Urinary Tract Infection

Symptoms occurring in both upper UTI (UUTI) and lower UTI (LUTI):

• dysuria
• urinary frequency
• haematuria
• lower abdominal tenderness
• the presence of dysuria and frequency in women indicates a probability of UTI of over 90%.

Additional symptoms indicative of UUTI:

• pyrexia
• loin pain
• systemic symptoms

Urinalysis

Diagnosis of UTI : primarily based on symptoms and signs,
However, urinalysis may contribute additional information to inform management. Dipstick tests are only indicated for women who have minimal signs and symptoms.
Where only one symptom or sign is present, a positive dipstick test (LE or nitrite) is associated with a high probability of bacteriuria (80%) and negative tests are associated with much lower probability (around 20%)

Mid Stream Sample of Urine (MSSU)

• Send an MSSU before starting treatment, if there are symptoms or signs of upper UTI
• No need to await the MSSU result before commencing treatment
• In women consider possibility of pregnancy prior to treatment
• Consider the possibility of STIs and PID and screen/treat appropriately
• An MSSU should be sent from symptomatic pregnant women and from those in whom symptoms have persisted after empirical treatment
• Narrow range antibiotics remain first line choice: broad spectrum drugs increase the risk of clostridium difficile, MRSA and resistant UTIs.

In uncomplicated lower UTI in non-pregnant women, treat with:-
nitrofurantoin 50mg orally four times daily for 3 days 
alternative trimethoprim 200mg orally twice daily for 3 days 
i.e. there is no need to send an MSSU at this point

In pregnant women 1st/2nd trimester, treat with:-
Nitrofurantoin 50mg orally four times daily for 7 days (theoretical risk neonatal haemolysis
at term)
(second-line: Cefalexin 500mg orally three times daily for 7 days)
(Trimethoprim 200mg twice daily for 7 days – off-label because folate metabolism)

In pregnant women 3rd trimester
Cefalexin 500mg orally three times daily for 7 days

If signs or symptoms of upper UTI are present, obtain an MSSU and treat
with:.
ciprofloxacin 500mg orally twice daily for 7 days (not if pregnant)
 co-amoxiclav 625mg orally three times daily for 7 days (for pregnancy or if allergy
cephalexin 500mg orally three times daily for 7 days)

lower UTI in men: trimethoprim 200mg orally twice daily for 7 days or nitrofurantoin
50mg orally four times daily for 7 days
upper UTI in men: ciprofloxacin 500mg orally twice daily for 7 days should be used for tissue
penetration – consider longer courses if signs of prostate involvement

• Urinary tract infection is rare in young men. All men with proven UTI should be referred to their GP for referral for imaging of the renal tract (ultrasound or IVP). Men with recurrent UTI should be referred to a urologist.
• Women with recurrent UTI may benefit from imaging of the renal tract and consideration of prophylactic antibiotics. This is best managed by urologists, following referral by the woman’s GP

• Cranberry products – evidence shows prevention of symptomatic UTI in young adult women with recurrent UTI is almost as good as trimethoprim. Cranberry is available as tablets, capsules and juice. High strength is more convenient and efficacious. Less benefit in older men, women, and those requiring catheterisation. These products are not available on the NHS. 

N.B: Warfarin should not be taken with Cranberry products owing to pharmacokinetic interaction.

• Oestrogen replacement locally has not been shown consistently to reduce the frequency of recurrent UTIs in women.
• Consider NSAIDs as first-line treatment in women aged <65 years with suspected uncomplicated lower UTI who describe their symptoms as mild
• Increasing fluid intake is thought to reduce UTI by dilution and flushing of bacteriuria. This reduces attachment to uroepithelial cells, reduces growth nutrients and/or improves clearance. While no evidence was identified for benefit, increasing fluid intake with water in women with urinary symptoms is a low-cost intervention without evidence of harm that may provide symptomatic relief.

SIGN 160 Management of suspected bacterial lower urinary tract infection in adult women (accessed on line May 2024)

NHS GGC Adult Therapeutics Handbook(accessed online May 2024)