Antibiotic selection in urinary tract infections (UTls)
Selection of antibiotics in urinary tract infection2
cefaclor1%
~-.-
----
amoxycillin+
clavulanate
7%
co-trimoxazole10%
Treatment of acute cystitis
E.coliand Staphylococcussaprophyticus are the most common causative organisms.
Some patients require investigation to exclude an underlying abnormality when cystitis
is confirmed by a positive urine culture.3
In non-pregnant women
In otherwise healthy, non-pregnant women, empiric
therapy with first-line drugs without urine culture is
reasonable.'
Trimethoprim 300 mg orally daily for 3 days or
Cephalexin 500 mg orally 12-hourly for 5 days or
Amoxycillin+clavulanate 500/125 mg orally
12-hourly for 5 days or
Nitrofurantoin 50 mg orally 6-hourly for 5 days.'
If resistance to all the above drugs is proven,
use norfloxacin 400 mg orally 12-hourlyfor 3 days.'
Single dose therapy is not as reliable as multiple dose
therapy in preventing relapse but can be useful in
remote communities.' Three-day regimens of
trimethoprim and quinolones have been shown to be
as effective as longer courses.'
In treatment failure consider resistance, reinfection
with a similar organism or anatomical abnormality
of the urinary tract.' See Therapeutic Guidelines:
Antibiotic Version 11 or NPSNews 21 for more
information.
In men
Following investigation for underlying abnormalities,
any of the regimens for non-pregnant women above
are suitable but should be continued for at least 14 days.'
- Asexpected,
first-linedrugscephalexin
and
trimethoprim are prescribedfor most patients.t3
- Co-trimoxazoleis not recommendedfor empiric
doxycycline1% treatmentof urinarytractinfectionin adults
otherantibiotic1%
- becauseof rarebutseriousadverseeffects.
Trimethoprim
aloneisaseffective
as co-trimoxazole.'
trimethoprim34% - Amoxycillin should only be usedif susceptibility
of the organism is proven,as a high proportion
of Escherichiacoli isolatesare resistant.'
- Norfloxacinshould only be usedwhere resistance
to all first-line drugs is proven.' as it is thought
that widespreaduse as a first-line drug will
encouragethe emergenceof quinolone
resistant organisms. '.'
In pregnant women
Consider the category of risk of the antibiotic in
pregnancy. Use antibiotic therapy for 10-14 days:
Cephalexin 250 mg orally 6-hourly (category A) or
Nitrofurantoin 50 mg orally 6-hourly (category A) or
Amoxycillin+clavulanate500/125mg orally 12-hourly
(category 81).'
Amoxycillin(category A) may be used if susceptibility
of the organism isproven.'
Trimethoprim (category 83, avoid in the
first trimester), quinolones (category 83)
and sulfonamides (category C, contraindicated
in late pregnancy) should be avoided in pregnancy.'"
In children
Cephalexin,trimethoprim, amoxycillin+clavulanate
or co-trimoxazolemay be used for initialtreatment.'
Investigation is usually required and, following the
initial treatment, prophylaxis should be used as an
interim measure until investigation is completed.'
 u_up_U-- P- --------

Does the patient really need a repeat prescription?

Check you do not inadvertently prescribe repeats for antibiotics if your prescribing software
defaults to maximum repeats.

The duration of antibiotic therapy recommended
for infections commonly treated in general practice
is highly variable. Repeat prescriptions will not be
required to supply the recommended duration of
therapy for some indications (e.g. acute cystitis in
non-pregnant women) however may be required for
complicated conditions (e.g. acute cystitisin pregnancy).
A study was conducted in NSWto investigate the
extent of repeat ordering and subsequent dispensing
for prescriptions for amoxycillin,amoxycillin+clavulanate,
cefaclor and roxithromycin..
Ofthe 1667prescriptions,54%were generated
electronically. Significantly more of the computer-
generated prescriptions (69%) had a repeat
ordered than the handwritten prescriptions (40%)
(RR1.73 95% CI1.54, 1.93).
Of the subset of patients who were surveyed, 63%
indicated they had filled their repeats. There was no
difference found between the rate of repeat filling
for computer-generated compared to handwritten
prescriptions.
Extrapolating to national use, if all doctors used
computerised prescribing packages this could result
in up to 944,000 additional prescriptions annually.
How to change number of repeats
In Medical Director, Genie and Medical Spectrum
software, it may be necessary to change the number
of repeats manually if you wish to prescribe nil
repeats. You can do this when selecting the drug
for prescription.
When using Medical Director, clickthe 'once only'
rather than the 'regular' button when selecting your
drug. In Locum software you may change the default
to no repeats for all antibiotics as a preference.
For detailed information on changing the number of
repeats using your prescribing software, refer to the
NPSwebsite http://www.nps.org.aufTopics/antibiotics.html
For a list of brand-names ofthe'mostcommonly
prescribed antibiotics, see'the,antibioticsisection of
Topics on theNPS website http://www.nps;org.au

References:
1.Macfarlane J, Holmes W, Gard P,et al. Reducing
antibiotic use for acute bronchitis in primary care:
Blinded, randomised controlled trial of patient
information leaflet, BMJ 2002;324:1-6.
2. Data provided by the AIHW General Practice Statistics
and Classification Unit, Family Medicine Research Centre,
University of Sydney, from the BEACH Program.
January-December 2001.
3. Therapeutic Guidelines: Antibiotic, Version 11, 2000.
North Melbourne: Therapeutic Guidelines Ltd, 2000.
4. Naber KG. Treatment options for acute uncomplicated
cystitis in adults. J Antimicrobial Chemotherapy
2000;46(suppl S1):23-7.
5. National Preferred Medicines Centre. Outpatient treatment
of lower urinary tract infection in adults. Medicines
Information Bulletin. Wellington: April 1997;No. 57.
6. Australian Medicines Handbook 2002, 3rd edition.
Adelaide: Australian Medicines Handbook Pty Ltd, 2002.
7. Stamm WE, Hooton TM. Management of urinary tract
infections in adults. N Eng J Med 1993;329:1328-34.
8. Newby D, Fryer J, Henry D, Prior F. Automatic repeats:
A possible negative impact on antibiotic use. Final report
to the National Prescribing Service Ltd. Newcastle:
University of Newcastle, October 2001.

The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence.
Any treatment decisions based on this information should be made
in the context of the individual clinical circumstances of each patient.

II mil
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Our programs To enable prescribers to make the best prescribing decisions for their patients, the NPS provides
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