Lower urinary tract infection/cystitis

Diagnosis is clinical, based on two or more of:

New dysuria
New frequency
New urgency
New nocturia
Visible haematuria
Cloudy urine
Supra-pubic tenderness

In patients over 65 years new incontinence or delirium can also be caused by a UTI. Consider other causes of delirium before prescribing antibiotics and ensure urine culture and other investigations are sent to exclude other causes of delirium.

Required investigations

Urine culture: preferably midstream specimen or catheter specimen if catheterised.

A positive urine culture without symptoms (asymptomatic bacteriuria) in men & non-pregnant women should not be treated

Don't be a dipstick

Do not routinely use urinalysis/dipstick to diagnose a urinary tract infection.

Use of urinalysis results in antibiotic overprescribing.
Urine dipstick in men and women >65s has a high false-positive rate and a significant false negative rate and should not be used.
Urine dipstick in women <65’s only: nitrites indicate that a UTI is possible, but ONLY when symptoms are present.

Risk factors for bacterial resistance to trimethoprim

Hospital inpatient
Nursing/Care home resident
Patient >65 yrs
Received Trimethoprim in past 3 months
Trimethoprim resistant organism in any of the last 3 urine culture (up to 12 months ago)

Antibiotic recommendation

In the following scenarios follow alternative guidance:

Signs of sepsis follow: Upper Urinary Tract Infection/Pyelonephritis and Sepsis 6
Symptoms of Prostatitis
Lower UTI in pregnancy
If you are unsure of the source of infection follow: Sepsis of unknown source

Recommended total duration: (Women - 3 days, Men - 7 days)

No risk factors for trimethoprim resistance	Trimethoprim 200mg every 12 hours
Risk factor(s) for trimethoprim resistance AND eGFR >30	Nitrofurantoin M/R 100mg every 12 hours

If Risk factors for trimethoprim resistance identified and eGFR <30, options include:

Cefalexin 500mg every 12 hours
Pivmecillinam 400mg stat, then 200mg 8-hourly ( 3 days for women and 7 days for men)
Fosfomycin sachet 3g (once only for women; for men repeat after 72 hours)

If Penicillin allergy and eGFR <10, discuss with Microbiology (Antibiotic and clinical advice)

Notes

Likely organisms: E.coli, other Enterobacteriaceae, less commonly Enterococci.