Background

UTI is the second most common clinical indication for antimicrobial treatment in primary and secondary care. The common local (Cork Kerry region) pathogens are Coliform (80%), Enterococcus (6%), Proteus (4%) and Staph. (3%). Others include Pseudomonas, Strep. and MRSA.

Diagnosis

Diagnosis UTI in women

Lab testing for Culture &Sensitivity indicated in

  • Pregnancy
  • Suspected UTI in children
  • Suspected pyelonephritis
  • Suspected UTI in men
  • Recurrent UTI in women
  • Failed antibiotic treatment
  • Patients with known abnormalities of the GU tract
  • Patients with renal impairment

Catheterised Patients

  • Avoid unnecessary samples as bacteruria is usual
  • Send sample if features of systemic infection
  • In presence of catheter antibiotics will not eradicate bacteruria
  • Only treat is systemically unwell or pyelonephritis likely

The Elderly

  • Asymptomatic bacteruria in the elderly is very common
  • It is not related to morbidity or mortality
  • Ix and Rx will increase side effects and medicalise the condition
  • Only sample if two signs of infection e.g. dysuria, >38° or new incontinence

Treatment

Management suspected UTI in men

  • DDx includes prostatitis, chlamydial infection and epididymitis.
  • Take urine sample for C&S.
  • UTI in men should be treated for 14 days (cannot exclude prostatitis).
  • Men should be referred to urology if:
    • recurrent UTI (2 or more episodes in 3/12).
    • symptoms of upper UTI.
    • fail to respond to appropriate antibiotics.

Recommended length of treatment

  • Uncomplicated UTI in women - treat for 3/7.
  • UTI in pregnant women and children treated for 7 days.
  • UTI in men should be treated for 14 days (cannot exclude prostatitis).
  • Upper UTI should:
    • Treat for 14 days (or 7 days if using quinolone).
    • Admit to hospital if upper UTI not responding within 24 hours.
    • UroSEPSIS has different antibiotic guidelines. Please also treat with Septic 6 bundle.

UTI - simple

Infection

Uncomplicated UTI

Most likely organisms E. coli
Empiric treatment

Nitrofurantoin 50mg q6h po
Or
Cefalexin
250mg q6h po or 500mg q12h po.

Review treatment when culture results available

In penicillin allergy

Nitrofurantoin 50 q6h po
Or
if no history of anaphylaxis with penicillin: Cefalexin 250mg q6h po or 500mg q12h po

Review treatment when culture results available.

Duration

3 days for women.

7 days for men.

Comments

Review treatment with culture results.

Do not use Nitrofurantoin in renal impairment (Creat. clearance <60ml/min).

Ciprofloxacin sensitivity is not generally reported. Contact microbiology to check sensitivity of urine isolate to ciprofloxacin if necessary.


UTI - pyelonephritis

Pyelonephritis

Infection

Complicated UTI (pyelonephritis)

Most likely organisms Coliforms, Pseudomonas sp. in chronic disease
Empiric treatment

Piperacillin-tazobactam 4.5g q8-6h iv ± Gentamicin 5mg/kg q24h iv (max 480mg), depending on severity.

Risk factors for MDRO:

Piperacillin-tazobactam
plus
Gentamicin
(doses above).

Only if documented Hx of ESBL:

Meropenem 1g q8h iv.

In penicillin allergy

Ciprofloxacin 400mg q8-12h iv / 500-750mg q12h po
plus
Gentamicin
5mg/kg q24h iv (max 480mg q24h).

If documented Hx of ESBL/ MDRO:

Check sensitivities. If sensitive & no recent exposure: As above. Otherwise seek advice from microbiology.

Duration 7-14 days.
Comments

Review need for Gentamicin once culture results available and clinical improvement.

Gentamicin course should not usually exceed 7 days.

Ciprofloxacin sensitivity is not generally reported.

Contact microbiology to check sensitivity of urine isolate.


If MUH / SIVUH

Ciprofloxacin 500-750mg q12h po
plus
Gentamicin 5mg/kg q24h iv (max 500mg q24h)


UTI - SEPTIC patient

Infection

Urinary tract sepsis

Most likely organisms

Coliforms, Enterococcus sp.

Empiric treatment

Piperacillin-tazobactam 4.5g q6-8h iv
plus
Gentamicin
5mg/kg iv (max 480mg q24h), depending on severity.

Seek daily review of Gentamicin.

Risk factors for MDRO:

Piperacillin-tazobactam
plus
Gentamicin
(doses above)

Only if documented Hx of ESBL:

Meropenem 1g tds iv.

In penicillin allergy

Ciprofloxacin 400mg q8-12h iv
plus
Gentamicin
5mg/kg iv (max 480mg q24h).

If documented history of ESBL/ MDRO:

Check sensitivities. If sensitive & no recent exposure: As above. Otherwise seek advice from micro.

Duration
Comments

Send urine sample in addition to blood culture.

Previous culture results may help guide therapy.

Seek advice on oral options and duration of therapy

Gentamicin is rarely required for more than 7 days.


Catheter Related Bacteruria

Infection

Catheter-related bacteriuria

Most likely organisms As above
Empiric treatment

Usually antibiotics are not indicated.

Only treat if clinical evidence of infection.

Seek advice from microbiology.

In penicillin allergy As above
Duration
Comments

Usually antibiotics are not indicated. Only treat if clinical evidence of infection. Seek advice from microbiology.