October/ 2019

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW) for the Management of

URINARY TRACT INFECTIONS
ICD-10-N39.0
DETERMINE UTI TYPE MANAGEMENT PRIMARY/ SECONDARY LEVEL

SIMPLE CYSTITIS/ LOWER UTI PRIMARY CARE INITIAL ASSESSMENT

• Dysuria, urgency, frequency • History and Examination • History
• Look for red flag signs and • Symptoms
PYELONEPHRITIS/ UPPER UTI refer • Recurrent UTI
WHAT IS UTI? • Fever • Refer special groups • Diabetes
At least 3 Symptoms • Chills and rigors • Treatment in primary care • Congenital
(dysuria, frequency, • Loin pain, pelvic pain • Acute cystitis females malformations
urgency, suprapubic • Renal angle tenderness • Acute cystitis males • Stones
pain) • Toxic and sick appearance • Treatment • Immunosuppression
OR • Nitrofurantoin • Examination
Dipstick +ve for COMPLICATED UTI • Trimethoprim • Temperature, renal
leucocyte esterase and • History of stones, congenital sulphamethoxazole angle tenderness,
nitrite if <3 symptoms anomalies, obstruction • Symptomatic relief genital exam
OR • Diabetes
• CUE >10 WBC/HPF in • Immunosuppression MALE UTI CYSTITIS/UTI IN FEMALES
uncentrifuged urine + Acute cystitis/ simple UTI • Empirical RX (only
• Urine culture WHEN TO DO URINE CULTURE? • Rx Men for 7 days symptoms no tests
>105 CFU of single • Complicated UTI • Nitrofurantoin* 100 mg PO BD x
needed)
species/ml in Mid 7d
• Pyelonephritis • Nitrofurantoin* 100
stream urine (multiple • TMP/SMX 1 DS tab PO BD x 7d
• Special situations • Ciprofloxacin 500 mg BD x 7 days mg
species indicate • All males (except • Levofloxacin 750 mg OD x 5 day PO BD x 5d
simple cystitis) • Acute cystitis is not to be referred • TMP/SMX 1 DS tab
• Children ALL OTHER UTI IN MALES-REFER PO BD x 3d

.in
• Pregnancy • Pyelonephritis or complicated UTI • If no response refer
• Recurrent UTI (> 2 • Pelvic/perineal pain (prostatitis) to higher centre
episodes/ 6 months)
• Catheter associated UTI *Avoid if GFR <45,caution in elderly

SYMPTOMATIC TREATMENT
Plenty of Urine alkalinizer recommended eg citrate Phenazopyridine
rg Local Estrogen creams for recurrent Paracetamol Cranberry
water - Avoid if patient on nitrofurantoin 200mg tid for 2 days UTI in post menopausal women for pain can be used

RED FLAG SIGNS - REFER

r.o
• Pyelonephritis • Special situations (Children, pregnancy, • Non response within 3 days of AB
• Complicated UTI males except simple cystitis, catheter UTI) • Recurrent UTI

TERTIARY LEVEL
• Send for culture Rx Rx Rx all male UTI Rx Rx
• Imaging if no response to antibiotics in 48 hrs Pyelonephritis/ pregnancy including recurrent non-resolving
• Urology services if obstruction complicated UTI UTI prostatitis UTI UTI
m

PYELONEPHRITIS PREGNANCY UTI CATHETER UTI MALES WITH PROSTATITIS RECURRENT UTI
Empiric Outpatient: • Urine culture at 1st • Rx of asymptomatic • UTI symptoms+ pelvic • Uncomplicated
• Urine c/s antenatal visit CAUTI NOT pain/ fever RUTI
• Consider initial dose of a parenteral • For asymptomatic recommended • Refer - post coital voiding
agent bacteriuria/acute cystitis: • Urinary catheters • Urine culture & MSU and post coital
.ic

- Ceftriaxone 1-2 g IV/IM x 1 - Nitrofurantoin 100 mg PO should be removed as • Digital rectal exam- antibiotic
- Gentamicin 5 mg/kg IV/IM x 1 BD x 5-7 d (avoid near- soon as not required tender prostate - Low dose
• Followed by term ) • If indwelling catheter • Older >35 yrs- nitrofurantoin 50
- Ciprofloxacin 500 mg PO BD x 7d - Cephalexin 500 mg PO for >2 weeks and is - Septran DS BD mgX 6 months
- Levofloxacin 750 mg PO OD x 5 d QID x 5-7 d still indicated, - Levofloxacin 500mg OD, - Single strength
- Cefuroxime 500 mg PO BD x10-14d - TMP/SMX 1 DS tab PO BD x replacing the catheter ciproflox 500 mg BD septran x 6
- Amoxy clav x10-14 days 5-7 d (avoid in 1st trimester is recommended - Avoid nitrofurantoin months
- Or norflox 200mg,
w

- TMP-SMX 1 DS BD x 7-10 days & near term; supplement • Symptomatic CAUTI • Young males-
Empiric Inpatient : with multivitamin - (Fever, back pain, new - Doxy 100mg bd /azithro ciproflox200mg ,
• Ceftriaxone 1-2 g IV once daily+ /-AMP containing folic acid) onset delirium, rigors) 1 gm / oflox 300mg BD cephalexin 250mg
• Gentamicin +/-AMP • Check repeat urine c/s - Send culture for chlamydia + Single - Vaginal cream in
• Others as per c/s- Carbapenem, 7days after Rx to confirm - Rx as complicated dose of Ceftrioxone post menopausal
Piperacillin Tazo clearing UTI 250mg IM for • Complicated RUTI
st

• Repeat urine culture in • No role of routine gonorrhoea - Urology referral

IV therapy required until afebrile x each antenatal visit antibiotic prophylaxis • Rx- 6 weeks - Cystoscopy,
48 hrs, then switch to PO If no • If recurrent- Antibiotic for prevention • Imaging to rule out urodynamics (post
response in 3 days imaging prophylaxis till term abscess menopausal)

ASYMPTOMATIC BACTERIURIA CHILDREN

• No symptoms
• Bacteria in urine culture SYMPTOMS
• Neonates and Infants < 1yr FIRST URINARY TRACT INFECTION*
>105CFU/ml
- Fever,vomiting, diarrhoea, jaundice, Poor
• No treatment required
stream
- Older children same as adults
• Exceptions when you TREATMENT
should treat - Infants <3months as upper UTI (PN) with
Age <1 yr Age >5 yr
- Pregnancy IV antibiotics • Ultrasound
- Before any urological - Urinary bladder catheterisation for infants • Ultrasound
• MCU If ultrasound
intervention with upper tract UTI abnormal:
- Older children • DMSA renal scan
MCU and DMSA
• Upper UTI- IV antibiotics scan
gentamicin, amikacin, ceftriax
* Pregnancy UTI, one
Catheter UTI may also be Age 1-5 yr
• Lower UTI- oral cefixime, oflox,
managed at secondary • Ultrasound
ciproflox, amoxyclav
level. • Duration of Rx • DMSA scan
- Upper UTI- 10-14 days MCU if ultrasound or
- Lower UTI 7-10 days DMSA scan is abnormal
LONG TERM CONSEQUENCES - Adolescents 3-5 days
• Renal scars REFER
Upper UTI(PN), infants UTI, recurrent UTI All patients with recurrent UTI need
• Hypertension
PREVENTION detailed evaluation with
• CKD
Avoid constipation, clean washrooms ultrasonography DMSA scan and MCU
• Poor quality of life

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.