Upper urinary tract infections (U-UTI) and urosepsis in non-pregnant adults - secondary care

Publication: 22/10/2013  --
Last review: 17/02/2022  
Next review: 17/02/2025  
Clinical Guideline
CURRENT 
ID: 3501 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

UPPER URINARY TRACT INFECTIONS (U-UTI) AND UROSEPSIS IN NON-PREGNANT ADULTS

Signs and symptoms of upper UTI include acute dysuria, frequency and fever (>38C) with systemic signs of infection, such as rigors and back/loin pain.

Any patient with a suspected or proven upper urinary tract source of infection should be treated as per this guideline.
This guideline should also be used for patient with a suspected or proven urinary tract source of severe sepsis or who are nil by mouth at the time of initiating antibiotics.

If your patient has signs of signs and symptoms of Lower UTI without signs of severe sepsis, please see the Lower UTI guideline.
Please see separate guidance for UTI in pregnancy and prostatitis.

Antibiotics are not routinely required following urinary tract instrumentation (see Urinary procedures prophylaxis guidance), and should only be initiated if there are clinical signs and symptoms of urinary sepsis, when this guidance should be followed.

UTI should not be diagnosed purely on the basis of bacteriuria or pyuria in a urine sample.

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DIAGNOSTICS

Whilst upper UTI or Urosepsis is ultimately a clinical diagnosis, appropriate sampling allows appropriately directed treatment.

All patients

Blood culture (prior to starting antibacterials)

MSU (or CSU if catheterised) should be sent from all symptomatic patients, prior to antibacterials
(do not delay antibacterials with severe sepsis)

Renal tract imaging is required

All patients

Do not perform urine dipsticks

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ASSESSMENT: Complicated or uncomplicated upper UTI

All UTIs should be classified as either complicated or uncomplicated as per the table below:

Uncomplicated upper UTIs

Acute, sporadic or recurrent upper UTI, limited to non-pregnant women with no known relevant anatomical or functional abnormalities within the urinary tract or comorbidities

Complicated upper UTIs

These are UTIs with an increased chance of a complicated course (e.g. persistent infection, treatment failure, recurrence): i.e. men, pregnant women, relevant anatomical or functional abnormalities of the urinary tract, indwelling urinary tract prosthetic material including catheters, renal diseases, immunocompromise, diabetes mellitus

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EMPIRICAL TREATMENT (renal dose adjustment may be required)

  • If your patient has had a positive urine or blood culture with a coliform (e.g. E.coli, Klebsiella spp, Enterobacter spp in the past, please:
    • Check previous results for evidence of multi resistant coliforms (e.g. ESBL, AMP-C, CPE)
    • Check for resistance to empirical treatment options below.
    • Discuss with microbiology if resistance has been previously reported.
  • Ensure adequate fluids and offer appropriate (simple) analgesia
  • Please use the DIRECTED TREATMENT section if your patient has a current blood culture or urine culture result available at the time of initiating antibiotics.
  • Notes on empirical options:
  • Doses assume normal renal and hepatic function

Severity classification

Recommended treatment

Notes

Duration:
Patients with no sepsis and uncomplicated UTI: 7 days
Patients with sepsis: see directed therapy for durations

No sepsis

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly

MHRA warning1
If unable to take orally, then give Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin IV 400mg 12-hourly.

Sepsis

Age <65
Cefuroxime electronic Medicines Compendium information on Cefuroxime IV 1.5g 8-hourly

Age ≥65 or allergy to penicillins/cephalosporins
Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly

Do not use cefuroxime in immediate (IgE mediated) reaction to Penicillin2, unless known to tolerate cephalosporins (since time of allergy).

Severe sepsis

Age <65
Cefuroxime electronic Medicines Compendium information on Cefuroxime IV 1.5g 8-hourly +/- a stat dose of Gentamicin3

Age ≥65
Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 8-hourly
Allergy to Penicillins/Cephalosporins
Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly +/- a stat dose of Gentamicin3  

Do not use cefuroxime in immediate (IgE mediated) reaction to Penicillin2, unless known to tolerate cephalosporins (since time of allergy).
Do not use piperacillin-tazobactam in penicillin allergy

A stat dose of Gentamicin3 can be given empirically whilst awaiting culture results if the patient does not initially respond to single agent therapy.

Gentamicin prescribing guidance can be found here.  LTHT uses once daily dosing with 7mg/kg IBW (ideal body weight) and the Yorkshire Hartford Nomogram for monitoring and dosing frequency. 
A level should be taken following all treatment doses of Gentamicin in case continuation is required.

Previous resistant organism4 (MR-GNB, e.g. ESBL, AMP-C or CPE) in any sample

Refer to susceptibility results.  If resistant (or not detailed on the report) to the severity/age appropriate choice(s) listed above, please discuss with Microbiology.

 

Previous Pseudomonas aeruginosa from the urinary tract (including swabs of sites of entry to the urinary tract)

Refer to susceptibility results and the DIRECTED TREATMENT table below.

Discuss with Microbiology if required.

*

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REVIEW BY 72 HOURS

By 72 hours of antibiotic treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis. If your patient is prescribed IV antibiotics then they should be reviewed daily.

The review, outcome and future plans (where appropriate) should be documented in the medical notes.

IVOS
(IV to Oral Switch)

If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 criteria consider switching using the oral options listed in the table above. 
A - Afebrile for 24 hours
C - Clinically improving
E - Eating and drinking
D - not Deep seated infection

Stop

If no signs of infection and diagnostics support this decision.

Change

If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis (including renal calculi, obstruction, abscess, etc).

If your patient does not meet the ACED criteria yet, please de-escalate to an appropriate IV option as per table 1 below and plan for the appropriate PO option from table 2 once the ACED criteria are met.

Continue

If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch.

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DIRECTED THERAPY

The tables below are in order of preference based on culture results.  Please select the first appropriate agent for your patient.

Doses assume normal renal and hepatic function.

Directed IV options: for use with culture results available prior to starting treatment, or with culture results and an oral switch is not yet appropriate.  Please switch to PO (table 2) at the first appropriate opportunity.

 

Treatment

Notes

Duration: 7-14 days including appropriate oral step-down, agent dependent; please see table 2 for more details.
Courses may need to be extended from the durations stated in table 2 if there are complicating factors, such as renal abscess, infected calculi/stents in situ - please discuss with Microbiology

1

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav IV 1.2 g 8-hourly

Avoid in penicillin allergy

2

Cefuroxime electronic Medicines Compendium information on Cefuroxime IV 1.5g 8-hourly

Avoid in penicillin allergy unless known to tolerate cephalosporins (since allergy identified). 
Avoid in ≥65 year olds if possible.

3

Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly

 

4

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 8-hourly

Increased to IV 4.5g 6-hourly for Pseudomonas aeruginosa

Avoid in penicillin allergy

5

Uncomplicated uUTI:
Fosfomycin IV 6g 12-hourly
Complicated uUTI:
Fosfomycin IV 8g 12-hourly

Fosfomycin can cause deranged electrolytes: monitoring is required with IV administration

If susceptible to either Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole or Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin consider earlier switch to PO due to excellent oral bioavailability, see table below for doses.  The IV dosing given below should be used only where the patient has inadequate enteral absorption.

 

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole IV 960mg 12-hourly

Avoid in Trimethoprim OR sulphonamide allergy

 

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin IV 400mg 12-hourly
(preference is PO if possible)

Increased to IV 400mg 8-hourly for Pseudomonas aeruginosa

MHRA warning1

Directed Oral options: for use with culture results prior to starting treatment where IVs are not required, or as IVOS step-down option.

Doses assume normal renal function 

 

Treatment

Duration

Notes

Duration of treatment: 7-14 days in total (including IV), agent dependent
Courses may need to be extended from the durations below if there are complicating factors, such as renal abscess, infected calculi/stents in situ - please discuss with Microbiology

1

Age <65
Cefalexin electronic Medicines Compendium information on Cefalexin 1.5g PO 6-hourly

Note: this is 12 tablets daily, consider alternative option if there is a concern about adherence.

7 to 10 days

Do not use cefalexin in immediate (IgE mediated) reaction to Penicillin2, unless known to tolerate cephalosporins (since time of allergy).

2

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav PO 625mg 8-hourly PLUS Amoxicillin electronic Medicines Compendium information on Amoxicillin PO 500mg 8-hourly

7 to 10 days

Do not use in penicillin allergy

3

Trimethoprim PO 200mg 12-hourly

14 days

 

4

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole PO 960mg 12-hourly

10-14 days

Do not use in Trimethoprim or sulphonamide allergy

5

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly
Increased to 750mg 12-hourly for Pseudomonas aeruginosa

7 days

MHRA warning1

6

Amoxicillin electronic Medicines Compendium information on Amoxicillin PO 1g 8-hourly

14 days

Do not use in penicillin allergy

Antibiotics that must NOT be used for upper UTIs or Urosepsis

Nitrofurantoin

It only achieves high concentration in urine, making it suitable for lower urinary tract infections (cystitis) only.

Pivmecillinam

No evidence supports its use in upper UTI

Oral Fosfomycin

No evidence supports its use in upper UTI

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Empirical oral switch from IV

Where the diagnosis is confirmed, but cultures have failed to isolate the pathogen and there are no recent results to guide directed therapy, there can be a need for an empirical oral switch from IV.  This table should NOT be used if culture results are available.

Doses assume normal renal and hepatic function.

IV treatment given

Empirical Oral switch

Total duration

Notes

Courses may need to be extended from the durations below if there are complicating factors, such as renal abscess, infected calculi/stents in situ - please discuss with Microbiology

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin1 PO 500mg 12-hourly

7 days

MHRA warning1

Cefuroxime electronic Medicines Compendium information on Cefuroxime

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav PO 625mg 8-hourly PLUS Amoxicillin electronic Medicines Compendium information on AmoxicillinPO 500mg 8-hourly

7-10 days

Different spectrum of activity between IV and oral option. 

Monitor for continued improvement.

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav PO 625mg 8-hourly PLUS Amoxicillin electronic Medicines Compendium information on Amoxicillin PO 500mg 8-hourly
OR
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin1 PO 500mg 12-hourly

7-10 days

7 days

Aztreonam electronic Medicines Compendium information on Aztreonam

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO 500mg 12-hourly1

7 days

Footnotes

  1. See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems.
    Warnings to be given to patients 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).
  2. The nature of the penicillin allergy needs to be determined to assess suitably to receive a cephalosporin or carbapenem.  Please see the guideline ‘Penicillin Allergy - Assessment and Management of a Patient presenting with a History of Penicillin Allergy’.  If unable to assess then cephalosporins or carbapenems should be avoided until it can be assessed.  As per the guideline patients with delayed reactions to penicillin could be given a graded challenge with cephalosporin.
  3. See MHRA advice for advice on prescribing aminoglycosides in patients with mitochondrial mutations
  4. Resistant organism abbreviations:
    1. MR-GNB: Multi-Resistant gram negative bacillus.  These are resistant to 2 or more classes of antibiotics and may or may not have a known mechanism of resistance, as listed below.
    2. ESBL: Extended spectrum β-lactamase producer
    3. AMP-C: An organism that carries and expresses the AMP-C gene conferring resistance to certain β-lactam antibiotics
    4. CPE: Carbapenemase producing enterobacterales.  The specific gene is normally defined, examples of these are KPC, OXA-48, IMP, VIM, NDM

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APPENDIX 1

Local susceptibility data for E coli isolated from blood cultures (BC) and Urine samples in the year 2019-2020 (1/5/19-30/4/20).  As the most common causative pathogen for UTIs, E coli resistance rates are monitoring to influence empirical treatment choices

Antibiotic tested

Amoxicillin

Co-amoxiclav

Ciprofloxacin

Trimethoprim

Cotrimoxazole

Cephalexin

Cefuroxime

Aztreonam

Piperacillin-tazobactam

Gentamicin

Number of blood culture isolates tested

821

820

821

 

821

 

820

820

821

821

Number of urine isolates tested

7739

1263

7741

7737

 

7742

 

 

 

 

For urine isolates identified as ESBL or AMPC+ that were tested for susceptibility to gentamicin 73.1% were sensitive (231 of 316), with 0.6% (2 isolates) Intermediate, with the remaining 26.3% resistant.  There were 1288 isolates identified as ESBL or AMPC, of which 1117 were E colis (mainly ESBLs).

In blood cultures there were 191 ESBL/AMPC isolates with 138 sensitive to Gent (72.3%) and 53 resistant (27.7%)

Provenance

Record: 3501
Objective:
Clinical condition:

Upper Urinary Tract Infection (pyelonephritis/urosepsis)

Target patient group: Adults (≥ 16 years of age)
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

  1. NICE guideline NG111: Pyelonephritis (acute): antimicrobial prescribing  https://www.nice.org.uk/guidance/ng111/resources/visual-summary-pdf-6544161037
  2. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54
  3. SIGN 88: Management of suspected bacterial urinary tract infection in adults (accessed April 2020)
  4. Johansen TE, Botto H, Cek M, Grabe M, Tenke P, Wagenlehner FM, Naber KG. Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system. Int J Antimicrob Agents. 2011 Dec;38 Suppl:64-70.
  5. Oral Antibiotics in pyleonephritis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858297/pdf/10096_2019_Article_3679.pdf
  6. NICE upper UTI guidance.  https://www.nice.org.uk/guidance/ng111/resources/visual-summary-pdf-6544161037
  7. NICE Clinical Knowledge Summary - Pyelonephritis - acute.  Complications | Background information | Pyelonephritis - acute | CKS | NICE Last revision date at time of access, March 2021.
  8. European Association of Urology Infection guidelines: EAU Guidelines: Urological Infections | Uroweb

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

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