Lower Urinary Tract Infections ( lower UTI ) in non-pregnant female adults ( ≥ 16 years of age ) - Guideline for the management of in secondary care

Publication: 22/10/2013  
Last review: 11/09/2017  
Next review: 01/09/2020  
Clinical Guideline
CURRENT 
ID: 3502 
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.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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Diagnosis and management of lower urinary tract infections (lower UTI) in non-pregnant female adults (≥ 16 years of age)

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Summary
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).

Investigations required
A urine dipstick test should be performed on a mid-stream or “single pass catheter” urine sample from any hospital patient in who lower UTI is being considered.

Urine dipstick test should not be used on urine samples collected from indwelling catheters because bacteria colonising the catheter and the inflammation caused by the catheter, will give falsely positive nitrite and leucocyte esterase results respectively.

On a urine dipstick test:

  • A positive nitrite test is good evidence of a UTI when combined with symptoms of a UTI.
  • If negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely, with a negative predictive value ≥ 95%.

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:

  • A midstream urine (MSU)
  • A “post insertion of catheter” urine
  • A catheter specimen urine (CSU) / ileal conduit/urostomy sample (See CAUTI guideline)

In patients with recurrent UTIs (≥3 per annum or ≥2 per 6 months) or upper UTI a renal ultrasound is recommended.

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.

Table 1. Empirical antimicrobial regimens- Oral

 

Recommended Treatments

Notes

1st Line
No evidence of upper UTI

Nitrofurantoin PO capsules 50mg 6-hourly
(liquid should not be used due to costs - please use fosfomycin sachets)

Avoid Nitrofurantoin in patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min.
Please ensure CrCl is used as eGFR overestimates renal function in the elderly. In these patients, move to second line choice.
Liquid should not be used due to costs - please use fosfomycin sachets.

Avoid in patients with suspected or known glucose-6-phosphate dehydrogenase (G-6-PD) deficiency.

2nd line
No evidence of upper UTI
No penicillin allergy

Pivmecillinam electronic Medicines Compendium information on Pivmecillinam PO 400mg stat dose then 200mg 8-hourly

Penicillin antibiotic: Avoid in penicillin allergy

3rd Line
No evidence of upper UTI

Fosfomycin PO 3g stat dose

If creatinine clearance <10mL/minute: Not recommended.

Duration of treatment: Please click on this link.

Consider a urological referral in patients with

  • Recurrent UTIs (≥ 3 per annum or ≥2 per 6 months) or who persistently fail to respond to appropriate treatment
  • Persistent haematuria
  • Features of urinary obstruction
  • Calculi
  • History of pyelonephritis or previous genito-urinary tract surgery.
  • Abnormality on renal imaging.

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Background

The urinary tract is exposed to bacteria from the environment e.g. E. coli from the bowel. These can ascend the urethra to the bladder. This may result in an infection of the urethra (urethritis) or bladder (cystitis). Both urethritis and cystitis are lower urinary tract infections (lower UTIs).

Aetiology [Evidence level B]:1

  • Over 95% of UTIs are caused by a single bacterial species.
  • The frequency of different species involved varies with the clinical setting, e.g. community or hospital acquisition.
  • The predominant organism in acute infection is Escherichia coli (75-85%).
  • Other relatively common pathogens include Proteus spp (which can be associated with renal stone formation), Klebsiella spp, and Enterococcus spp.
  • Staphylococcus saprophyticus accounts for 5-15% cases of cystitis in young women of sexually active age. S. saprophyticus is a coagulase negative staphylococcus.
  • Pseudomonas spp, Staphylococcus aureus and yeasts are uncommon causes of lower UTI.
  • Pseudomonas spp and S. aureus are more often a cause of catheter associated UTI.
  • Yeasts may suggest vaginal candidiasis.

Natural History [Evidence level B]2

  • Most uncomplicated lower urinary tract infections resolve without antimicrobial therapy.
  • Uncomplicated UTI rarely progresses to upper UTI (pyelonephritis).
  • Most uncomplicated UTIs resolve spontaneously although it can take months for symptoms to resolve.
  • Antibiotic therapy for uncomplicated lower UTIs can reduce the duration of urinary symptoms but are associated with an increased rate of side effects e.g. vaginal candidiasis.

Classification [Evidence level B]3

Lower UTIs can be sub-classified as below:

  • Uncomplicated lower UTI: Lower UTI in a structurally normal urinary tract.
  • Complicated lower UTI: Lower 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; or recent instrumentation. It also includes infection in a patient with certain underlying host factors, such as immune system compromise or impaired renal function. Pregnancy and hospitalisation are not considered as markers of complicated infection in this guideline.

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Clinical Diagnosis

Recommendation: The diagnosis of urinary tract infection is primarily based on symptoms and signs. [Evidence level A]

Symptoms and signs to classify a UTI are:4
Lower UTI: Dysuria and frequency without other features e.g. fever, back pain, loin pain or systemic features of infection.
Upper UTI: Dysuria, frequency and fever with other features including rigors, back pain, costovertebral angle (loin) pain which is usually unilateral and may worsen on micturition, nausea, vomiting and diarrhoea. Dysuria and frequency are not present in all cases of upper UTI. [Evidence level C]

If vaginal itch and/or discharge are present, consider alternative diagnoses such as vulvovaginitis (usually secondary to Candida) or chlamydial infection [Evidence level B].

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Severity Assessment

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].

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Investigation

Recommendations:5/6

  • A urine dipstick test should be performed on a mid-stream or “single pass catheter” urine sample from any hospital patient in who lower UTI is being considered. [Evidence level B]
  • Urine dipstick testing should not be used on urine samples collected from indwelling catheters because bacteria colonising the catheter and the inflammation caused by the catheter, will give falsely positive nitrite and leucocyte esterase results respectively. [Evidence level B]
  • On a urine dipstick test:
    • A positive nitrite test is good evidence of a UTI when combined with symptoms of a UTI.
  • If negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely, with a negative predictive value ≥ 95%. [Evidence level B]
  • 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:
  • The method of urine collection should always be stated on the request form.
  • Patients with a systemic inflammatory response or signs of severe sepsis should have a blood culture taken before antibiotics are started.
  • In patients with recurrent lower UTIs (≥3 per annum or ≥2 per 6 months) or a upper UTI renal ultrasound is recommended.

Evidence review/justification for recommendations5/6

Interpretation of microbiology results
The interpretation of microbiology investigations for UTIs is heavily dependent upon the pre-test probability i.e. the probability of infection based on the clinical examination and history. For example, where there is a high probability of infection based on the clinical history negative microbiology results do not exclude a diagnosis of urinary tract infection. A guide to when to use urine dipstick and MSU/CSU testing in the investigation of a lower UTI is provided in Figure 1, see below.

Urine dipstick testing [Evidence level B]
Near patient testing using a commercially available dipstick test is rapid and reliable. It has a good negative predictive value i.e. if all the results are negative it is unlikely a patient has a UTI.
Dipstick results that have been used in the assessment of UTI include nitrite, leukocyte esterase, blood and protein.

  • Nitrite is produced by the action of the bacterial enzyme nitrite reductase. If this test is positive it is good evidence of a UTI. This enzyme is not present in all bacteria therefore a negative result does not exclude a UTI.
  • Leucocyte esterase is detected if intact and lysed leucocytes are present. This enzyme indicates inflammation but inflammation may or may not be caused by infection. If this test is positive it is suggestive of, but does not confirm a UTI.
  • Blood and protein: haematuria and proteinuria can occur with UTIs, but are also present in many other conditions. Their presence in urine is not well associated with UTIs.

Interpreting the urine dipstick result
Urine samples can be easily contaminated at the time of sampling. It is not possible to know this at the time of sampling although it may be suggested by the patient’s ability to provide a clean catch MSU. Contamination may be indicated when the sample is analysed in the laboratory, by a mixed growth and/or the presence of epithelial cells. [Evidence level B]

Nitrite positive: Evidence of UTI when combined with symptoms of a UTI.
Leucocyte esterase positive: Possible UTI though other causes of inflammation equally as likely.
Blood and/or protein positive: Not diagnostic of a UTI.
If negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely, with a negative predictive value ≥ 95%. If negative, urine sample should only be sent for microbiological investigations if there is high clinical suspicion of urinary tract infection, or from patients at particular risk of urinary tract infection/asymptomatic bacteriuria.

Laboratory urinary analysis (including culture) [Evidence level B]
The interpretation of urine samples is heavily dependent upon the clinical details and the method of urine collection. For example, in the absence of urinary symptoms any growth of bacteria is likely to represent asymptomatic bacteruria or contamination. Asymptomatic bacteriuria is not a disease entity outside pregnancy and normally requires no treatment. Urinary catheters inevitably become colonised with bacteria so the growth of bacteria from urine collected via an indwelling catheter cannot be used alone as evidence of a urinary tract infection.

In the microbiology laboratory urine samples may undergo the following tests:

  • White cell count
  • Red cell count
  • Epithelial cell count
  • Bacterial culture and identification
  • Antibiotic susceptibility testing

White cell count

  • A raised white cell count in urine is called a pyuria.
  • At LTHT we define pyuria as ≥ 104 leukocytes/mL of urine (>40 leukocytes/microlitre).
  • Pyuria can be present without UTI, but its presence does increase the probability that a UTI is present.
  • Causes of pyuria in the absence of detectable bacteriuria (“sterile pyuria”) commonly include concurrent antibiotics, the presence of a foreign body (e.g. catheter), urinary calculus or neoplasm, lower genital tract infections (including urethritis, such as caused by Chlamydia). Renal tract tuberculosis is a rare cause. Early morning urine specimen(s) for acid fast bacilli (AFB) investigations should NOT be sent solely on the basis of one urine sample with “sterile” pyuria.

Red cell count

  • A raised red cell count is called haematuria
  • At LTHT we define haematuria as >140 red cells/microlitre.
  • There are many causes of haematuria one of which includes infection. Haematuria is a poor indicator of bacterial infection.

Epithelial cells

  • Epithelial cells are found on the surface of internal and external body surfaces.
  • Types of epithelial cells found in urine samples include vaginal epithelial cells, urethral epithelial cells and bladder epithelial cells.
  • Epithelial cells from these different sites have different physical appearances. When microscopy of urine sample was performed manually it was possible to report the cell type.
  • If vaginal epithelial cells were seen this indicated the urine sample was contaminated by vaginal contents and so the results of the test were unreliable. This is because vaginal contents may contain white cells, red cells and bacteria.
  • Microscopy is now automated i.e. completed by machine. Automated microscopy cannot differentiate between the different types of epithelial cell. Therefore, when epithelial cells are reported it suggests there may be vaginal contamination but does not confirm it.

Bacterial count and culture

  • An estimate of the quantity of bacteria is made based on the number of bacteria growing on urine culture.
  • At LTHT we define a significant growth of bacteria as ≥105 colony forming units of pure growth/mL mid-stream specimen of urine (MSU). Urinary tract infections, principally lower UTIs, may be associated with lower bacterial counts.
  • Mixed growth from a midstream urine sample can occur e.g. E. coli and Enterococcus spp. This increases the probability that the sample is contaminated.
  • Patients with UTI often have a significant growth of bacteria. Bacterial counts below this level do not exclude the diagnosis of upper UTI.
  • Rapid transport and culture, or special measures to assure preservation of the sample are essential for reliable laboratory diagnosis.
  • Delays and storage at room temperature allow organisms to multiply which generates results that do not reflect the true clinical situation. Where delays in processing are unavoidable, refrigeration at 4°C or the use of a boric acid preservative is essential.

Antibacterial susceptibility testing
Routine susceptibility testing of urines is standardised i.e. it is not different depending upon if a patient has upper or lower tract infection. Therefore not all antibiotics reported on urine culture results are suitable for the treatment of upper UTI. For example, Nitrofurantoin is suitable for the treatment of lower UTI but not upper UTI. The susceptibility testing completed and reported may be modified if clinical details provided by the requester indicate upper tract infection.

Collecting urine sample(s) for Microbiology

  • Urine cultures are positive in around 90% of cases of lower UTI
  • Therefore for all suspected UTIs, if possible, a urine sample should be collected prior to starting empiric antimicrobial therapy.
  • The preferred sample is the mid-stream urine. This should be collected half way through urination preferably without interruption of flow to reduce contamination with urethral or peri-urethral flora.
  • Prior cleansing with water does not reduce contamination rates; and use of an antiseptic may lead to a false negative culture result.
  • For patients from whom a mid-stream urine specimen cannot be obtained, a clean-catch urine sample should be taken. After peri-urethral cleaning, the whole voided urine is collected into a sterile container; and a sample for examination is then taken from this.
  • The urine sample for Microbiology should normally be sent in a red-topped (boric acid containing) sterile universal container. Boric acid inhibits bacterial growth in the container post sample collection. The container should ideally be filled to the line as directed – a false negative culture result can occur with a small urine volume.

Blood cultures [Evidence level B]
Both upper and lower tract UTI are likely to have urinalysis which suggests UTI.
Where patients have sepsis blood cultures should be taken.

Non microbiological investigation

  • Blood tests:
    • Inflammatory markers e.g. neutrophils/CRP are not well correlated with a diagnosis of lower UTI or response to treatment. Their use is not routinely recommended.
  • Radiological imaging of the urinary tract is not normally indicated in patients with lower UTI. In patients with recurrent UTIs (≥3 per annum or ≥2 per 6 months) or upper UTI renal ultrasound is recommended.

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]

Figure 1: A summary of the process to be followed when considering if a patient has a lower urinary tract infection.

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Treatment
Non-Antimicrobial Treatment

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)

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Empirical Antimicrobial Treatment

Empirical antimicrobial therapy: Clinical scenarios

  • Probable diagnosis of uncomplicated or complicated lower UTI
    • Empirical antibiotic therapy.
  • Possible diagnosis of uncomplicated or complicated lower UTI
    • Empirical antibiotic therapy may not be indicated.
    • Consider directed antibiotic therapy, based on a laboratory result (available 24-48 hours after arrival in the laboratory).

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.
Evidence of upper UTI/SIRS: If the patient has evidence of upper UTI or has SIRS (systemic inflammatory response syndrome) please see the upper UTI guideline.

Table 2. Empirical antimicrobial regimens- Intravenous

Recommended Treatments

Note

Aztreonam electronic Medicines Compendium information on Aztreonam

Creatinine clearance > 30mL/minute
      • Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 12-hourly

Creatinine clearance 10–30 mL/minute
      • Initial dose 1g then 500mg 12 hourly

Creatinine clearance <10mL/minute
      • Initial dose 1g then 250mg 12 hourly

Suitable in penicillin allergy

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.

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Directed Antimicrobial Treatment (when microbiology results are known)

Asymptomatic patients
It is common for an MSU to grow uropathogens e.g. E. coli. Many of these patients do not have symptoms of a UTI. These patients are classed as having asymptomatic bacteruria. There is no evidence that treatment of asymptomatic bacteriuria either reduces mortality or the risk of symptomatic episodes; this includes patients with co-morbidities such as diabetes or primary biliary cirrhosis [Evidence level A]. Antibiotic treatment significantly increases the risk of adverse events.

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]

Symptomatic patients7/8
Treatment for UTIs can be directed against the pathogen when the result of a microbiological analysis is available. In these circumstances we suggest selecting from the following antibiotics. These directed therapies are ordered in preference in Table 3.

Table 3. Directed antimicrobial regimens- Oral

 

Treatment

Note

1st line

Nitrofurantoin 50mg 6-hourly

New MHRA advice is that Nitrofurantoin is now contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min. Please ensure CrCl is used as eGFR overestimates renal function in the elderly. In these patients, move to second line choice.

Avoid in patients with suspected or known glucose-6-phosphate dehydrogenase (G-6-PD) deficiency.

2nd Line

Trimethoprim 200mg 12-hourly1

 

3rd Line

Amoxicillin electronic Medicines Compendium information on Amoxicillin 500mg 8-hourly

Penicillin antibiotic: assume cross allergy if allergy reported to other penicllins

4th Line

Pivmecillinam electronic Medicines Compendium information on Pivmecillinam 400mg stat dose then 200 mg 8-hourly

Penicillin antibiotic: Avoid in penicillin allergy

5th Line

Fosfomycin PO 3g stat dose

If creatinine clearance <10mL/minute: Not recommended.

6th Line

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 625mg 8-hourly

C. difficile risk.
Penicillin antibiotic: assume cross allergy if allergy present to other penicllins

7th Line

Cefalexin electronic Medicines Compendium information on Cefalexin 500mg 8-hourly

C. difficile risk.
Avoid if severe penicillin allergy

8th Line

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 250mg 12-hourly2

C. difficile and MRSA risk.

  1. Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole at 960mg PO 12-hourly can be used instead of Trimethoprim.

  2. The rationale ciprofloxacin dosage regimen is that:
    • 250mg 12-hourly is the BNF dose for cystitis: Urinary-tract infections, 250–750 mg twice daily (250 mg twice daily for 3 days usually adequate for acute uncomplicated cystitis in women).
    • There is a theoretical reduction in side effects with this lower dose.
    • PK/PD analysis suggests 250mg 12-hourly will be effective for cystitis.

Table 4. Directed antimicrobial regimens- Intravenous

Recommended Treatments

Note

Aztreonam electronic Medicines Compendium information on Aztreonam

Creatinine clearance > 30mL/minute
      • Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 12-hourly

Creatinine clearance 10–30 mL/minute
      • Initial dose 1g then 500mg 12-hourly

Creatinine clearance <10mL/minute
      • Initial dose 1g then 250mg 12-hourly

Amoxicillin
      • Amoxicillin electronic Medicines Compendium information on Amoxicillin IV 500mg 8-hourly

Suitable in penicillin allergy

Alternative Treatments

 

Gentamicin

Consider risks of renal/auditory side effects

Justification/evidence review

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.

Table 5. E. coli antimicrobial resistance rates in MSU samples- All LTHT samples 2011-12

Organism

Antibiotic

% Sensitive

E. coli

Amoxicillin electronic Medicines Compendium information on Amoxicillin

46%

Trimethoprim 1

63%

Pivmecillinam electronic Medicines Compendium information on Pivmecillinam

84%

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin

91%

Nitrofurantoin

94%

Fosfomycin

97%

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav /Cephalexin

Not known

1- Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole at 960mg PO 12-hourly can be used instead of Trimethoprim .

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Duration of Treatment

Table 6. Treatment duration

Recommended Treatments

Uncomplicated

Complicated

Nitrofurantoin

3 days

7 days

Pivmecillinam electronic Medicines Compendium information on Pivmecillinam

Amoxicillin electronic Medicines Compendium information on Amoxicillin

Trimethoprim

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav

Cefalexin electronic Medicines Compendium information on Cefalexin

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin

Fosfomycin PO 1 dose (see table 1) 3g repeated every 2 days (Day 0/2/4/6)

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Switch to oral agent(s)

See microbiology results and use these in combination with the directed antibiotic therapy options, Table 3. If no result please refer to directed therapy Table 1.

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Treatment Failure

To investigate treatment failure consider

  • Repeat urine testing for microbiological culture and susceptibility testing
  • Alternative diagnoses or drug failure e.g. vaginal candidiasis, upper urinary tract infection, renal impairment.

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Referral Criteria

Criteria for referral
Consider a urological referral in patients with

    • Recurrent UTIs (≥3 per annum or ≥ 2 per 6 months) or who persistently fail to respond to appropriate treatment
    • Persistent haematuria
    • Features of urinary obstruction
    • Calculi
    • History of pyelonephritis or previous genito-urinary tract surgery.
    • Abnormality on renal imaging e.g. ultrasound

Referral imaging
Patients meeting the criteria for urological referral should have urinary tract investigations completed prior to their specialist review. For women, this normally includes a renal ultrasound and a cystoscopy.

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Provenance

Record: 3502
Objective:

Aims

  • To improve the diagnosis and management of lower urinary tract infections (lower UTIs) in non-pregnant female adults (≥ 16 years of age). The adults may be hospitalized or seen in out-patient departments and accident and emergency.

Objectives

  • To provide evidence-based recommendations for appropriate investigation and antimicrobial management of lower urinary tract infections in non-pregnant female adults (≥ 16 years of age).
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of lower urinary tract infections in non-pregnant female adults (≥ 16 years of age).
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of lower urinary tract infections in non-pregnant female adults (≥ 16 years of age).
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Lower urinary tract infections (lower UTI)

Target patient group: Non-pregnant female adults (= 16 years of age).
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

  • 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.
  • http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947404720
  • 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.
  • BNF
  • 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

Evidence levels:
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)

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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