (UTI) in men in Primary Care

See NICE visual summary lower UTI NG109

  • Symptoms of lower UTI include dysuria/frequency without either fever or symptoms suggestive of prostatitis
  • UTI’s in men should all be treated as complicated.
  • UTI in men result from anatomic or functional anomaly or instrumentation of GUT
  • Consider Chlamydia, epididymo-orchitis, prostatitis in the differential diagnosis of male presenting with dysuria/frequency
  • Consider diagnosis of upper UTI if presenting with back pain/fever
  • Send MSU on all male patients with symptoms of UTI before commencing therapy.
  • Review antibiotic choice when results available, change antibiotic if organism is resistant to prescribed treatment and symptoms not improving.
  • 50% recurrent UTI’s and 90% of febrile UTI’s in adult men have prostatic involvement - if symptoms recur or fail to respond to treatment consider referral to a specialist. Nitrofurantoin is not recommended for men with suspected prostate involvement (lack of therapeutic levels in prostate). Quinolones are appropriate empirical treatment if prostatitis is suspected.
  • Lower UTI may be recurrent and if this occurs should prompt consideration of a diagnosis of prostatitis.
  • Refer to urology if suspected renal tract abnormality, failure to respond to appropriate antibiotics or recurrent UTI. Consider referral if upper UTI.

Asymptomatic bacteriuria (AB) = significant levels of bacteria in urine but NO symptoms of UTI

  • Do not screen for or treat AB in men, even if WBC raised (when asymptomatic)
  • AB is more common in >65 year old, diabetic patients.

Empirical Antimicrobial Treatment of lower UTI in men

  • Be guided by any previous urine culture results. 

Do not use nitrofurantoin if prostatic involvement suspected. Quinolones or trimethoprim (or co-trimoxazole) can be suitable options for treatment of prostatitis (see prostatitis guideline, and be aware of strengthened MHRA advice regarding quinolones).

 Preferred Option

Alternative Option

Notes

Nitrofurantoin MR PO 100mg 12-hourly for 7 days

(covers 90% of UTI organisms)

 

Nitrofurantoin is CONTRA-INDICATED in patients with CrCl<30mL/min, and should be used with CAUTION in patients with CrCl 30-44mL/min for short courses for bacteria and on benefit vs risk assessment.
Avoid in patients with suspected or known glucose-6-phosphate dehydrogenase (G6PD) deficiency.
Nitrofurantoin is less effective in alkaline urine; patients should not take alkalinizing agents when on nitrofurantoin.

Pivmecillinam PO 400mg stat dose then 200mg 8-hourly for 7 days

Pivmecillinam is a Penicillin antibiotic: Avoid in penicillin allergy.
Pivmecillinam tablets may be cut/crushed and they dissolve quite well in water to administer in liquid form (unlicensed use of licensed medication). The tablet needs to be cut/crushed as near to administration as possible (manufacturer advice, Apr 2019).

Fosfomycin (Prescribe as Monuril 3g granules sachets)

3g as a single stat dose, repeated after 3 days for men

[Can be used when no other suitable alternative e.g. CrCl<45mL/min, penicillin allergy, known resistance]

Fosfomycin: Avoid if creatinine clearance < 10ml/min. No evidence for use in upper UTIs

Note: Other alternatives include trimethoprim PO 200mg 12-hourly for 7 days but local resistance rates to trimethoprim are >30% so not advised to use empirically unless limited alternative options and no recent treatment with trimethoprim. If trimethoprim is prescribed empirically, check MSU results to confirm organism is sensitive.

Directed Antimicrobial Treatment
Guided by culture and sensitivity results.
Options include amoxicillin 500mg TDS, trimethoprim 200mg BD, nitrofurantoin MR 100mg BD, pivmecillinam 400mg stat then 200mg TDS, cefalexin 500mg BD, fosfomycin 3g sachet (repeated after 3 days).

Treatment Duration
A 7 day course is recommended except in the case of Fosfomycin.

NICE
SIGN 2012
CKS

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General Principles for Treating Infections

This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

  1. This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
  2. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
  3. If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
  4. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
  5. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
  6. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 07825 906030, 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
  9. Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
  10. Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
  11. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.
  12. Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

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Provenance

Record: 2235
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Lower Urinary Tract Infection in Men

Target patient group: Men
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

Evidence base

Not supplied

Document history

LHP version 2.0

Related information

Not supplied