Women with Lower Urinary Tract Infection ( UTI ) in Primary Care
|Last review: 04/07/2019|
|Next review: 04/07/2022|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Lower Urinary Tract Infection (UTI) in Non-Pregnant Women in Primary Care (non-catheterised)
See NICE visual summary lower UTI NG109
Dipstick for leucocyte esterase and nitrites only if 1 symptom
Microscopy & Culture
Asymptomatic bacteriuria (AB) = significant levels of bacteria in urine but NO symptoms of UTI
Empirical Antimicrobial Treatment of lower UTI in non pregnant, non-catheterised women
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
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.
- 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.
- Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
- 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
- Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
- 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.
- 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)
- Limit prescribing over the telephone to exceptional cases.
- 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.
- 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.
- 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.
- 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.
- Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.
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
Upper Urinary Tract (Acute pyelonephritis) in Adult Women
|Target patient group:||Adult women|
|Target professional group(s):||Primary Care Doctors
LHP version 1.0