Upper Urinary Tract Infection (pyelonephritis/urosepsis) in adults (over 16 years old) in Primary Care

Publication: 30/09/2010  --
Last review: 05/11/2019  
Next review: 07/11/2022  
Clinical Guideline
CURRENT 
ID: 2238 
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.

The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (MHRA advice November 2018).

Upper Urinary Tract Infection (pyelonephritis/urosepsis) in adults (over 16 years old) in Primary Care

See NICE visual summary
The clinical diagnosis of Upper Urinary Tract Infection (Upper UTI) is primarily based on symptoms and signs which can include:

  • Dysuria
  • Frequency
  • Fever (≥ 37.7°C)
  • other features include rigors, back pain, costovertebral angle (loin) pain.

Refer to Secondary Care if systemically very unwell/sepsis, if deterioration, or if no clinical improvement in first 48 hours of antibiotics. Consider referral if very dehydrated/unable to tolerate orals, pregnant or at high risk of complications (e.g. abnormal renal tract, immunosuppressed).
Investigations

  • All patients ≥ 16 years old with suspected upper UTI should have a urine sample sent for microbiological analysis (MC&S)
  • A urine dipstick test (performed on a mid-stream or “single pass catheter” urine sample) may help confirm the diagnosis: if negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely (although not completely excluded) with a negative predictive value ≥ 95%. Urine dipstick should not be used in people:
    • With an indwelling catheter — make a working diagnosis based on clinical judgement.
    • Aged over 65 years — dipsticks become more unreliable with increasing age over 65 years.
  • Send a follow-up MSU after treatment finished in pregnant women

Management

  • Pain relief (e.g. paracetamol)
  • Encourage oral fluids
  • Empirical (initial) antimicrobial treatment (after MSU obtained where possible).

Empirical treatment depends upon:

  • Severity of infection (may require admission for IV antibiotics)
  • Any previous microbiological results and recent antibiotics.

Targeted antibiotics
Antibiotic choice should be reviewed with culture and sensitivity results; the antibiotic should be changed if the cultured organism is resistant to the empirical choice, based on susceptibility results, choosing the narrowest-spectrum agent possible (targeted option).

 Empirical Option

Targeted Options (when culture results available)

Notes

Men and non-pregnant women

 

Cefalexin PO 500mg TDS, may be increased to 1-1.5g TDS for severe infections
OR
Ciprofloxacin PO 500mg 12-hourly
See MHRA advice for restrictions and precautions for using fluoroquinolones due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding co-administration with a corticosteroid (March 2019).

When culture results available:
Cefalexin PO 500mg 8-hourly for 7-10 days
OR
Ciprofloxacin PO 500mg 12-hourly for 7 days, or for 14 days if renal tract abnormality (eg presence of a calculus, vesicoureteric reflux, reflux nephropathy, indwelling catheter, urinary obstruction, a urinary stent; or recent instrumentation) or infection in a patient with impaired renal function or immunosuppression.

See MHRA advice for restrictions and precautions for using fluoroquinolones due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding co-administration with a corticosteroid (March 2019).
OR
Trimethoprim PO 200mg BD for 14 days
OR  
 Co-trimoxazole PO 960mg 12-hourly for 14 days
OR
Co-amoxiclav  PO 625mg 8-hourly for 7-10 days
OR
Amoxicillin PO 500mg 8-hourly for 14 days

Durations include initial empiric antibiotic treatment before culture results available if susceptible.
Cefalexin contraindicated in patients with severe penicillin allergy/type 1 hypersensitivity, unless known to tolerate cephalosporins.

Avoid Ciprofloxacin in pregnancy
Co-Amoxiclav contains penicillin and should be avoided in patients with penicillin allergy.

Avoid Nitrofurantoin Does not achieve sufficient concentration in kidneys

Avoid Pivmecillinam No evidence to support efficacy in Upper UTI
Avoid oral fosfomycin No evidence to support efficacy in Upper UTI
Refer to BNF for doses in renal impairment etc

Pregnant women

Cefalexin PO 500mg TDS, may be increased to 1-1.5g TDS for severe infections.
OR
Discuss with microbiology

When culture results available:
Cefalexin PO 500mg 8-hourly for 7-10 days
OR
Amoxicillin PO 500mg 8-hourly for 14 days
OR
Co-Amoxiclav PO 625mg 8-hourly for 7-10 days (avoid in late pregnancy or if at risk of pre-term delivery due to risk of neonatal necrotizing enterocolitis) 
OR
Discuss with microbiology

NICE
CKS
LTHT secondary care guideline

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. 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

Provenance

Record: 2238
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: Upper Urinary Tract (Acute pyelonephritis) in Adults
Target patient group: Adults
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

Evidence base

Not supplied

Document history

LHP version 2.0

Related information

Not supplied