Women with Lower Urinary Tract Infection ( UTI ) in Primary Care

Publication: 30/09/2010  
Last review: 04/07/2019  
Next review: 04/07/2022  
Clinical Guideline
CURRENT 
ID: 2239 
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 Non-Pregnant Women in Primary Care (non-catheterised)

See NICE visual summary lower UTI NG109

Diagnosis

Symptoms

  • Lower UTI include dysuria, frequency, urgency, strangury, suprapubic pain, haematuria, cloudy/offensive urine.
  • Upper UTI include fever, loin/flank/back pain (see Upper UTI Guideline)
  • Elderly patients may present with non-typical symptoms eg delirium
  • The probability of bacteriuria in nonpregnant women presenting with symptoms of UTI is lower if vaginal discharge is present; consider alternative diagnoses eg STI, vulvovaginitis

Dipstick for leucocyte esterase and nitrites only if 1 symptom

  • May help diagnosis in patients with few or non-specific symptoms.
  • 80% probability of bacteriuria if only 1 symptom/sign combined with a positive dipstick (nitrite or leucocyte esterase)
  • UTI unlikely (but not excluded) if both negative
  • Dipstick NOT indicated if 2 or more or moderate/severe symptoms (treat empirically)
  • Dipstick NOT indicated in >65yo .

Microscopy & Culture

  • Routine cultures are unnecessary
  • Send MSUsample on any patient when suspecting resistance (eg. recent antibiotics, recurrent UTI, failed to respond to initial treatment), impaired renal function, immunosuppressed, abnormal urinary tract. Include clinical information when sending MSU on relevant allergies, current/intended antibiotics.
  • Review antibiotic choice when results available, change antibiotic if organism is resistant to prescribed treatment and symptoms not improving.

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

  • Do not screen for or treat AB in non-pregnant women
  • AB is more common in >65 year olds, diabetic patients

Empirical Antimicrobial Treatment of lower UTI in non pregnant, non-catheterised women

  • Consider delayed prescription (see NICE guidance).
  • Be guided by any previous urine culture results.

Preferred Option

Alternative Option

Notes

Nitrofurantoin PO 50mg 6-hourly for 3 days
or Nitrofurantoin MR PO 100mg 12-hourly for 3 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 MR bacteria and on benefit vs risk assessment.

Avoid in patients with suspected or known glucose-6-phosphate dehydrogenase (G-6-PD) 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 3 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 sachet) 3g as a single stat dose for adult and adolescent women over 12 years.

[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 3 days butlocal resistance rates to trimethoprim are >30% so not advised to use empirically unless limited alternative options and no recent treatment with Trimethoprim . Have a low threshold to send MSU if prescribed or if symptoms persist.

Directed Antimicrobial Treatment
Guided by culture and sensitivity results.
Options include Amoxicillin 500mg TDS, Trimethoprim 200mg BD, Nitrofurantoin MR 100mg BD or Nitrofurantoin 50mg QDS, Pivmecillinam 400mg stat then 200mg TDS, Cefalexin 500mg BD-TDS, Fosfomycin 3g sachet STAT.

Treatment Duration
A 3 day course is recommended for most women. Consider a longer antibiotic course (5-7 days) in some patients eg immunosuppressed , diabetes mellitus, abnormal renal tract (eg renal stones, urinary obstruction, reflux).

NICE
SIGN 2012
CKS
PHE

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

Provenance

Record: 2239
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 Adult Women

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

Evidence base

Not supplied

Document history

LHP version 1.0

Related information

Not supplied