Urology and Urinary Tract Infections in Adults

Full Title of Guideline:
Author (include email and role):
Division & Speciality:
Scope (Target audience, state if Trust
wide):
Review date (when this version goes out August 2019
of date):
Explicit definition of patient group
to which it applies (e.g. inclusion and
exclusion criteria, diagnosis):
Guideline for the treatment of urinary tract infections in
adults
Dr A Joseph, SpR Microbiology
Mr R Parkinson, Consultant Urologist
Annette Clarkson Specialist Pharmacist antimicrobials
and Infection Control
All adult specialties except Obstetrics
Doctors, Pharmacists, Nurses
Inclusion: Adult patients including Urology
Exclusion: Pregnant patients, refer to guideline for
antibiotics in obstetrics

Changes from previous version (not Addition of fosfomycin for first line treatment of lower UTI
applicable if this is a new guideline, enter Changes to UTI diagnostic algorithm
below if extensive): Changes to format of antimicrobial treatment regimens.
Updated wording and clarification of advice around oral
follow on therapy in upper UTI.
Updated information on epididymitis/orchitis algorithm
15/12/17 updated frequency of fosfomycin dosing as per
PHE
Summary of evidence base this IDSA guideline for treatment of uncomplicated cystitis and
guideline has been created from: pyelonephritis in women 2010
Local microbiological sensitivity surveillance and local audit of
E. coli bacteraemias.
Recommended best practice based on clinical experience of
guideline developers.
Public Health England. Management of infection guidance for
primary care for consultation and local adaptation -updated
2016
BASHH Prostatitis 2008
European Association of Urology Guidelines on Urological
Infections 2015
BASHH 2010 guidelines epididymitis orchitis
GRASP 2013 report: The gonococcal resistance to
antimicrobials surveillance program (England & Wales)
Cochrane Database of Systematic Reviews: Antibiotic duration
for treating uncomplicated, symptomatic lower urinary tract
infections in elderly women 2008.
Renal Drug Database – access 10/07/2017
Diagnosis, Prevention, and Treatment of Catheter-Associated
Urinary Tract Infection in Adults: 2009 International Clinical
Practice Guidelines from the Infectious Diseases Society of
America (2010)
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.

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Contents

Urinary tract infection diagnosis algorithms:

- Non-catheterised patient ≥65 years Page 3
- Non-catheterised patient <65 years Page 4
- Catheterised patient Page 5

Lower urinary tract infection (cystitis) Page 6

Catheter-associated urinary tract infection Page 8

Prophylaxis for change of long-term catheters Page 9

Recurrent urinary tract infections Page 9

Upper urinary tract infections Page 10

(pyelonephritis and systemic infection of
urinary tract origin)

Acute prostatitis Page 13

Epididymitis and Orchitis Page 14

Appendix 1: Example fosfomycin Page 15

prescriptions

Glossary of abbreviations:

NPV Negative predictive value

MSU Mid-stream urine
CSU Catheter specimen urine
MC&S Microscopy, culture and sensitivity test
WCC White Cell Count
CRP C-reactive protein
ESBL Extended beta-lactamase

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* Urine samples sent in red top containers must have a minimum volume of 20ml to provide sufficient sample for testing. If <20ml urine, please send in a white top container.
All samples should be sent to the lab immediately.
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* Urine samples sent in red top containers must have a minimum volume of 20ml to provide sufficient sample for testing. If <20ml urine, please send in a white top container.
All samples should be sent to the lab immediately.
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* Urine samples sent in red top containers must have a minimum volume of 20ml to provide sufficient sample for testing. If <20ml urine, please send in a white top container.
All samples should be sent to the lab immediately.
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Lower Urinary Tract Infection (Cystitis)

An infection of the bladder or lower urinary tract; without features of pyelonephritis or

high risk of death red sepsis.

Clinical practice points:

1. Use algorithm on pages 3-5 to determine if treatment is needed.

2. Review previous cultures prior to prescribing. If a multi-resistant isolate is
present or the following choices are unsuitable, discuss with Microbiology
regarding other treatment options.
3. For patients with a urinary catheter please see the section on page 5.
4. Antibiotics are not indicated for asymptomatic bacteriuria, unless pregnant
or awaiting urology surgery where bleeding is expected.
5. Review antibiotic with culture results at 24-48 hours.
6. Simple lower UTI in women - 3 days oral treatment is usually sufficient
(excluding when prescribing fosfomycin single dose)
7. For male patients, diabetics, those with structural or functional abnormality of
the urinary tract, or recent urinary surgery/ instrumentation (excluding urinary
tract catheterisation) - treat for 5-7 days (or two fosfomycin doses 48 hours
apart – on day 1 and day 3).

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Lower UTI Treatment first-line oral choices
• These agents are concentrated in the urine so are good options for lower UTI.
• They all currently have low resistance rates and minimal effect on normal flora
(low C. difficile risk).
• However they are NOT suitable for patients who are systemically unwell or have
High risk of death Red Sepsis (see guidelines).
• These are agents specifically targeting urinary tract infections. They will not offer
broad cover for foci of infection outside of the urinary tract.
• Most multi-resistant isolates including ESBL-producing strains remain sensitive
to nitrofurantoin, pivmecillinam and fosfomycin; these options should be used
when possible. If these are not suitable, then discuss with Microbiology.
Fosfomycin Nitrofurantoin Pivmecillinam
Lower UTI in women: 100mg MR BD orally 400mg immediately, followed
3g as a single dose orally by 200mg TDS orally
Duration:
Lower UTI in men, Lower UTI in women: Duration:
diabetes, those with 3 days Lower UTI in women:
structural or functional 3 days
abnormality of the urinary Lower UTI in men, diabetes,
tract, or recent those with structural or Lower UTI in men, diabetes,
surgery/instrumentation: functional abnormality of the those with structural or
3g on day 1 and a second urinary tract, or recent functional abnormality of the
dose of 3g on day 3 surgery/instrumentation: urinary tract, or recent
7 days surgery/instrumentation:
(The second dose is off 7 days
label, though it is If to be used via an enteral
recommended practice feeding tube prescribe
within the literature and in Nitrofurantoin normal release
PHE guidelines) tablets 50mg QDS and see
memo on antibiotic website:
Ensure prescribe on the
antibiotic section of the
prescription chart, even for
single doses- See appendix
1 (page 15) for examples
Not recommended when Not recommended when Not recommended when
CrCl <10mL/min CrCl <45mL/min CrCl <10mL/min
Considerations:
• A 3g dose provides • This is a urinary • Contra-indicated in
effective therapy for antiseptic with no activity penicillin allergy
approximately 48 outside of the bladder • Contra-indicated in
hours • Should not be used in patients with
• Most effective when systemically unwell oesophageal strictures
taken an hour before patients, or where • Avoid in patients taking
or two hours after food pyelonephritis is a sodium valproate or
possibility. valproic acid
• Pulmonary reactions are • Tablets are film coated
rare (0.001%) but more and must be swallowed
common in the elderly whole with at least half a
and those with impaired glass of water whilst
renal function upright

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Catheter-associated Urinary Tract Infections (CA-UTI):

In patients with urinary catheters in situ, bacteriuria is commonly present and

treatment is not indicated in the absence of symptoms.
• Urine dipstick is not clinically useful.
• Do not send catheter-specimen urine (CSU) for culture as a routine
"screen" in the absence of symptoms.
• Only send a CSU for culture if the patient is symptomatic, or has signs of
pyelonephritis or systemic infection
• The results of CSU samples should always be interpreted in conjunction
with clinical parameters.

Clinical assessment should be made regarding whether infection is likely to involve

only the lower urinary tract, or upper urinary tract (pyelonephritis and systemic
infection of urinary tract origin), see the empirical treatment of Sepsis Guideline for
further information.
http://nuhnet/diagnostics_clinical_support/antibiotics/Pages/septicaemia/septicaemi
a.aspx

The ongoing need for the urinary catheter should be assessed, alternatives
considered, and the catheter should be removed if possible. If an indwelling
catheter has been in place for longer than 2 weeks at the onset of CA-UTI (and
there is ongoing need for a urinary catheter) the catheter should be changed during
the treatment course.

Treatment
• Review previous Microbiology results prior to prescribing, send a pre-
treatment CSU sample.
• Follow the first-line treatment choices outlined in either the lower or upper
urinary tract sections of this guideline (page 7, and page 11) according to
the clinical assessment.

Duration
• 7 days.
• In women who have had the catheter removed, this can be shortened to 3
days if rapid clinical response to antibiotics.

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Prophylaxis for change of long-term catheters

• Routine antibiotic prophylaxis is not recommended and will select for

resistant bacteria.
• Urine dipstick is not clinically useful, only send CSU if the patient has
symptoms. Do not send a catheter-specimen urine (CSU) for culture as a
routine "screen".

Consider prophylaxis for those who have history of recurrent post catheter change
infections. The antibiotic choice is as follows:

1st Line:
• Gentamicin 2mg/kg IV as a single dose. Check for history of Gentamicin-
resistant organisms before prescribing.

2nd Line:
• Treat according to previous sensitivities, where possible use PO
Nitrofurantoin M/R 100mg BD give two doses only (one dose approx. 4
hours before catheter change and second dose 12 hours after the first dose)
• Not suitable for patients with CrCl < 45mL/min.

MRSA Positive patients:

Patients with a catheter and a diagnosis of MRSA in their urine who are at risk of
developing a bacteraemia at catheter change because they have traumatic
catheter changes or who have had infections following catheter change previously.

• Gentamicin 2mg/kg IV single dose prior to catheter change. A minority of

MRSA strains locally are resistant to Gentamicin so please review the
susceptibility results and seek advice if required.

Recurrent Urinary Tract Infections

Patients with recurrent UTIs may be more likely to have resistant organisms due to
repeated exposure to antibiotics. In patients known to have recurrent UTIs, a pre-
treatment MSU should be sent and previous microbiology results reviewed prior to
prescribing.

Assessment for possible underlying urinary tract abnormalities should be

considered and Urology referral made if appropriate. Prophylaxis for recurrent
urinary tract infections should not be routinely started. If considering prophylaxis
then discussion with Microbiology and/or Urology is required, with regards to
choice of agent, monitoring and follow-up.

If a patient is admitted on prophylactic antibiotics for recurrent UTIs, review urine

culture results and stop the prophylaxis if resistance is demonstrated on culture.
Consider whether ongoing antibiotic prophylaxis is appropriate and discuss with
microbiology regarding choice of agent. All changes must be communicated to the
GP on discharge.

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Upper Urinary Tract Infections:
Pyelonephritis and Systemic Infection of Urinary Tract origin

Defined as:
• Patients with pyelonephritis: usually have loin pain, kidney tenderness and
signs of systemic infection.
• Patients with lower urinary tract symptoms and signs of systemic infection.
• Patients with known or possible structural or functional abnormalities of the
urinary tract and signs of systemic infection.

Assess patient according to the NUH Sepsis guidelines

http://nuhnet/diagnostics_clinical_support/antibiotics/Pages/septicaemia/septicaemi
a.aspx . Ensure two sets of blood cultures and a urine sample are sent (clearly
labelled with the type of specimen e.g. MSU, CSU, nephrostomy urine)

Review previous culture results and assess risk of Multi-resistant Gram-negative

Organisms (MRGNO) prior to prescribing antibiotic:

Risk factors for Multiresistant Gram-negative Organisms (MRGNO)

• Previous history of isolation of ESBL positive E. coli or multi-resistant gram

negative organisms
OR
• Recurrent urinary or biliary tract infections (≥3 in last 12 months)
• Systemic infection despite current or recent (within last week) treatment with
broad-spectrum antibiotics e.g. co-amoxiclav, cefuroxime or quinolones
(ciprofloxacin, levofloxacin)
• Recurrent admissions with neutropenic sepsis requiring treatment with
piperacillin-tazobactam.

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Treatment

If no risk factors for Multiresistant Gram Negative Organism (MRGNO)

1st line Non-severe penicillin Severe penicillin
allergy allergy
E.g. No anaphylaxis,
angioedema or urticarial
rash in first 72 hours

Temocillin IV 2 gram BD Cefuroxime Ciprofloxacin

IV 1.5gram TDS
Note, THIS IS A PENICILLIN
If patient is previous C.
difficile positive (PCR or
toxin), cefuroxime required
microbiology approval
before use.
IV 400mg BD if High risk
red sepsis or unable to
take orally, converting as
soon as possible to:
PO Ciprofloxacin 500mg
BD
If patient is previous C.
difficile positive (PCR or
toxin), or MRSA colonisation,
ciprofloxacin requires
microbiology approval before
use.

If the patient has High risk red sepsis or the blood pressure fails to respond
to initial bolus fluids:
Consider adding single dose Gentamicin IV 5mg/kg (max 500mg) if normal
renal function.
For advice on dosing in renal impairment, refer to Trust antibiotic website.
http://nuhnet/diagnostics_clinical_support/antibiotics/Pages/A-Z/gentamicin.aspx

If at risk of Multiresistant Gram Negative Organism (MRGNO)

Meropenem IV 500mg QDS

Review antibiotics with microbiology within 48 hours

Not to be used in severe penicillin allergy (i.e. anaphylaxis, angioedema, urticarial
rash within 72 hours of starting). Please discuss with microbiology.

Further therapy
• Review need for IV antibiotics at 48 hours with microbiology results using
IV-PO switch guideline on antibiotic website. If culture results available to
guide therapy, a narrow spectrum agent should be used according to
sensitivities.
• See table below for recommended course lengths

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MSU sensitivity Total Course length Comments
IV+PO
No MSU result available
Switch to Ciprofloxacin 7 days Micro approval required if
PO 500mg BD previous C. difficile (PCR or
toxin) or MRSA colonisation
MSU result available and agent chosen based on sensitivities
Trimethoprim PO 200mg 10 days Targeted therapy to be used
BD whenever sensitive
Severe drug interaction with
methotrexate, avoid
concomitant use.

Ciprofloxacin PO 500mg 7 days Micro approval required if

BD previous C. difficile (PCR or
toxin) or MRSA colonisation
Cefalexin PO 500mg 10 days Not in severe penicillin allergy
TDS Micro approval required if
previous C. difficile (PCR or
toxin)
If above options not appropriate due to resistance, allergies etc:
Discuss with microbiology
Pivmecillinam and Fosfomycin – little evidence in upper-UTI. Discuss with
microbiology before prescribing
DO NOT USE Nitrofurantoin as an oral stepdown after IV therapy for upper UTI
(pyelonephritis or systemic infection of urinary tract origin) as it has insufficient
systemic concentrations to be used for this indication.

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Acute Prostatitis

Acute prostatitis is caused by urinary tract pathogens. Infection may spread from
the distal urethra but can also spread from the bladder, blood and lymphatic
system. Acute prostatitis is an uncommon complication of UTI, urological
instrumentation or catheterisation.

Acute prostatitis is an acute severe systemic illness. Symptoms include:

• symptoms of a urinary tract infection: dysuria, frequency and urgency
• symptoms of prostatitis: low back pain, perineal, penile and sometimes rectal
pain
• symptoms of bacteraemia: fever and rigors; arthralgia and myalgia; recurrent
Gram negative bacteraemia of unknown focus.
Signs include:
• an extremely tender, swollen and tense, smooth textured prostate gland
which is warm to the touch

Cases of suspected prostatitis should be discussed with Urology, so that

appropriate imaging +/- intervention can be arranged.
Ensure a urine sample is sent for MC&S (clearly-labelled with the specimen type
e.g. MSU), and two sets of blood cultures are taken.

First line:
• PO Ciprofloxacin 500mg bd for 28 days
• If patient is previous C.difficile positive (PCR or toxin) ciprofloxacin
requires Microbiology approval before use
• If vomiting, concerns about absorption or if High risk red sepsis, give
IV ciprofloxacin 400mg BD, converting to oral as soon as oral route
available

Second line (If ciprofloxacin unsuitable e.g. resistant organism or contra-indicated):

• PO Trimethoprim 200mg bd for 28 days (off label use)

Antibiotic choice should be reviewed at 48 hours with urine MC&S, blood cultures,
and imaging results.

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MANAGEMENT OF EPIDIDYMITIS AND ORCHITIS
Clinical presentation: Pain and swelling of the epididymis +/- testes (Orchitis), pyrexia, with or without urethral discharge
(ENSURE TESTICULAR TORSION EXCLUDED).
Sexual history: It is important to take a sexual history in ALL cases.
Sexually transmitted infections (STIs) may be the underlying cause of epididymitis and orchitis, especially in
younger patients (under 35 years). However, patients over 35 years of age without suggestion of sexual contact
are more likely to have infections of urological origin. Gram negative enteric organisms are more commonly the
cause if recent instrumentation or catheterisation has occurred.
Causative agents: Organisms of the urinary tract e.g. Escherichia coli.
Sexually transmitted infection (STI) e.g. Chlamydia trachomatis, Neisseria gonorrhoea
In non-immunised males born between 1982-1986 mumps orchitis must be considered. Send an inside cheek/throat
viral swab for mumps PCR testing.

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Appendix 1: Example Prescriptions for Fosfomycin dosing in lower UTI:

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