The diagnosis of urinary tract infection (UTI) is primarily based on symptoms and signs. Typical symptoms or signs of lower urinary tract infections (cystitis) include dysuria, urinary frequency, urgency, haematuria and suprapubic tenderness but no fever. Acute upper urinary tract infection (pyelonephritis) present with signs of loin pain, flank tenderness, nausea/vomiting, pyrexia, rigors with/without symptoms of a lower UTI Urosepsis is defined as sepsis whose source is the urogenital tract. It is most often related to an upper urinary tract infection Catheter –associated UTI (CAUTI) is difficult to diagnose. Signs and symptoms compatible with CAUTI include new onset fever or worsening fever, rigors, altered mental status, malaise , or lethargy with no other identified cause; flank pain, costo-vertebral angle tenderness, acute haematuria, pelvic discomfort and in those whose catheters have been removed , dysuria, urgent or frequent urination, or supra-pubic pain or tenderness. Investigations
Dipstick screening test for nitrites and leucocyte esterase. DO NOT use dipstick testing to diagnose UTI in catheterised patients
Mid-stream urine (MSU) to be taken before starting antimicrobial treatment
Catheter specimen of urine (CSU) only if the patient has clinical sepsis, not because the appearance or smell of urine suggests that bacteriuria is present
Blood culture in suspected acute pyelonephritis or clinical signs of sepsis or temperature > 380C
For epididymo-orchitis, send a urethral swab for N. gonorrhoeae culture and first pass urine or urethral swab for C.trachomatis NAAT
Renal tract ultrasound for suspected sepsis secondary to acute pyelonephritis(please note that this investigation is not very sensitive)
If previously or currently positive for Clostridium difficile - discuss with a Microbiologist
INFECTION Asymptomatic bacteriuria
FIRST LINE
ALTERNATIVE
NOTES
Antibiotics are NOT appropriate for
Antibiotic treatment is indicated
majority of these patients. This includes:
for pregnant women with
premenopausal non- pregnant
bacteriuria
females
Older patients (>65 years )
Catheterised patients
Cystitis in a non-pregnant
Trimethopim 200mg 12hrly
female
OR
Depends on susceptibility of
Trimethoprim :
organism isolated
* if eGFR between 15-30ml – use half dose after 3 days
Nitrofurantoin 50mg 6 hrly Duration : 3 days
If allergic to Nitrofurantoin or
* avoid if eGFR < 15 ml or CKD
Trimethoprim - use amoxicillin if
* avoid in patients on methotrexate
susceptibility results available or Cystitis in Males
Trimethoprim 200mg 12hrly OR Nitrofurantoin 50mg 6hrly
cephalexin
as increased risk of haematological toxicity
Nitrofurantoin * do not use in chronic kidney disease
Duration : 7 days
* avoid if eGFR < 45mls/min * avoid in males where prostatitis is suspected
INFECTION
FIRST LINE
Cystitis in Pregnant
Nitrofurantoin 50mg 6hrly
Females
(except in 3rd trimester)
ALTERNATIVE
NOTES Trimethoprim :
Contact Microbiologist
OR Trimethoprim 200mg 12hrly
* teratogenic risk in first trimester (folate antagonist) Nitrofurantoin :
(except in 1st trimester)
* avoid in the third trimester , may
Duration : 7 days
produce neonatal haemolysis
AKI Urosepsis including post
IV Gentamicin 7mg/kg daily
Oral alternative should be based
prostatic biopsy sepsis
(see trust policy)
on culture results but avoid
suspected AKI then give a stat
Nitrofurantoin
dose of cefuroxime which can
(refer to sepsis IPOC) AND
be switched to gentamicin if the
OR
Acute pyelonephritis
OR IV Cefuroxime 1.5g tds
( for patients with renal impairment ) Duration : Pyelonephritis: 10-14 days
* If U&E are not available or in
Contact Microbiology
renal function is subsequently found to be normal * Contact Microbiology if patient has had a previous 5-day course of Cephalosporins or Co-amoxiclav in the previous 2 weeks
Urosepsis: 7-10 days Please review all IV antibiotics at 48 hours
INFECTION Catheter- associated UTI (CAUTI)
FIRST LINE Catheters will invariably get colonised
ALTERNATIVE IV Gentamicin 7mg/kg daily – ( see Trust policy)
Antibiotics only indicated signs and
OR
symptoms compatible with CAUTI -
IV Cefuroxime 1.5g tds
susceptibility results are available on
with bacteria which will continue to multiple over time
( for patients with renal impairment )
Do Not treat catheterised patients with asymptomatic bacteriuria with an antibiotic
NOTES
Duration : - 7 days if prompt resolution of symptoms - 10 days if delayed response - 3 days if catheter removed in
request Contact Microbiology if patient has had a previous 5-day course of Cephalosporins or Co-amoxiclav in the previous 2 weeks
females ≤65yr and no fever
Epididymo-orchitis Under 35 years
Single dose of Ceftriaxone 500mg IM PLUS Doxycycline 100mg bd
