UTI Treatment & Management

IM

MANAGEMENT OF UTI

(MAINLY CYSTITIS)

1. Antibiotics
2. High fluid intake
3. Remove/replace catheter, if present
4. Cranberry juice(?)

Antibiotics are started empirically, then modified according to culture reports, if needed

A) YOUNG FEMALES WHO ARE NOT PREGNANT

• First choice : Tmp/Smx (Bactrim )DS, 1 tab. bid., or Nitrofurantoin or Fosfomycin
• Second choice : Ciprofloxacin (quinolones) (according to infec. Dis. Society of America)

ONE OF THEM, FOR 3 DAYS (resistance to cipro is very high in many countries)

B) FEMALES WHO ARE PREGNANT

1. 6% of preg. females have significant bacteria in urine, even without UTI symptoms. If not treated, it can cause pyelo-nephritis (can lead to maternal & fetal complications)
2. Routine urine C/S is done in the 1^st trimester
3. Rx is given even if no symptoms (asymp. bacteriuria)
4. Rx of choice : * Nitrofurantoin * Fosfomycin

TREAT FOR 7 DAYS (NOT 3 DAYS)

C) MALES:

• Same as A
• 7 day Rx (not 3 days)

In A) & C) no need to do a urine C/S after treatment.

D) Asymptomatic bacteriuria : Treat only :

• a) If the patient is pregnant
• b) If the person is going to have any urologic surgery( if the pre-op routine tests show bacteria in urine)

DURATION OF CYSTITIS TREATMENT

1. Non-pregnant female: 3 days
2. Males } 7 Days
3. Pregnant female } 7 Days
4. DM } 7 Days

PROPHYLAXIS FOR RECURRENT UTI

If a patient gets recurrent UTI, do the following:

1. Advise increased fluid intake
2. Frequent urination( to avoid stasis in the bladder)
3. Investigate for any urinary tract pathology (by ultrasound / pyelogram etc) & treat it
4. Do urine culture( to see if any antibiotic resistance is there)

Special situations

Chronic indwelling Foley’s catheter

• WBC & bacteria are almost always present
• No treatment if patient is asymptomatic
• Treat w/antibiotics only if symptoms present
• Change Foley’s catheter

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FM

Management

Non-pregnant women <65 years without a catheter. Give immediate antibiotics for women with severe symptoms who have:

• 2 or 3 of the key diagnostic signs and symptoms for UTI (dysuria, new nocturia, cloudy-looking urine) OR
• 1 key diagnostic sign or symptom AND
  • A urine dipstick positive for nitrite OR
  • A urine dipstick positive for leukocytes and negative for nitrite OR
  • A urine dipstick positive for both leukocytes and red blood cells.

Watch and wait and provide a back-up prescription for antibiotics for women with mild symptoms.

SIGN Guideline Recommendations

• SIGN guideline recommends considering NSAIDs as a first-line treatment in women aged under 65 with mild symptoms.
• This offers an alternative to antibiotics in order to reduce antibiotic prescribing.
• Consider and discuss with the patient the risks and benefits if considering this approach.
• Limit the duration to 3 days and ask the patient to make contact if the symptoms do not resolve or worsen in this time.

Back-up Prescriptions

• For women with acute uncomplicated UTI seem to be as effective as immediate prescriptions (measured by severity of symptoms, duration of symptoms, and time to reconsultation) and reduce the number of women using antibiotics.
  • Do not give immediate or back-up antibiotics to women
    • with no key diagnostic signs or symptoms and a dipstick test negative for nitrites, leukocytes, and red blood cells.
  • Do not send a urine culture. Do not treat non-pregnant women who have asymptomatic bacteriuria.

Choice of Antibiotic

• Nitrofurantoin if estimated glomerular filtration rate (eGFR) ≥45 mL/minute.

• Nitrofurantoin is effective against Escherichia coli, the most common causative pathogen in uncomplicated UTIs (70%-95% of patients).

• Trimethoprim if low risk of resistance.

Duration of treatment - NICE recommends a 3-day course.

Non-pregnant women <65 years without a catheter. Give immediate antibiotics for women with severe symptoms who have:

• 2 or 3 of the key diagnostic signs and symptoms for UTI (dysuria, new nocturia, cloudy-looking urine) OR
• 1 key diagnostic sign or symptom AND
  • A urine dipstick positive for nitrite OR
  • A urine dipstick positive for leukocytes and negative for nitrite OR
  • A urine dipstick positive for both leukocytes and red blood cells.

Watch and wait and provide a back-up prescription for antibiotics for women with mild symptoms.

Case Description	Best Medication	Duration of Treatment	Other Notes
Non-pregnant women <65 years without a catheter.	Empirically Nitrofurantoin, Trimethoprim	3 days	2 or 3 of dysuria, new nocturia, cloudy-looking urine - or positive test, leuko rbc, nitrite
Women ≥65 Years (Without a Catheter) - Severe Symptoms	Nitrofurantoin, Trimethoprim	7-10 days	Immediate antibiotics after urine culture
Women ≥65 Years (Without a Catheter) - Mild Symptoms	Nitrofurantoin, Trimethoprim	7-10 days	Watch and wait, back-up prescription after urine culture
Pregnant Women (Without a Catheter) - Symptomatic UTI	Nitrofurantoin, Amoxicillin, Cefalexin	7 days	Immediate antibiotics after urine culture
Pregnant Women (Without a Catheter) - Asymptomatic Bacteriuria	Nitrofurantoin, Amoxicillin, Cefalexin	7 days	Prescribe after urine culture
Women (Any Age) with a Catheter	Nitrofurantoin, Trimethoprim	At least 7 days	Urine culture before prescribing
Pregnant Women with Catheter-Associated UTI	Cephalexin, Cefotaxime (IV)	7 days	Cefotaxime for severe cases or inability to take oral antibiotics
Older Women	Nitrofurantoin, Trimethoprim	7-10 days	Longer duration needed
Men Aged 15-50 Years	Nitrofurantoin, Trimethoprim	7-10 days	Low incidence, specific risk factors
Pregnant Women - Special Circumstances	Cephalexin, Amoxicillin	7 days	Avoid Trimethoprim and Quinolones

Women ≥65 Years (Without a Catheter)

• Give immediate antibiotics, ideally after sending urine for culture, for women aged ≥65 years with severe symptoms and a likely UTI.

• Watch and wait and give a back-up prescription for antibiotics, ideally after sending urine for culture, for women aged ≥65 years with mild symptoms and a likely UTI.

For first-choice antibiotic:

• Nitrofurantoin (nitrofurantoin: 100 mg orally (modified release) twice daily; 50 mg orally (immediate release) four times daily).
• Trimethoprim if low risk of resistance (200 mg orally twice daily).

Pregnant Women (Without a Catheter)

• Initial management: Prescribe an immediate antibiotic, after sending urine for culture, for all pregnant women with symptoms of a UTI.

First-choice antibiotic in women with symptoms of a UTI:

• Nitrofurantoin if eGFR ≥45 mL/minute.

Second-choice antibiotic:

• Amoxicillin

• Cefalexin

• For women with asymptomatic bacteriuria prescribe nitrofurantoin, amoxicillin, or cefalexin.

Duration of treatment is 7 days.

Women (Any Age) with a Catheter

• Send a urine sample for culture and susceptibility testing, noting a suspected catheter-associated infection, before prescribing any antibiotic.
• Prescribe at least a 7-day course of antibiotics to ensure complete cure.
  • Nitrofurantoin
  • Trimethoprim if low risk of resistance.

Pregnant Women with Catheter-Associated UTI

• Prescribe cephalexin.
• For first-choice intravenous antibiotic, in patients who are vomiting, are unable to take oral antibiotics, or are severely unwell, prescribe cefotaxime.

Special Circumstances

• Older women:
  • Need longer duration of antibiotics (7-10 days).
• In men aged 15-50 years, incidence is very low:
  • Risk factors: homosexuality, lack of circumcision.
  • Need 7-10 days duration.
• In pregnancy:
  • Cephalexin 250/125mg 6-hourly.
  • Amoxicillin 250mg 3 times daily.
  • Trimethoprim and Quinolones to be avoided.

Follow-up

• Patients with acute cystitis or pyelonephritis who have persistent symptoms after 48 to 72 hours of appropriate antimicrobial therapy or recurrent symptoms within a few weeks of treatment

• should have urine culture repeated and empiric treatment should be initiated with another antimicrobial agent.

Prevention

Health Recommendations

• Fluid intake of at least 2 L/day.
• Timed voiding (regular complete emptying of the bladder).
• Good personal hygiene, especially during sexual intercourse.
• Females should wipe from front to back after voiding to prevent contaminating the urethra with bacteria from the anal area.
• Cranberry juice may be effective.

Prophylactic Therapy

• In recurrent infections
• Treatment for 6–12 months
• Low-dose prophylaxis:
  • Trimethoprim 100 mg
  • Co-Trimoxazole 480 mg
  • Cefalexin 125 mg at night