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
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 Review treatment when culture results available |
| In penicillin allergy | Nitrofurantoin 50 q6h 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 Only if documented Hx of ESBL:Meropenem 1g q8h iv. |
| In penicillin allergy | Ciprofloxacin 400mg q8-12h iv / 500-750mg q12h po 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 / SIVUHCiprofloxacin 500-750mg q12h po |
UTI - SEPTIC patient
Infection |
Urinary tract sepsis |
| Most likely organisms | Coliforms, Enterococcus sp. |
|---|---|
| Empiric treatment | Piperacillin-tazobactam 4.5g q6-8h iv Seek daily review of Gentamicin. Risk factors for MDRO:Piperacillin-tazobactam Only if documented Hx of ESBL:Meropenem 1g tds iv. |
| In penicillin allergy | Ciprofloxacin 400mg q8-12h iv 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. |