Urinary Tract

Written by: Dr Kavitha Gajee, Consultant Microbiologist

Date: June 2016

Approved by: Drugs & Therapeutics Committee Date: July 2016

Implementation Date: August 2016

Amended by: Dr Manyando Milupi

Date: May 2017

Approved by: Drugs & Therapeutics Committee

Date: May 2017

For Review: July 2018

URINARY TRACT INFECTIONS

The diagnosis of urinary tract (UTI) is primarily based on symptoms and signs.

Typical symptoms or signs of lower urinary tract infections (cystitis) include , urinary frequency, urgency, haematuria and suprapubic tenderness but no fever.

Acute upper () 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. 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 , 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 FIRST LINE ALTERNATIVE NOTES Asymptomatic bacteriuria are NOT appropriate for treatment (based on majority of these patients. This includes: antibiotic sensitivities) is indicated  premenopausal non- pregnant for pregnant women with females asymptomatic bacteriuria  Older patients (>65 years ) confirmed by a repeat urine  Catheterised patients sample with the same organism.

Cystitis in a non-pregnant Nitrofurantoin 50mg 6 hrly Pivmecillinam 400mg 8hrly Nitrofurantoin female OR * avoid if eGFR < 45ml/min Duration : 3 days If organism is susceptible, use * avoid in males where prostatitis is any of: suspected Cystitis in Males Nitrofurantoin 50mg 6hrly Trimethoprim 200mg 12hrly Pivmecillinam OR * is a beta-lactam antibiotic Trimethoprim : 500mg 8hrly * if eGFR between 15-30ml/min – Duration : 7 days OR use 500mg 12hrly half dose after 3 days Duration: * avoid if eGFR < 15 ml/min or CKD Female: 3 days Male: 7 days * avoid in patients on methotrexate If allergic/resistant to 1st line and as increased risk of alternative, please contact the haematological toxicity Microbiologist INFECTION FIRST LINE ALTERNATIVE NOTES If organism is susceptible, use Cystitis in Pregnant Nitrofurantoin 50mg 6hrly any of: Females (except in 3rd trimester) Trimethoprim 200mg 12hrly Nitrofurantoin : * avoid in the third trimester , may (except in 1st trimester) produce neonatal haemolysis OR OR Amoxicillin 500mg 8hrly (in 3rd trimester only) Duration : 7 days Cefalexin 500mg 12hrly If allergic/resistant to 1st line and alternative, please contact the Duration : 7 days Microbiologist * If U&E are not available or in Urosepsis including post IV Gentamicin 7mg/kg daily Oral alternative should be based suspected AKI then give a stat prostatic biopsy sepsis (see Gentamicin policy) on culture results but avoid dose of which can (refer to sepsis IPOC) OR Nitrofurantoin be switched to gentamicin if the renal function is subsequently AND (only in suspected/confirmed AKI, severe OR within the acceptable range(see Acute pyelonephritis CKD [CrCl <40] or U&E unavailable) Contact Microbiology Gentamicin policy) IV Cefuroxime 1.5g tds * Contact Microbiology if patient has Duration : had a previous 5-day course of Pyelonephritis: 10-14 days or Co-amoxiclav in Urosepsis: 7-10 days the previous 2 weeks Please review all IV antibiotics at 48 hours INFECTION FIRST LINE ALTERNATIVE NOTES Catheter- associated UTI Catheters will invariably get colonised IV Gentamicin 7mg/kg daily see -Antibiotics only indicated signs and (CAUTI) with bacteria which will continue to Trust policy) symptoms compatible with CAUTI - multiple over time OR susceptibility results are available on request ( only in suspected/confirmed -Avoid Nitrofurantoin in these AKI, severe CKD [CrCl <40] or patients Do NOT treat catheterised patients with U&E unavailable) -Contact Microbiology if patient has asymptomatic bacteriuria with an IV Cefuroxime 1.5g tds had a previous 5-day course of antibiotic Duration : Cephalosporins or Co-amoxiclav in - 7 days if prompt resolution the previous 2 weeks - 10 days if delayed response -Consider removing and replacing - 3 days if catheter removed in catheter within 24 – 48 hours of females ≤65yr and no fever starting antibiotics. Epididymo-orchitis Single dose of 500mg IM If allergic to cephalosporins then Under 35 years PLUS in the under 35 years use : Usually sexually transmitted in the Doxycycline 100mg bd Ofloxacin 200mg bd for 14 days under 35 years but in the over 35 Duration : 10-14 days years, it is usually due to enteric (It is vital that specimens for organisms Over 35 years Ciprofloxacin 500mg bd sensitivity testing are taken first ) Duration 10 days Acute Prostatitis Ciprofloxacin 500mg bd Trimethoprim 200mg bd Send MSU Duration: 28 days Duration: 28 days