Lower Urinary Tract Infections ( lower UTI ) in non-pregnant female adults ( ≥ 16 years of age ) - Guideline for the management of in secondary care
|Last review: 11/09/2017|
|Next review: 01/09/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Which guideline to use
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Diagnosis and management of lower urinary tract infections (lower UTI) in non-pregnant female adults (≥ 16 years of age)
Lower Urinary Tract Infections ( lower UTI ) in non-pregnant female adults ( ≥ 16 years of age )
The diagnosis of urinary tract infection is primarily based on symptoms and signs.
Symptoms and signs to classify a lower UTI are dysuria and frequency without other features e.g. fever, back pain, loin pain or systemic features of infection.
If there are symptoms of upper UTI please see the upper UTI guideline. Upper UTI symptoms include fever (≥ 37.70C), costovertebral angle tenderness, back pain or where the severity of infection is not in keeping with a lower urinary tract infection e.g. hypotension or evidence of a Systemic Inflammatory Response Syndrome (SIRS).
On a urine dipstick test:
All in-patients with suspected lower UTI should have a urine sample sent for microbiological analysis except those where there is poor clinical evidence of a UTI and a negative urine dipstick result. Urine samples may be one of:
In patients with recurrent UTIs (≥3 per annum or ≥2 per 6 months) or upper UTI a renal ultrasound is recommended.
Empirical antimicrobial regimens
Duration of treatment: Please click on this link.
Consider a urological referral in patients with
Recommendation: If a lower UTI is associated with severe sepsis please manage according to the upper UTI guideline.
Recommendation: If a lower UTI is associated with systemic inflammatory response syndrome (SIRS) please consider if the patient should be managed according to the upper UTI guideline.
Lower UTIs are not normally associated with SIRS [Evidence level B].
Evidence review/justification for recommendations5/6
Interpretation of microbiology results
Urine dipstick testing [Evidence level B]
Interpreting the urine dipstick result
Nitrite positive: Evidence of UTI when combined with symptoms of a UTI.
Laboratory urinary analysis (including culture) [Evidence level B]
In the microbiology laboratory urine samples may undergo the following tests:
White cell count
Red cell count
Bacterial count and culture
Antibacterial susceptibility testing
Collecting urine sample(s) for Microbiology
Blood cultures [Evidence level B]
Non microbiological investigation
Urine appearance: Production of turbid urine is reported to have a susceptibility 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. 5/6[Evidence level B]
Recommendation: If catheterised consider catheter exchange/removal when the urinary tract is considered to be sterile and the patient is still on antibiotics. [Evidence level D] (CAUTI guideline)
|Empirical Antimicrobial Treatment|
Empirical antimicrobial therapy: Clinical scenarios
Empirical antimicrobial regimens
Before commencing an empirical regimen please check the results server to see if previous results are available to allow immediate initiation of directed antimicrobial therapy e.g. GP MSU sample.
Empirical antimicrobial regimens- Oral
Empirical antimicrobial regimens- Intravenous
Unable to be administered oral antibiotics: If the patient is diagnosed with a lower UTI but is unable to be administered oral antibiotics e.g. NBM (Nil By Mouth), please prescribe intravenous antibiotics as per Table 4.
These empirical regimens are suitable for most patients with suspected lower urinary tract infection. In some patients where the consequences of a lower urinary tract infection may be significant e.g. urological patients, alternative agents may be considered empirically e.g. Gentamicin IV. Consideration should be given to the risk benefit of alternative regimens e.g. renal impairment and ototoxicity.
|Directed Antimicrobial Treatment (when microbiology results are known)|
Antibiotic therapy is indicated for bacteriuria prior to transurethral prostatic resection [Evidence level A], and should be considered before other urological procedures in which mucosal bleeding is anticipated. [Evidence level C]
Empirical antibiotics have been chosen from those antibiotics with a high level of susceptibility in E. coli, as shown in table 5 and a low risk of side effects, principally C. difficile.
|Duration of Treatment|
|Switch to oral agent(s)|
To investigate treatment failure consider
Lower urinary tract infections (lower UTI)
|Target patient group:||Non-pregnant female adults (= 16 years of age).|
|Target professional group(s):||Secondary Care Doctors
- Echols RM, Tosiello RL, Haverstock DC, Tice AD. Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis. Clin Infect Dis. 1999;29(1):113.
- Naber KG, Wullt B, Wagenlehner FM.Antibiotic treatment of uncomplicated urinary tract infection in premenopausal women. Int J Antimicrob Agents. 2011 Dec;38 Suppl:21-35.
- Johansen TE, Botto H, Cek M, Grabe M, Tenke P, Wagenlehner FM, Naber KG. Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system. Int J Antimicrob Agents. 2011 Dec;38 Suppl:64-70.
- 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
- Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20.
- NICE: Multidrug resistant urinary tract infections: fosfomycin trometamol https://www.nice.org.uk/advice/esuom17/chapter/key-points-from-the-evidence
- PHE: Management of infection guidance for primary care for consultation and local adaptation https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/591916/managing_common_infections.pdf
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
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