SIGN Guideline 88: Management of suspected bacterial urinary tract infection in adults

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Summary of recommendations

3.1 Diagnosis

DConsider empirical treatment with an antibiotic for otherwise healthy women aged less than 65 years presenting with severe or =3 symptoms of UTI.

BExplore alternative diagnoses and consider pelvic examination for women with symptoms of vaginal itch or discharge.


DConsider the possibility of UUTI in patients presenting with symptoms or signs of UTI who have a history of fever or back pain.

 

3.2.3 Dipstick tests

BUse dipstick tests to guide treatment decisions in otherwise healthy women under 65 years of age presenting with mild or =2 symptoms of UTI.

[Good practice point]Discuss the risks and benefits of empirical treatment with the patient and manage treatment accordingly.

[Good practice point]In elderly patients (over 65 years of age), diagnosis should be based on a full clinical assessment, including vital signs.

3.4.1 Aymptomatic bacteriuria, LUTI

BTreat non-pregnant women of any age with symptoms or signs of acute LUTI with a three day course of trimethoprim or nitrofurantoin.

 

[Good practice point]Particular care should be taken when prescribing nitrofurantoin in the elderly, who may be at increased risk of toxicity.

[Good practice point]Investigate other potential causes in women who remain symptomatic after a single course of treatment.

DAdvise women with LUTI, who are prescribed nitrofurantoin, not to take alkalinising agents (such as potassium citrate).

 

DTake urine for culture to guide change of antibiotic for patients who do not respond to trimethoprim or nitrofurantoin.

 

3.4.2 Symptomatic bacteriuria, UUTI

[Good practice point]Consider hospitalisation for patients unable to take fluids and medication or showing signs of sepsis.

DTake urine for culture to guide change of antibiotic for patients who do not respond to trimethoprim or nitrofurantoin.

 

DTreat non-pregnant women with symptoms or signs of acute UUTI with ciprofloxacin (7 days) or co-amoxiclav (14 days).

[Good practice point]A 14 day course of trimethoprim can be considered where the organism is known to be sensitive to the antibiotic.

3.4.3 Asymptomatic bacteriuria

ADo not treat non-pregnant women (of any age) with asymptomatic bacteriuria with an antibiotic.

 

3.5.1 Cranberry products

AAdvise women with recurrent UTI to consider using cranberry products to reduce the frequency of recurrence.

 

[Good practice point]Women should be advised that cranberry capsules may be more convenient than juice and that high strength capsules may be most effective.

DAdvise patients taking warfarin to avoid taking cranberry products unless the health benefits are considered to outweigh any risks.

[Good practice point]Consider increased medical supervision and INR monitoring for any patient taking warfarin with a regular intake of cranberry products.

[Good practice point]Advise women with recurrent UTI that cranberry products are not available on the NHS, but are readily available from pharmacies, health food shops, herbalists and supermarkets.

3.5.3 Oestrogen

ADo not use oestrogens for routine prevention of recurrent UTI in postmenopausal women.

 

4.2 Near patient testing

AStandard quantitative urine culture should be performed routinely at first antenatal visit.

 

AConfirm the presence of bacteriuria in urine with a second urine culture.

 

ADo not use dipstick testing to screen for bacterial UTI at the first or subsequent antenatal visits.

 

[Good practice point] Dipsticks to test only for proteinuria and the presence of glucose in the urine should be used for screening at the first and subsequent antenatal visits as a more cost-effective alternative to multi- reagent dipsticks that detect the presence of nitrite, leukocyte esterase and blood in addition to protein and glucose.

4.3.1 Symptomatic bacteriuria

B Treat symptomatic UTI in pregnant women with an antibiotic.

 

[Good practice point] Take a single urine sample for culture before empiric antibiotic treatment is started.

[Good practice point] Refer to local guidance for advice on the choice of antibiotic for pregnant women.

[Good practice point] A seven day course of treatment is normally sufficient.

[Good practice point] Given the risks of symptomatic bacteriuria in pregnancy, a urine culture should be performed seven

[Good practice point] days after completion of antibiotic treatment as a test of cure.

4.3.2 Asymptomatic bacteriuria

A Treat asymptomatic bacteriuria detected during pregnancy with an antibiotic.

 

[Good practice point] Refer to local guidance for advice on the choice of antibiotic for pregnant women.

[Good practice point] A seven day course of treatment is normally sufficient.

4.3.3 Teratogenicity

DDo not prescribe trimethoprim for pregnant women with established folate deficiency, low dietary folate intake, or women taking other folate antagonists.

4.4 Screening during pregnancy

CWomen with bacteriuria confirmed by a second urine culture should be treated and have repeat urine culture at each antenatal visit until delivery.

[Good practice point] Women who do not have bacteriuria in the first trimester should not have repeat urine cultures.

5.1 Diagnosis

[Good practice point]Urine microscopy should not be undertaken in clinical settings in primary or secondary care.

[Good practice point]In all men with symptoms of UTI a urine sample should be taken for culture.

[Good practice point]In patients with a history of fever or back pain the possibility of UUTI should be considered.

5. 2 Antibiotic treatment

BTreat bacterial UTI empirically with a quinolone in men with symptoms suggestive of prostatitis.

 

5.3 Referral

DRefer men for urological investigation if they have symptoms of upper urinary tract infection, fail to respond to appropriate antibiotics or have recurrent UTI.

[Good practice point] Consider renal and post-void bladder ultrasound and a kidneys, ureters and bladder (KUB) plain X-ray of the abdomen to look for abnormalities.

6.1 Diagnosis

DDo not rely on classical clinical symptoms or signs for predicting the likelihood of symptomatic UTI in catheterised patients.

 

[Good practice point] In catheterised patients who present with fever:

[Good practice point] Only send urine samples for laboratory culture if the patient has clinical sepsis, not because the appearance or smell of the urine suggests that bacteriuria is present.

6.2.1 Urine microscopy

CDo not use laboratory microscopy to diagnose UTI in patients with catheters.

 

6.2.2 Dipstick tests

BDo not use dipstick testing to diagnose UTI in patients with catheters.

 

6.3 Antibiotic prophylaxis to prevent catheter-related UTI

ADo not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters.

 

[Good practice point] Consider antibiotic prophylaxis in patients for whom the number of infections are of such frequency or severity that they chronically impinge on function and well-being.

[Good practice point] When changing catheters, antibiotic prophylaxis should only be used for people with a history of catheter-associated urinary tract infection following catheter change.

CIn a hospital setting, when prophylaxis for catheter change is required, consider using a narrow spectrum agent such as gentamicin rather than ciprofloxacin to minimise the risk of C. difficile infection.

6.4.1 Symptomatic bacteriuria

[Good practice point] Patients should be admitted to hospital if systemic symptoms, such as fever, rigors, chills, vomiting or confusion appear.

BChange long term indwelling catheters before starting antibiotic treatment for symptomatic UTI.

 

[Good practice point]Choice of empirical treatment should be guided by symptoms and follow local antibiotic policy.

6.4.2 Asymptomatic bacteriuria

BDo not screen women with asymptomatic bacteriuria after short term catheterisation.

 

BDo not treat catheterised patients with asymptomatic bacteriuria with an antibiotic.

 

6.5 Management of bacterial UTI in patients with urinary stomas

[Good practice point]Cnly send urine samples for laboratory culture if the patient has clinical sepsis, not because the appearance or smell of the urine suggests that bacteriuria is present.

 

Scottish Intercollegiate Guidelines Network, Healthcare Improvement Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB
Tel. 0131 623 4720 Web contact duncan.service@nhs.net
Last modified 9/09/13 © SIGN 2001-2013

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