Upper Urinary Tract Infection ( UTI ) ( pyelonephritis/urosepsis ) in Adults ( ≥ 16 years of age ) - Guideline for the management of in secondary care
|Last review: 22/08/2018|
|Next review: 22/08/2021|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2018|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
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Update October 2018: Table 1 and reference to aztreonam under Directed therapy have been updated to reflect Aztreonam dose change as 1g vials are now available.
Guideline for Management of Upper Urinary Tract Infection (pyelonephritis/urosepsis) in Adults (≥ 16 years of age)
Upper Urinary Tract Infection ( UTI ) ( pyelonephritis/urosepsis ) in Adults ( ≥ 16 years of age )
Empirical (initial) antimicrobial treatment
Therefore, before treating:
Referral criteria for specialist input
Abnormality seen on ultrasound imaging.
The distal urethra is exposed to bacteria from the environment and from a patient’s normal bowel flora (e.g. Escherichia coli). These bacteria can ascend the urethra to the bladder and from there ascend the ureters to the kidneys. This may result in an upper urinary tract infection (upper UTI). Occasionally bacteria in the blood or from adjacent structures in the pelvis/abdomen can enter the kidneys and cause upper UTI. [Evidence level B]
Risk factors for upper UTI in non-pregnant women include sexual intercourse three or more times per week during the previous 30 days, UTIs in the previous 12 months, diabetes, stress incontinence in the previous 30 days, a new sex partner in the previous year, recent spermicide use, and a history of UTIs in the patient's mother. Older women, women who are menopausal or pregnant, and women who have preexisting urinary tract structural abnormalities or obstructions have a higher risk of UTI, but not necessarily of acute upper UTI.1 [Evidence level B]
Among the female population, annual rates of outpatient and inpatient upper UTI have been estimated at 12–13 cases per 10,000 population and 3–4 cases per 10,000 population, respectively; among the male population, the rates were 2–3 cases per 10,000 population and 1–2 cases per 10,000 population, respectively. Incidence was highest among young women, followed by infants and the elderly population. The ratio of outpatient to inpatient cases was highest among young women (ranging from 5:1 to 6:1). Escherichia coli causes 80% of cases of acute upper UTI in women and 70% of cases in men but is less dominant in older age groups. 2 [Evidence level B]
Complications include renal abscess and death but estimates of their frequency are poorly documented. [Evidence level D]
Upper Urinary tract infection is often called pyelonephritis. This name derives from the Greek words pyelum (renal pelvis which is formed by the proximal dilated ureter) and nephron (kidney) and itis (inflammation). Inflammation in the case of pyelonephritis is caused by infection.
Urosepsis refers to a urinary tract infection associated with sepsis. Most Urosepsis is related to the upper urinary tract and this term is used by some as an equivalent term to upper UTI/pyelonephritis.
Recommendation: The diagnosis of the upper urinary tract infection is primarily based on symptoms and signs.
Symptoms and signs to classify a UTI: 3
In a patient with a urinary tract infection who is sufficiently unwell as to require blood cultures collecting their UTI should be considered an upper UTI
Evidence review/justification for recommendations
Interpretation of microbiology results
Urine dipstick testing.4/5[Evidence level B]
Dipstick results that have been used in the assessment of UTI include nitrite, leukocyte esterase, blood and protein.
Interpreting the urine dipstick result4/5
Nitrite positive: Evidence of UTI when combined with symptoms of a UTI.
The dipstick test should not be used to exclude bacteriuria in pregnancy.
Laboratory urinary analysis4/5 (including culture) [Evidence level B]
White cell count
Red cell count
Bacterial count and culture
Bacteria which are recognised as a cause of upper UTI are:
Antibacterial susceptibility testing7
Collecting urine sample(s) for Microbiology
blood cultures [Evidence level B]
In a hospital study of patients aged 5-62 years old (median 27 years) admitted with a primary discharge diagnosis of upper UTI blood cultures contributed little to clinical management. Therefore where the diagnosis of upper UTI is very likely and a good quality MSU is collected blood cultures are not mandatory.6
Non microbiological investigation
Recommended imaging is:
Urine appearance: Production of turbid urine is reported to have a sensitivity of 90% and a specificity of 66% for the presence of symptomatic bacteriuria. This means if a patient has clear urine it is unlikely they have a UTI, but does not exclude it. It also means many patients with turbid urine do not have a UTI. Turbid urine should not in itself be used to diagnose a UTI. 5[Evidence level B]
Supportive therapy includes management of severe sepsis and sepsis. This includes:
Consider a urological referral in patients with
|Empirical Antimicrobial Treatment|
Recommendation: Empirical treatment depends upon the severity of infection and previous microbiological results. Therefore, before treating define the severity of infection and check the patient’s previous susceptibility testing results. Modify the following guidance if antimicrobial resistance has been previously identified. [Evidence level B]
Empirical Antimicrobial [Evidence level A-D]
3 -Trimethoprim can normally be replaced by PO Co-trimoxazole (contains trimethoprim and suxamethoxazole) at 960mg 12-hourly.
Advice on the use of gentamicin
Gentamicin for synergy
Gentamicin to cover for resistant bacteria
Antibiotic resistance is increasing. When considering all bacteraemias from LTHT there is resistance to commonly used antibiotics e.g. Co-Amoxiclav (Amoxicillin-Clavulanate) (35%) Ciprofloxacin (17%), Cefuroxime (9%), piperacillin-tazobactam (9%), Aztreonam (8%). These figures are likely to represent an artificially high rate of resistance compared to all E. coli causing upper UTI. Gentamicin is sometimes used to cover for resistance until the infecting organism is known and susceptibility results are available, or the patient has clinically improved. For example, of Ciprofloxacin /Cefuroxime /piperacillin-tazobatam resistant E. coli approximately 70% are sensitive to Gentamicin. The rationale for gentamicin’s use is based on evidence that early treatment of infections with an antibiotic the bacteria is sensitive to is associated with a reduced mortality. 9 There is though no evidence that this strategy is associated with a reduced mortality in upper UTI. The decision to use Gentamicin is therefore a risk-benefit decision. The risk of using Gentamicin is that there is an increased risk of nephrotoxicity and ototoxicity, the benefit is that there is an increased chance the patient will receive an antibiotic the bacteria is sensitive to. [Evidence level D]
Gentamicin when a patient has renal impairment/transplant
Daily review of gentamicin
|Directed Antimicrobial Treatment (when microbiology results are known)|
Recommendation: Antimicrobial susceptibility results should be reviewed 48-72 hours after sending a urine result to microbiology. [Evidence level B]
Recommendation: Where susceptibility results are available these should guide antimicrobial prescription. [Evidence level B]
Review urine culture results at 48-72hours
Antibiotics to be avoided in upper UTI 10 (despite being suitable for lower UTI) [Evidence level B-C]
|Duration of Treatment|
Recommendations [Evidence level B]
Uncomplicated upper UTI
Complicated upper UTI*
*Complicated upper UTI: LTHT defines this as upper UTI in the presence of functional or structural abnormalities of the genitourinary tract. These include the presence of a calculus, vesicoureteric reflux, reflux nephropathy, indwelling catheter, urinary obstruction, a urinary stent; or recent instrumentation. It also includes infection in a patient with certain underlying host factors, such as immune system compromise or impaired renal function. Hospital admission does not equate to complicated upper UTI. [Evidence level B]
|Switch to oral agent(s)|
Recommendation: Oral antimicrobials are indicated when clinical assessment indicates oral therapy is suitable and when susceptibility testing results are available. 48-72 hours after starting therapy is good time to assess if oral antibiotics are suitable as susceptibility testing results should be available.
Recommendation: If microbiology results are not available a decision must be made about switching to an oral antibiotic. Without microbiology results there is an increased risk an antibiotic without activity against the infecting bacteria will be prescribed. This may lead to a relapse. In some instances e.g. elderly, there may be a high risk from the oral antibiotics e.g. Co-Amoxiclav (Amoxicillin-Clavulanate) , for Clostridium difficile infection. Consideration can therefore be given to completing a course of IV therapy with an antimicrobial with a low risk of C. difficile infection (piperacillin-tazobactam or Aztreonam ).
3 No published criteria are available to test if Trimethoprim is likely to be effective for upper UTIs and some Gram positive bacteria. We therefore report Co-trimoxazole (contains trimethoprim and suxamethoxazole) susceptibility results in some patients.
Co-trimoxazole (contains trimethoprim and suxamethoxazole) sensitivity can normally be used to infer Trimethoprim sensitivity.
Trimethoprim can be replaced by PO Co-trimoxazole (contains trimethoprim and suxamethoxazole) at 960mg 12-hourly which is recommended in a number of international guidelines10.
Prescribers of Co-trimoxazole (contains trimethoprim and suxamethoxazole) should note that Co-trimoxazole (contains trimethoprim and suxamethoxazole) is associated with rare but serious side-effects (e.g. Stevens-Johnson syndrome and blood dyscrasias, notably bone marrow depression and agranulocytosis) especially in the elderly.
|Please discuss these patients with microbiology for a full review of their diagnosis and previous microbiology results.|
Upper Urinary Tract Infection (pyelonephritis/urosepsis)
|Target patient group:||Adults (≥ 16 years of age)|
|Target professional group(s):||Secondary Care Doctors
- Diagnosis and treatment of acute upper UTI in women. Colgan R, Williams M, Johnson JR. Am Fam Physician. 2011 Sep 1; 84(5):519-26.
- Population-based epidemiologic analysis of acute pyelonephritis. Czaja CA, Scholes D, Hooton TM, Stamm WE. Clin Infect Dis. 2007 Aug 1; 45(3):273-80.
- Sobel J D and Kaye D. Urinary tract infections. In: Mandell GL, Bennett JE, Dolin R. (eds) Principles and Practice of Infectious Diseases 7th Edn 2009 875-905.
- SIGN Management of suspected bacterial urinary tract infection in adults A national clinical guideline July 2006
- McMurray BR, Wrenn KD, Wright SW.Usefulness of blood cultures in pyelonephritis. Am J Emerg Med. 1997 Mar; 15(2):137-40.
- A. Kucers, N. McK. Bennett, and R. J. Kemp, The Use of Antibiotics: A Comprehensive Review with Clinical Emphasis, Lippincott Williams & Wilkins, Philadelphia, Pa, USA, 4th edition, 1987.
- Beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and meta-analysis of randomised trials. BMJ. 2004 Mar 20; 328(7441):668.
- Paul M, Benuri-Silbiger I, Soares-Weiser K, Leibovici L. (Liebovici).
- IDSA Guidelines for Antimicrobial Treatment of Uncomplicated Acute Bacterial Cystitis and Acute Pyelonephritis in Women. Clinical Infectious Diseases 1999; 29:745-758.
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
Improving Antimicrobial Prescribing Group
LHP version 1.0
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