Lower UTI ( cystitis ) and prostatitis in male patients ( ≥ 16 years of age: both hospitalised and those seen in Out-Patient Department and Accident & Emergency ) - 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: 3503 
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.
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Diagnosis and management of lower UTI (cystitis) and prostatitis in male patients (≥ 16 years of age: both hospitalised, and those seen in Out-Patient Departments and Accident and Emergency)

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Summary
Lower UTI ( cystitis ) and prostatitis in male patients ( ≥ 16 years of age: both hospitalised and those seen in Out-Patient Department and Accident & Emergency )

Clinical syndromes

Lower UTI/Cystitis. This is an episode of lower UTI principally related to the bladder. Symptoms of lower UTI are dysuria/frequency without either fever or symptoms of prostatitis (see below). Lower UTI may be recurrent and if this occurs should prompt consideration of a diagnosis of prostatitis. If there are symptoms of upper UTI see the upper UTI guideline. Upper UTI symptoms include fever, 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).

Acute bacterial prostatitis. An acute infection of the prostate which causes a painful and swollen prostate. Additionally patients can have symptoms of lower UTI (dysuria and frequency), obstruction secondary to narrowing of the urethra, fever and systemic evidence of infection.

Chronic prostatitis. Inflammation of the prostate (prostatitis) may be bacterial or non-infective in origin. Most cases (>90%) of chronic prostatitis are non-infective and are classified as chronic pelvic pain syndrome (CPPS), but it may also be an infective condition. Symptoms of prostatitis are mainly of pain which may be perineal, suprapubic, infrapubic, penile, scrotal, or inguinal in location. Symptoms can also include: dysuria, frequency, difficulty urinating, pain when ejaculating and a fever.

  • Chronic bacterial prostatitis: Symptoms of prostatitis with a urine culture growing a uropathogen e.g. E. coli. Symptoms may relapse after short course antibiotic therapy as ≥2 weeks of antibiotics are required for clinical cure. Relapse should be associated with the same bacterial species being isolated from the urine as before treatment.
    Recurrent isolation of the same species of bacteria causing cystitis should prompt consideration of a diagnosis of prostatitis.
  • Chronic pelvic pain syndrome: Symptoms of prostatitis with a negative urine culture.

Investigations

  • Urine sample for Microbiological Culture and Susceptibility testing
  • If Chlamydial infection suspected, urine sample for Chlamydial PCR
  • Lower UTI: Renal ultrasound with upper UTI symptoms.
  • Lower UTI: A single lower UTI in a male should prompt renal ultrasound and urinary flow studies.

Empirical Therapy

Lower UTI

Empirical therapy for the management of lower UTI in male adults- Oral

 

Recommended Treatments

Note

Treatment Duration

1st Line

Nitrofurantoin capsules PO 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.

Avoid if Upper UTI is suspected

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.

7 days

2nd Line

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

Penicillin antibiotic: Avoid in penicillin allergy
No evidence to support use in Upper UTI

7 days

3rd Line

Fosfomycin PO 3g

Creatinine clearance
< 10mL/minute: Not recommended.

No evidence to support use in Upper UTI

3g dose repeated after 3 days (Day 0/3)

Acute bacterial prostatitis

Empirical therapy for acute bacterial prostatitis.

Empirical therapy

Recommended Treatments

Treatment Duration

Mild

Moderate - Severe

All ages 1st Line

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 8-hourly

**On-going supply problems with piperacillin/tazobactam please see link for alternatives**

10 days

2-4 weeks

Penicillin allergy <65years

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin IV 400mg 12-hourly or PO 500mg 12-hourly

10 days

2-4 weeks

Penicillin allergy >65 years

Gentamicin (See gentamicin guidelines) OR Ciprofloxacin IV 400mg 12-hourly

10 days

2-4 weeks

Chronic bacterial prostatitis

Empirical/directed antimicrobial therapy for chronic bacterial prostatitis.

Empirical therapy

Recommended Treatments

Note

Treatment Duration

All patients

Not recommended
Suggest directed therapy based on MSU/CSU result

   

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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 and prostate causing infection.

Bacterial aetiology [Evidence level B]:1

  • Over 95% of UTIs are caused by a single bacterial species.
  • The frequency of different species involved varies with 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 species (which can be associated with renal stone formation), Klebsiella spp, and enterococci.
  • Staphylococcus aureus is an uncommon cause of lower UTI. In men it can cause prostatitis.
  • The sexually transmitted infection Chlamydia trachomatis can cause chronic bacterial prostatitis.

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Clinical Diagnosis

Recommendation: The diagnosis of urinary tract infection is primarily based on symptoms and signs [Evidence level B]:Recommendation: Symptoms and microbiological culture results should be used to differentiate lower UTI/acute bacterial prostatitis/chronic prostatitis.

Clinical syndromes [Evidence level B]2:

Lower UTI/Cystitis: This is an episode of lower UTI principally related to the bladder. Symptoms of lower UTI are dysuria/frequency without either fever or symptoms of prostatitis (see below). Lower UTI may be recurrent and if this occurs should prompt consideration of a diagnosis of prostatitis. If there are symptoms of upper UTI see the upper UTI guideline. Upper UTI symptoms include 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).

Acute bacterial prostatitis: An acute infection of the prostate which causes a painful and swollen prostate. Additionally patients can have symptoms of lower UTI (dysuria and frequency), obstruction secondary to narrowing of the urethra, fever and systemic evidence of infection.

Chronic prostatitis: Inflammation of the prostate (prostatitis) may be bacterial or non-infective in origin. Most cases (>90%) of chronic prostatitis are non-infective and are classified as chronic pelvic pain syndrome (CPPS), but it may also be an infective condition. Symptoms of prostatitis are mainly of pain which may be perineal, suprapubic, infrapubic, penile, scrotal, or inguinal in location. Symptoms can also include: dysuria, frequency, difficulty urinating, pain when ejaculating and a fever.

  • Chronic bacterial prostatitis: Symptoms of prostatitis with a urine culture growing a uropathogen e.g. E. coli. Symptoms may relapse after short course antibiotic therapy as ≥2 weeks of antibiotics are required for clinical cure. Relapse should be associated with the same bacterial species being isolated from the urine as before treatment.
    Recurrent isolation of the same species of bacteria causing cystitis should prompt consideration of a diagnosis of prostatitis.
  • Chronic pelvic pain syndrome: Symptoms of prostatitis with a negative urine culture.

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Severity Assessment

In acute bacterial prostatitis please assess for the presence and degree of sepsis.

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Investigation

Recommendations 1/3/4

Lower UTI [Evidence level B]

  • All patients with suspected cystitis should have a urine dipstick completed, except those with a urinary catheter. Only a positive nitrite test is good evidence of a UTI.
  • All patients with suspected upper UTI should have a urine sample sent for microbiological analysis. 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
      he method of urine collection should always be stated on the request form.
  • The interpretation of microbiology investigations for UTIs is heavily dependent upon 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 the diagnosis.
  • Lower UTI: A single lower UTI in a male should prompt renal ultrasound and urinary flow studies.

Prostatitis/Chronic pelvic pain syndrome [Evidence level B]

  • Urine dipstick testing is not validated for the diagnosis of prostatitis and is therefore not recommended.
  • All patients with suspected prostatitis should have a urine sample for microbiological analysis
  • If Chlamydial infection suspected, send a urine sample for Chlamydial PCR.
  • Referral to urologists for further investigation should be completed.

Microbiological investigations

Urine dipstick [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 lower UTI.

Dipstick results that have been used in the assessment of lower 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 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, including that caused by infection, is present. Inflammation may or may not be caused by infection. If this test is positive it is suggestive of, but does not confirm UTI.
  • Blood and protein: haematuria and proteinuria can occur with UTI, but are also present in many other conditions. Their presence in urine is not well associated with UTI.

It is recommended a urine dipstick is performed routinely on all mid-stream and “single pass catheter” urine samples from any hospital patient in whom lower UTI is being considered. Urine dipsticks should not be used on catheter specimen urines. Bacteria growing on the catheter, and the inflammation caused by the catheter, will give falsely positive nitrite and leucocyte esterase results respectively.
[Evidence level B and C]

Urine dipstick testing is not validated for the diagnosis of prostatitis and is therefore not recommended.

Interpreting the urine dipstick result

Do not test catheter specimen urines.

Nitrite positive: Evidence of cystitis
Leucocyte esterase positive: Possible cystitis though other causes of inflammation equally as likely.
Blood and/or protein positive: Not diagnostic of cystitis.

If negative (for nitrite, leukocyte esterase, protein and blood), then a urinary tract infection is unlikely, with a negative predictive value ≥ 95%. If negative a 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.
[Evidence level C].

Laboratory urinary analysis [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/prostatic symptoms any growth of bacteria is likely to represent asymptomatic bacteruria. This is not a disease entity outside pregnancy and requires no treatment. Catheter specimen urines become colonised with bacteria and the growth of bacteria on these samples cannot be used as evidence of a urinary tract infection.

In the microbiology laboratory urine samples 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 cystitis 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/microliter.
  • 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

  • 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 can occur in urine samples e.g. E. coli and Enterococcus spp. This increases the probability that the sample is contaminated.
  • Patients with pyelonephritis normally have a significant growth of bacteria. Bacterial counts below this level do not exclude the diagnosis of pyelonephritis.
  • 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.

Bacteria which are recognised as a cause of lower UTI and prostatitis are:

  • E. coli
  • Other coliforms including Klebsiella spp, Enterobacter spp and Proteus spp.
  • Enterococcus: antimicrobial therapy of enterococci can be difficult as they are only reliably sensitive to Amoxicillin electronic Medicines Compendium information on Amoxicillin and Vancomycin electronic Medicines Compendium information on Vancomycin .
  • Pseudomonas grows well in water and is a common contaminant of urine samples. It can though cause UTIs, it is most commonly seen when a urinary catheter is in situ. Pseudomonas is only sensitive to Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin , ceftazidime, Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam , and meropenem.

Bacteria associated with prostatitis

  • Staphylococcus aureus is an uncommon cause of lower UTI. In men, it can cause prostatitis.
  • The sexually transmitted infection Chlamydia trachomatis can cause chronic bacterial prostatitis.

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 pyelonephritis. For example, Nitrofurantoin is suitable for the treatment of lower UTI but not prostatitis. 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 UTIs
  • Therefore for all suspected cases of 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.
  • For catheterised patients, the specimen should be obtained aseptically from a sample port in the catheter tubing. The specimen should not be taken from the collection bag.
  • 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.

Non microbiological investigation

  • Blood tests:
    • Inflammatory markers and prostate specific antigen levels are not well correlated with cystitis or prostatitis and their use is not recommended.
    • Lower UTI: A single lower UTI in a male should prompt renal ultrasound and urinary flow studies.
  • The management/investigation of patients with prostatitis should be carried out by urologists. Investigations that may be completed include: Bladder outflow and urethral obstruction: uroflowmetry, retrograde urethrography, or endoscopy.
  • If suspected, bladder cancer must be excluded by urine cytology and cystoscopy.
  • Ureteric calculus is ruled out by unenhanced spiral CT or intravenous pyelography.
  • Interstitial cystitis is diagnosed by means of a micturition chart, cystoscopy and biopsy.
  • Anorectal examination is carried out whenever indicated.

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Treatment
Non-Antimicrobial Treatment

Recommendation: Consider catheter exchange/removal when the urinary tract is considered to be sterile and the patient is still on antibiotics. [Evidence level D]

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Empirical Antimicrobial Treatment
Empirical and directed antimicrobial treatment and durations of treatment

Empirical therapy: Lower UTI [Evidence Levels B-C]2/4/6

Table 1: Empirical therapy for the management of lower UTI in male adults- Oral

 

Recommended Treatments

Note

Total Treatment Duration: Includes empirical and directed therapy.

1st Line

Nitrofurantoin 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.

7 days

2nd Line

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

Penicillin antibiotic: Avoid in penicillin allergy

7 days

3rd Line

Fosfomycin PO 3g

Creatinine clearance <10mL/minute: Not recommended.

3g dose repeated after 3 days (Day 0/3)

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.

Table 2: Empirical therapy for the management of lower UTI in male adults-intravenous

Recommended Treatments

Note

Total Treatment Duration: Includes empirical and directed therapy.

Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly

Suitable in penicillin allergy

7 days

Directed therapy: Lower UTI

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.

Table 3: Directed antimicrobial regimens for the management of lower UTI in male adults - oral

 

Treatment

Note

Total Treatment Duration: Includes empirical and directed therapy.

1st Line

Trimethoprim 200mg 12-hourly1

 

7 days

2nd Line

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

Penicillin antibiotic: Avoid in penicillin allergy

7 days

3rd Line

Nitrofurantoin capsules 50mg 6-hourly

(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.

Avoid Nitrofurantoin in patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min.

(liquid should not be used due to costs - please use fosfomycin sachets)

Please ensure CrCl is used as eGFR overestimates renal function in the elderly. In these patients, move to second line choice.

7 days

4th Line

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

Penicillin antibiotic: Avoid in penicillin allergy

7 days

5th Line

Fosfomycin PO 3g

Creatinine clearance <10mL/minute: Not recommended.

3g dose repeated after 3 days (Day 0/3)

6th Line

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

Avoid unless the other recommended treatments are not indicated: C. difficile risk.

7 days

7th Line

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

Avoid unless the other recommended treatments are not indicated: C. difficile risk.

7 days

8th Line

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly

C. Difficile and MRSA risk.

5 days

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

Table 4: Directed antimicrobial regimens for the management of lower UTI in male adults - intravenous

Recommended Treatments

Note

Total Treatment Duration: Includes empirical and directed therapy.

Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly

Suitable in penicillin allergy

5 days

Acute bacterial prostatitis [Evidence Levels B-C]2/4/6

Empirical therapy: Acute bacterial prostatitis

Table 5: Empirical therapy for acute bacterial prostatitis.

Empirical therapy

Recommended Treatments

Total Treatment Duration: Includes empirical and directed therapy.

Mild

Moderate - Severe

All ages 1st Line

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 8-hourly

10 days

2-4 weeks

Penicillin allergy <65years

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin IV 400mg 12-hourly or PO 500mg 12-hourly

10 days

2-4 weeks

Penicillin allergy >65 years

Gentamicin (See gentamicin guidelines) OR Ciprofloxacin IV 400mg 12-hourly

10 days

2-4 weeks

Directed therapy: Acute bacterial prostatitis

Table 6: Directed therapy/Oral step down for the management of acute bacterial prostatitis.

 

Recommended Treatments

Total Treatment Duration: Includes empirical and directed therapy.

Mild prostatitis

Moderate – Severe prostatitis

 

Please review with results of microbiology results

   

1st Line

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly

10 days

2-4 weeks

2nd Line

Trimethoprim PO 200mg 12-hourly

10 days

2-4 weeks

3rd Line

Discuss with microbiology

   

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

Chronic bacterial prostatitis [Evidence Levels B-C]2/4/6

Table 7: Empirical/directed antimicrobial therapy for chronic bacterial prostatitis.

Empirical therapy

Recommended Treatments

Note

Total Treatment Duration: Includes empirical and directed therapy.

All patients

Not recommended

Suggest directed therapy based on MSU/CSU result

   

Directed therapy

     

1st line

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly

 

2-4 weeks

2nd line

Trimethoprim PO 200mg 12-hourly

 

4 weeks

Chlamydial therapy

Doxycycline electronic Medicines Compendium information on Doxycycline PO 100mg 12-hourly

For chlamydial prostatitis

4 weeks

Chronic pelvic pain syndrome

The role of antimicrobial therapy for chronic pelvic pain syndrome is unclear. If treatment is prescribed see chronic bacterial prostatitis recommendation.

Justification

Antimicrobial recommendations are made based upon the following susceptibility profiles.

Table 8: 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

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 /Cefalexin electronic Medicines Compendium information on Cefalexin

Not known

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Directed Antimicrobial Treatment (when microbiology results are known)
See above

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Duration of Treatment

See antibiotic therapy.

Where duration of therapy is recommended for IV regimens this can include both PO and IV antimicrobials i.e. if the patient becomes able to tolerate an oral antimicrobial it can be prescribed without extending the duration of treatment. For example, if five days Aztreonam electronic Medicines Compendium information on Aztreonam are recommended for lower UTI this could include three days Aztreonam electronic Medicines Compendium information on Aztreonam and two days Trimethoprim .

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Switch to oral agent(s)
See microbiology results and use these in combination with the directed antibiotic therapy options.

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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.

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Referral Criteria

The following men should be referred to urology for assessment

  • Prostatitis (acute or chronic).
  • ≥1 UTI per year
  • Persistently failure to respond to appropriate antibiotic treatment
  • Persistent haematuria
  • Features of urinary obstruction
  • Renal Calculi
  • History of upper UTIs or previous genito-urinary tract surgery.
  • Abnormality seen on ultrasound imaging.

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Provenance

Record: 3503
Objective:

Aims

  • To improve the diagnosis and management of lower UTI and prostatitis in male patients who are ≥ 16 years of age; both hospitalised, and those seen in Out-Patient Departments and Accident and Emergency.

Objectives

  • To provide evidence-based recommendations for appropriate investigation and management of lower UTI (cystitis) and prostatitis in male adults (≥ 16 years of age).
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of lower UTI (cystitis) and prostatitis in male adults (≥ 16 years of age).
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of lower UTI (cystitis) and prostatitis in male 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 UTI (cystitis) and prostatitis

Target patient group: Male patients = 16 years of age; both hospitalised, and those seen in Out-Patient Departments and Accident and Emergency.
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

  1. 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.
  2. Guidelines on Urological Infections. Grabe M, Bjerklund-Johansen TE, Botto H,Wullt B, Çek M, Naber KG, Pickard RS, Tenke P, Wagenlehner F. European Association of Urology 2012.
  3. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947404720
  4. SIGN Management of suspected bacterial urinary tract infection in adults A national clinical guideline July 2006
  5. Lipsky BA, Byren I, Hoey CT. Treatment of bacterial prostatitis. Clin Infect Dis. 2010 Jun 15;50(12):1641-52.
  6. 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.
  7.  NICE: Multidrug resistant urinary tract infections: fosfomycin trometamol https://www.nice.org.uk/advice/esuom17/chapter/key-points-from-the-evidence
  8. PHE: Management of infection guidance for primary care for consultation and local adaptation

 

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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