Urinary Tract Infection (UTI)
Microbiological specimens
- Urine dipstick (UTI unlikely if nitrate and leucocyte esterase are negative and urine is clear, consider alternative source of sepsis)
- Asymptomatic bacteruria in the elderly does not need treatment in the absence of symptoms
- MSSU for culture and sensitivity (if STD suspected send a first void urine for chlamydia PCR)
- EMU x3 on consecutive days if TB considered
- For diagnosis of prostatitis an MSSU post prostatic massage is indicated
- The choice of agent should take into account the patient's risk for C. difficile infection.
Uncomplicated Lower Urinary Tract Infection (Cystitis)
Duration of therapy:3 days (females) 5 days (males)
Common Pathogen(s)
E. coli;Staphylococcus saprophyticus.
Recent increase in ESBL+ve E. coli.
Antibiotic - 1st line
Nitrofurantoin 50mg q6h PO (caution if renal impairment - see antibiotic dosing in renal impairment)
or
Trimethoprim 200mg q12h PO (please check prior urine sensitivity as a high proportion of isolates may be resistant) |
2nd Line
Co-amoxiclav 625mg PO q8h or
Non-serious penicillin allergy (e.g. mild rash) - Cefalexin 500mg PO q8h
or
Multidrug resistant coliforms [AmpC/ ESBL+ve or others] or serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)
Gentamicin one stat dose (click here for full gentamicin policy) and contact Microbiologist during working hours to discuss further management.
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.
5mg/kg IV one stat dose (max 500mg): if <70 years and CrCl≥30mL/min or
3mg/Kg IV one stat dose (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight - use adjusted body weight
|
Comment
Refer to previous culture results for recurrent infections.
Refer to genital guidance system if prostatitis suspected.
Gentamicin*: 5mg/ kg but for elderly patients or with moderate/severe renal impairment (CrCl <30ml/min), may require 3mg/ kg or shorter duration treatment.
Upper Urinary Tract Infection / Pyelonephritis / Septicaemia
Common Pathogen(s)
Enterobacteriacea.
Antibiotic - 1st line
Gentamicin (click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.
5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight - use adjusted body weight
Consider restricting Gentamicin to initial 48hrs and step down to oral therapy according to sensitivities. |
2nd Line
Cefuroxime IV 1.5g q8h |
Comment
Gentamicin*: 5mg/ kg but for elderly patients or with moderate/severe renal impairment (CrCl <30ml/min), may require 3mg/ kg or shorter duration treatment.
Bacteruria (pregnant patients)
- Asymptomatic [3d treatment unless if using Nitrofurantoin then 5d]
- UTI [Duration 7d]
Common Pathogen(s)
Enterobacteriacea.
Antibiotic - 1st line
Nitrofurantoin 50mg q6h PO (<36 weeks).
Or
Amoxicillin 500mg q8h PO (if susceptible) |
2nd Line
Cephalexin 500mg q8h PO
Or Trimethoprim 200mg q12h PO (if urine culture is sensitive to this) Caution if low folate status or on known folate antagonist (e.g. antiepileptic drugs). UKTIS recommends that high dose of folic acid (5mg) is recommended for all women treated with trimethoprim during the 1st trimester as a precaution. |
Comment
REF: 1: Public Health England Management of Infection Guidance for Primary Care Oct 2014.
2: UKTIS. Trimethoprim in pregnancy 2013.
Catheterised patients
Comment
- Urine dipsticks are NOT indicated for catheter urine.
- Antibiotics are NOT required unless the patient is febrile or systemically unwell.
- Send CSU if patient systemically unwell. Treat according to culture.
Indiscriminate use of antibiotics in patients with long-term catheter leads to selection of ESBL+ve, MRSA and other multi-drug-resistant bugs.
Asymptomatic bacteruria
(low risk patients)
Comment
- Asymptomatic bacteriuria is very common in elderly patients and rarely requires antibiotic treatment.
Urine samples may give positive dipsticks, but antibiotics are usually NOT required unless the patient is systemically unwell.
Acute prostatitis (>35 yrs)
Duration of therapy 4 weeks
Link to BASHH guidelines
Severe infection requiring parenteral therapy:
(< 35 years; follow guidance as for epididymo-orchitis but treat for 4-weeks).
Common Pathogen(s)
Enterobactericeae.
Antibiotic - 1st line
Cefuroxime 1.5g q8h IV
plus
Gentamicin for 2 doses (click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.
5mg/kg IV q24h for 2 doses (max 500mg): if <70 years and CrCl≥30mL/min or
3mg/Kg IV q24h for 2 doses (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight - use adjusted body weight
Review for appropriate oral switch 48hours according to culture and sensitivity
|
2nd Line
Ofloxacin 200mg q12h PO for 28 days |
Comment
Treat according to culture/ sensitivity results.
Refer to GUM clinic for diagnosis, treatment and contact tracing
Treat sexual partners as well.
Epididymo-orchitis (<35yrs)
Link to BASHH guidelines
Common Pathogen(s)
Gonococci;Chlamydia;
Enteric organisms (uncommon).
Antibiotic - 1st line
Doxycycline 100mg q12h PO for 10-14 days
plus
Ceftriaxone 500mg single dose IM. |
2nd Line
If most probably due to chlamydia or other non-gonococcal organisms (i.e. where
Gonorrhoea considered unlikely as microscopy is negative for Gram negative
intracellular diplococci and no risk factors for gonorrhoea identified*) could consider
Doxycycline 100mg q12h PO for 10-14 days.
Or
Ofloxacin 200mg PO q12h for 14days |
Comment
Refer to GUM.
First voided urine sample,
urethral swab, and culture.
* Common risk factors for gonorrhoea are: previous N. gonorrhoeae infection; known contact of gonorrhoea;
presence of purulent urethral discharge, men who have sex with men and black ethnicity
Epididymo-orchitis (>35yrs)
Link to BASHH guidelines
Common Pathogen(s)
Enteric organisms.
Antibiotic - 1st line
Patients with severe symptoms or sepsis should receive
Ofloxacin PO 200mg q12h for 14 days. Please check culture sensitivity and change to a sensitive narrow spectrum agent. If not available, consider step down to oral ofloxacin alone.
Plus
Gentamicin (for 24-48hours) (click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.
5mg/kg IV q24h (for 24-48hours) (max 500mg): if <70 years and CrCl≥30mL/min or
3mg/Kg IV q24h (for 24-48hours) (max 300mg): If ≥70 years or CrCl 10-29.9ml/min,
known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight - use adjusted body weight
|
2nd Line
Ciprofloxacin 500mg PO BD for 10days |
Comment
Treat according to culture/ sensitivity results.
Refer to GUM clinic for diagnosis, treatment and contact tracing
Treat sexual partners as well.