Urinary Tract

Microbiological specimens

  • Urine dipstick (UTI unlikely if nitrate and leucocyte esterase are negative and urine is clear, consider alternative source of sepsis)
  • Asymptomatic bacteruria (bacteria in urine greater than 105 colony forming unit/ml) in the elderly female does not need treatment in the absence of symptoms
  • MSSU prior antibiotics for culture and sensitivity and review empiric antibiotic once results available (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.
  • Self-care – use simple analgesia such as paracetamol for pain, ensure adequate hydration.

Duration of therapy:3 days (females) 5 days (males)

Lower urinary tract infection (UTI) is an infection of the bladder usually caused by bacteria from the gastrointestinal tract entering the urethra and travelling up to the bladder

If there are symptoms of pyelonephritis or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure – consider the options as per pyelonephritis.

There is no evidence to support cranberry products or urine alkalinising agents to treat lower UTI

Common Pathogen(s)
E. coli;Staphylococcus saprophyticus.

Recent increase in ESBL+ve E. coli.

Antibiotic – 1st line
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)Trimethoprim is preferred in male patients. Wherever possible, use trimethoprim only if sensitivity is available. If using empirically – monitor after 24 hours for patient’s response.

 

Antibiotic – 2nd line
Co-amoxiclav 625mg PO q8h or

Non-serious penicillin allergy (e.g. mild rash) – Cefalexin 500mg PO q8h

or

Our preferred approach for MDRO is to use gentamicin empirically in hospitalised patients based on local sensitivities. Other oral agents may have been tested and should be on microbiologist’s advice only.

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
Consider previous culture results for recurrent infections or previous antimicrobial use.

Refer to genital guidance system if prostatitis suspected.

Acute pyelonephritis is an infection of one or both kidneys usually caused by bacteria travelling up from the bladder.

Common Pathogen(s)
Enterobacteriacea.

Take account of: severity of symptoms, the risk of developing complications, which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract or immunosuppression

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.

Where sensitive – trimethoprim 200mg po q12h for 14 days can be used as oral step down. If using oral agents empirically rather than based on sensitivity results – the following can be used:

Co-amoxiclav 625mg po q8h  for 7-10 days or

Cefalexin 500mg po q8h for 7-10days

Do not use quinolones without discussing with microbiologists and providing patients with appropriate BNF warnings.

 

Antibiotic – 2nd line and for pregnant patients
Cefuroxime IV 1.5g q8h
Or
Cefalexin 500mg po q8h for 7-10days

  • Asymptomatic bacteriuria requires treatment as risk factor for pyelonephritis and premature delivery [3d treatment unless if using Nitrofurantoin then 5d]
  • UTI [Duration 7d]
  • Treatment choice should be reviewed based on recent urine culture and sensitivity results and previous antibiotic use

Common Pathogen(s)
Enterobacteriacea.

Antibiotic – 1st line
Nitrofurantoin 50mg q6h PO (<36 weeks).
Or
Amoxicillin 500mg q8h PO (if susceptible)

 

Antibiotic – 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.

 

A catheter-associated UTI is a symptomatic infection of the bladder or kidneys in a person with a urinary catheter

  • the longer a catheter is in place the more likely bacteria will be found in the urine; after 1 month nearly all people have bacteriuria

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 – mark specimen with comment about current clinical presentation of patient and need for sensitivity test. Treat according to culture.
  • Consider removing or, if this cannot be done, changing the catheter as soon as possible in people with a catheter-associated UTI if it has been in place for more than 7 days
  • Do not routinely offer antibiotic prophylaxis to prevent catheter-associated UTI in people with a short-term or a long-term (indwelling or intermittent) catheter.

Indiscriminate use of antibiotics in patients with long-term catheter leads to selection of ESBL+ve, MRSA and other multi-drug-resistant bugs.

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 is a bacterial infection of the prostate, usually caused by bacteria entering the prostate from the urinary tract, can occur spontaneously or after medical procedures such as prostate biopsy, can last several weeks and can cause complications such as acute urinary retention and prostatic abscess.

Duration of therapy review after 14 days and either stop or continue for a further 14 days if needed depending on clinical response
Check BASHH guidelines  for any updated advice.
Severe infection requiring parenteral therapy:
(< 35 years; follow guidance as for epididymo-orchitis but treat for 14 days and review response and test for cure).

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 48 hours according to culture and sensitivity

 

Antibiotic – 2nd line
Ofloxacin 200mg q12h PO for 14 days and then review – stop or continue for another 14 days if needed based on clinical assessment.

Comment
Treat according to culture/ sensitivity results.

Refer to GUM clinic for diagnosis, treatment and contact tracing
Treat sexual partners as well.

BASHH guidelines  -please note it is essential to check gonococcal sensitivity as resistance pattern in UK are changing. This regime may not be effective for resistant strains.

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.

 

Antibiotic – 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

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 24-48 hours) (max 500mg): if <70 years and CrCl≥30mL/min  or

3mg/Kg IV q24h (for 24-48 hours) (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 

 

Antibiotic – 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.