Upper Urinary Tract Infection (pyelonephritis/urosepsis) in adults (over 16 years old) in Primary Care |
Publication: 30/09/2010 -- |
Last review: 05/11/2019 |
Next review: 07/11/2022 |
Clinical Guideline |
CURRENT |
ID: 2238 |
Approved By: |
Copyright© Leeds Teaching Hospitals NHS Trust 2019 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (MHRA advice November 2018).
Upper Urinary Tract Infection (pyelonephritis/urosepsis) in adults (over 16 years old) in Primary Care
See NICE visual summary
Refer to Secondary Care if systemically very unwell/sepsis, if deterioration, or if no clinical improvement in first 48 hours of antibiotics. Consider referral if very dehydrated/unable to tolerate orals, pregnant or at high risk of complications (e.g. abnormal renal tract, immunosuppressed).
Management
Empirical treatment depends upon:
Targeted antibiotics |
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Empirical Option |
Targeted Options (when culture results available) |
Notes |
Men and non-pregnant women |
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Cefalexin PO 500mg TDS, may be increased to 1-1.5g TDS for severe infections |
When culture results available: See MHRA advice for restrictions and precautions for using fluoroquinolones due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding co-administration with a corticosteroid (March 2019). |
Durations include initial empiric antibiotic treatment before culture results available if susceptible. |
Pregnant women |
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Cefalexin PO 500mg TDS, may be increased to 1-1.5g TDS for severe infections. |
When culture results available: |
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General Principles for Treating Infections
This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.
- 1. This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
- Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
- If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
- Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
- In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
- Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 07825 906030, 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
- Limit prescribing over the telephone to exceptional cases.
- Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
- Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
- Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
- Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.
- Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.
Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion
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Provenance
Record: | 2238 |
Objective: |
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Clinical condition: | Upper Urinary Tract (Acute pyelonephritis) in Adults |
Target patient group: | Adults |
Target professional group(s): | Primary Care Doctors Pharmacists |
Adapted from: |
Evidence base
Not supplied
Document history
LHP version 2.0
Related information
Not supplied