Management of UTIs

Chris Longstaff

Adult Non-Pregnant Women

When not to dipstick?

Do not dipstick if UTI highly likely SIGN and HCA - more than 2 symptoms CKS – moderate-severe symptoms

90% of these do have a UTI

When to Dipstick?

Dipstick if diagnosis uncertain

With only 1 symptom 20% false negative rate

SIGN advise to offer this group Abx even with negative dip

HPA advise only treat this group if nitrite or leukocyte positive dipstick

Looking for cloudiness is also reasonable (91% of non-cloudy urine in this group is not infected)

Urine Culture

Often results only available after symptoms settle

Relatively expensive lab investigation

Do not culture unless treatment failure (SIGN, CKS, EAU all agree)

If all possible UTIs were cultured Cost per day of symptoms saved - £215 Reduction in duration – 0.04-0.32 days

Antibiotics

Acute Cystitis tends to be self-limiting in this group

If UTI likely, offer antibiotics with an explanation

Average duration 4-9 days without antibiotics 3-8 days with antibiotics

Pregnant Women

Asymptomatic Bacteriuria

20-40% of pregnant women with asymptomatic bacteriuria develop pyelonephritis in pregnancy

NNT is 7

Association with increased low birth weight low gestational age increased neonatal mortality

Asymptomatic Bacteriuria Screening

Needs MSU culture

Send at first booking appointment

Confirmed positive needs 2 positive cultures growing the same bacteria

(40% false positive for single positives)

What to do with Positive Results

Treat according to sensitivities If there are options, CKS advises the

following order of preference Amoxicillin Nitrofurantoin Trimethoprim (unless folate defic) Cefalexin

Recheck At every subsequent antenatal visit (SIGN

and CKS)

Treating Acute Cystitis

Insufficient evidence for short courses, so treat for 7 days

CKS advises empirical treatment with the following Abx in order of preference

Nitrofurantoin Trimethoprim Cefalexin (not Amoxicillin as resistance is too high)

Men

Why do they have a UTI?

Often underlying complications

Consider Chlamydia

Refer if 2 or more episodes in 3/12

Concomitant Prostatitis

A significant proportion of males with UTI also have prostatitis

If inadequately treated this can lead to chronic prostatic infection or abscess

50% of all men with UTI also have prostatitis

90% of men with febrile UTI also have prostatitis

Only 9% of these actually had a tender prostate

To Treat Prostatitis or Not?

Treating Prostatitis

Treat for 14 days

Quinolone 1st line

Not Nitrofurantoin

Recommended by EAU and SIGN for treatment of all male UTIs

Only treating UTI

Treat for 7 days

Nitrofurantoin or Trimethoprim 1st line

Recommended by CKS and HPA