Lower Urinary Tract Infections (LUTI): cystitis - non-pregnant adults - Secondary care management

Publication: 22/10/2013  
Next review: 17/06/2024  
Clinical Guideline
CURRENT 
ID: 3502 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

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.

Lower Urinary Tract Infections (LUTI): cystitis - non-pregnant adults

Lower UTIs are usually caused by gastrointestinal tract bacteria ascending the urethra to the bladder. They are normally caused by a single pathogen.

Signs and symptoms include acute dysuria, frequency, urgency and suprapubic pain/discomfort without upper UTI features (back/loin pain, fever) or systemic signs of infection.

Older people may present with delirium or may be unable to provide a history of acute symptoms, in which case diagnosis is made based on:

  1. MSU results (bacteriuria + pyruria) AND
  2. Evidence of infection (e.g. raised inflammatory  markers) AND
  3. No other more plausible source of infection.  Asymptomatic bacteriuria, and pyuria is common in this population.

If delirium is present with a UTI, then review for upper tract or prostatic involvement and refer to the relevant guideline

If your patient is pregnant please see UTI in pregnancy guidelines .

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DIAGNOSTICS

Whilst Lower UTI is ultimately a clinical diagnosis, appropriate sampling allows appropriately directed treatment.

Samples must be sent in boric acid containers and filled to the marked line.

All patients

Samples should only be sent from symptomatic patients

Cloudy or smelly urine is not an indication for culture

Do not send samples to ‘screen’ for asymptomatic bacteriuria

Patients >= 65 years

Do not perform urine dipsticks

Women <65 years

Dipsticks are best used to rule out lower UTIs where the diagnosis is clinically dubious. 
If negative for leucocytes, red cells and nitrite then alternative diagnosis more likely and antibacterials should not be prescribed, nor MSU sent.

Symptomatic women <65 years, with no risk factors for complicated UTI*

If there are no risk factors for complicated UTI*, diagnosis can be made by dipstick (send sample if treatment failure)

Symptomatic patients:
all men, all patients >=65 years, all patients with risk factors for complicated UTI*

MSU should be sent, prior to antibacterials (do not delay antibacterials if severe sepsis)

Patients who require IV antibiotics

Refer to the  Upper UTI guideline

Blood cultures (prior to starting antibacterial)

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EMPIRICAL TREATMENT (renal dose adjustment may be required)

  • Do NOT treat asymptomatic bacteriuria or pyuria
  • If your patient has had a recent urine culture, please use the sensitivity results to provide directed therapy (see table for order of preference).
  • Consider prostatitis in men: if recurrent UTI or signs of prostatitis, then refer to the prostatitis guideline
  • Ensure adequate fluids and offer appropriate (simple) analgesia
  • If your patient has a current or recent catheter (removed in the last 48 hours) please refer to the CA-UTI guideline
  • Notes on empirical options:
  • Doses assume normal renal and hepatic function

Empirical options for L-UTI with no signs of sepsis or concomitant upper UTI

 

Recommended treatment

Notes

Duration

Men

Women

1st line

Nitrofurantoin PO 50mg
6-hourly

Do not use if CrCl <45 mL/min. Do not rely on eGFR as this may over-estimate renal function.
Avoid liquid -consider fosfomycin sachets as an alternative.

7 days

3 days (uncomplicated)

7 days (complicated, but no upper UTI symptoms*)

2nd line

Pivmecillinam electronic Medicines Compendium information on Pivmecillinam PO 400mg stat then 200mg 8-hourly

Avoid in penicillin allergy

3rd line

Fosfomycin PO 3g stat (and repeated at 72 hours for men)

Do not use if CrCl <10mL/min

IV antibiotics are not normally required for Lower-UTI.  If there are signs of sepsis, concomitant upper UTI, or unable to take oral medication then please refer to the Upper UTI guideline

*A complicated lower UTI is defined as a lower UTI in the presence of functional or structural abnormalities of the genitourinary tract, including the presence of a calculus, vesicoureteric reflux, reflux nephropathy, urinary obstruction or recent instrumentation; as well as patients with immunocompromise or impaired renal function.

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REVIEW BY 72 HOURS

By 72 hours of antibacterial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis.
You should document the outcome of the review in the medical notes.

IVOS

Please refer to the Upper UTI guideline for oral switch options if your patient was started on IV antibiotics for signs of sepsis or concomitant upper UTI.
If your patient is on IV antibiotics they should be reviewed daily.

Stop

If no signs of infection and diagnostics support this decision.

Change

  • If diagnosis still valid, use culture results to review current antibiotic and change to directed therapy if needed.
  • If initial diagnosis now changed - review appropriate guideline.

Continue

If already on a narrow spectrum agent and improving.

Note duration of antibiotics for uncomplicated lower UTI in women is only 72 hours.  If there are on-going symptoms then please send a sample and consider further treatment with an alternative antibiotic.

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DIRECTED THERAPY

The table below is in order of preference based on culture results, patient allergy status and review of other contra-indications.

If the patient has been started on empirical therapy and the bacterial isolate is susceptible, then this agent can be used to complete the course

Doses assume normal renal and hepatic function.

 

Treatment

Notes

Duration of treatment:
Men: 7 days in total of effective antibacterial
Women: 3 days in total of effective antibacterial (uncomplicated), 7 days (complicated*)

1

Nitrofurantoin PO 50mg 6-hourly

Do not use if CrCl <45 mL/min. Do not rely on eGFR as this may over-estimate renal function.

2

Trimethoprim PO 200mg 12-hourly 

 

3

Amoxicillin electronic Medicines Compendium information on Amoxicillin PO 500mg 8-hourly

Avoid in penicillin allergy

4

Pivmecillinam electronic Medicines Compendium information on Pivmecillinam PO 400mg stat then 200mg 8-hourly

Avoid in penicillin allergy

5

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

 

6

Cefalexin electronic Medicines Compendium information on Cefalexin PO 500mg 8-hourly

Avoid in penicillin allergy, unless known to tolerate cephalexin.
Avoid in >65 year olds
C.difficile risk

7

Fosfomycin PO 3g stat (repeated at 72 hours for 7 day course duration)

Avoid if CrCl <10mL/min

8

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

MHRA warning1
C. difficile risk.

9

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

Avoid in penicillin allergy
C. difficile  risk

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).

Provenance

Record: 3502
Objective:
Clinical condition:

Lower UTIs in men and women

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

Evidence base

  • Diagnosis of urinary tract infections: Quick reference tool for primary care for consultation and local adaption, Public Health England, version 2, latest update Sept 2019.
  • 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
  • SIGN 88: Management of suspected bacterial urinary tract infection in adults (accessed April 2020) https://www.sign.ac.uk/media/1051/sign88.pdf
  • Urinary tract infection (lower): antimicrobial prescribing.  NICE guideline Published 31 October 2018.  Nice.org.uk/guidance/ng109
  • Ninan S, Walton C, Barlow G. Investigation of suspected urinary tract infection in older people. BMJ. 2014;349:g4070. Published 2014 Jul 3. doi:10.1136/bmj.g4070
  • Local antibiotic resistance data for E coli isolates from all urine samples in the year 01/05/2019 to 30/04/2020.  Note resistance rates are different for Blood culture isolated and this table is therefore only relevant to lower UTIs.

Antibiotic tested

Nitrofurantoin

Pivmecillinam electronic Medicines Compendium information on Pivmecillinam1

Fosfomycin1

Trimethoprim

Cefalexin electronic Medicines Compendium information on Cefalexin

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin

Amoxicillin electronic Medicines Compendium information on Amoxicillin

% resistant

3.7%

20.8% (15.2%)

6.8% (3.3%)

29.2%

11.0%

12.7%

49.7%

% susceptible

96.3%

79.2% (84.8%)

93.2% (96.7%)

70.8%

89.0%

87.2%

50.3%

Number of isolates tested/results available

7741

7559 (1266)

7549 (1261)

7741

7742

7741

7739

  •  
    1. Pivmecillinam and fosfomycin are mastascan results, which tend to over report resistance to this antibiotics.  Secondline (disc) testing uses a more accurate method, but is undertaken on far fewer isolates, and reports sensitivity rates of 84.8% for Pivmecillinam and 96.7% for Fosfomcyin (from 1266 and 1261 isolates respectively).  These results are present in the table in brackets.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 3.0

Related information

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