Acute lower urinary tract infection in adults (no fever or flank pain) (Antimicrobial)

• PHE URINE
• SIGN 160
• CKS women
• CKS men
• RCGP UTI clinical module
• SAPG UTI
• NHS Highland guideline: UTI Management in Pregnancy (NHS Highland intranet access required)
• Clostridioides Difficile (CDI) Information pack for general practitioners

Evidence of bacteria in urine (culture or positive dipstick test) but NO signs or symptoms of infection - antibiotic therapy is not required, except in pregnancy. See NHS Highland guideline: UTI Management in Pregnancy (NHS Highland intranet access required).

Women with symptoms or signs - for women with less severe or limited symptoms, a delayed prescription for antibiotics may be a suitable management option in some patients. Symptom relief with ibuprofen along with general advice about maintaining fluid intake may provide resolution of symptoms without need for antibiotics. Use trimethoprim and Nitrofurantoin with caution in severe renal impairment (eGFR less than 30mL/min). If no response in 3 days, send mid stream sample (MSU), continue on the same antibiotic and await sensitivity of organism isolated. Use narrow spectrum where possible. When treating symptomatic UTI in pregnancy only, perform a culture 7 days after completion of antibiotics as test of cure. See NHS Highland guideline: UTI Management in Pregnancy (NHS Highland intranet access required).

In pregnancy, short-term use of nitrofurantoin is unlikely to cause problems to the foetus (at term, theoretical risk of neonatal haemolysis).  Trimethoprim, as a folate antagonist, has a theoretical risk in first trimester in patients with poor diet or on another folate antagonist – manufacturers recommend avoiding in pregnancy.  Infection specialists may still recommend trimethoprim in pregnancy on an individual patient basis. See NHS Highland guideline: UTI Management in Pregnancy (NHS Highland intranet access required).

Asymptomatic bacteriuria in pregnancy - confirm bacteriuria with second MSU sample and treat according to sensitivity for 7 days. Repeat urine culture at each antenatal visit until delivery. See NHS Highland guideline: UTI Management in Pregnancy (NHS Highland intranet access required).

Men with symptoms or signs - send urine sample for culture before staring empiric treatment and rationalise once sensitivity information available. If fever present, treat as prostatitis. If uncomplicated lower UTI suspected, treat as for women with signs and symptoms for 7 days.

Recurrent UTI - refer to Urology Shared Clinical Guideline on Recurrent UTIs, consider discussing treatment of recurrent UTI in women and catheterised patients with Microbiology. Consider alternatives to antimicrobial management due to high risk of resistance developing – see Scottish Antimicrobial Prescribing Group Guidance document.
If a patient has 2 or more episodes of symptomatic UTI in a 6 months period, continuous low-dose antibiotic prophylaxis or single dose post-coital prophylaxis can be considered. After counselling, and when behaviour modifications and non-antimicrobial measures have been unsuccessful, a 3 month course of low dose nitrofurantoin 50mg daily may be appropriate. This can be extended to 6 months in total but must be reviewed thereafter. After 6 months of continuous therapy with nitrofurantoin there is a significant risk of developing hepatitis or chronic pulmonary reactions such as pulmonary fibrosis and diffuse interstitial pneumonitis. For advice in pregnancy or where nitrofurantoin is unsuitable, please discuss with Microbiology. The decision to initiate low dose prophylaxis must be clearly documented to ensure all staff caring for the patient are clear of the date of review and expected duration of therapy.

For glossary of terms see Glossary.