Checked: 13-04-2018 by
vicky.ryan Next Review: 31-05-2018
Lower UTI in females NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
assessment and management of lower urinary tract infections (UTIs) in female adults
recurring infections and relapses
special considerations for pregnant women, the elderly (older than age 65 years), and catheterised patients [1,7]
Out of scope:
diagnosis and management of UTIs in children (younger than age 14 years 
management of upper UTIs
UTI is an infection in any part of the urinary tract by :
other microorganisms (rare)
lower UTI (also known as cystitis) – infection/inflammation of the bladder 
upper UTI – includes pyelitis and pyelonephritis 
recurrent UTI :
relapse – recurrent UTI  with the same strain or species of organism from established reservoir in urinary tract 
reinfection – recurrent UTI with a different strain or species of organism with no urinary tract reservoir of infection (such as a stone) [1,7]
uncomplicated UTI :
infection with usual pathogen
normal urinary tract and normal kidney function
complicated UTI :
UTI when one or more factors are present that predispose the person to persistent/recurrent/treatment failure, eg:
abnormal urinary tract
virulent organism (such as Staphylococcus aureus)
impaired host defences
impaired renal function
progression to pyelonephritis (fever and loin pain) 
In pregnancy [3,5]:
symptomatic bacteriuria occurs in 17–20% of pregnancies and 2-9% of pregnant women are bacteriuric in the first trimester 
most women are prone to or acquire asymptomatic bacteriuria before pregnancy, and 20-40% of women with asymptomatic bacteriuria develop pyelonephritis during pregnancy 
pregnant women should be screened for bacteriuria during the first trimester 
This care map has been updated to incorporate new guidance from the National Institute for Health and Care Excellence (NICE) regarding urgent referral and direct access tests for suspected cancer for patients with haematuria, and recurrent or persistent urinary tract infection in line with:
 National Institute for Health and Clinical Excellence (NICE). ). Suspected cancer: recognition and referral. NICE guideline 12. London: NICE; 2015.
Guidance on the detection of haematuria and referral criteria has been added in line with:
 National Institute for Health and Care Excellence (NICE). Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. Clinical guideline 182. London: NICE; 2014.
Date of publication: 31-Jan-2015
Contraindication information for nitrofurantoin has been updated in line with:
 Medicines and Healthcare Products Regulatory Agency (MHRA). Nitrofurantoin now contraindicated in most patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min/1.73m2. Drug Safety Update; September, 2014: A3.
Date of publication: 31-Oct-2013
This care map has been drafted using the Map of Medicine editorial methodology and represents best clinical practice according to the highest quality evidence available, including the following guidelines:
 Clinical Knowledge Summaries (CKS). Urinary tract infection (lower) - women. (updated February 2013). Newcastle upon Tyne: CKS; 2009.
 Scottish Intercollegiate Guidelines Network (SIGN). Management of suspected bacterial urinary tract infection in adults. A national clinical guideline. SIGN Publication no. 88. Edinburgh: SIGN; 2012.
 Grabe M, Bjerklund-Johansen TE, Botto H et al. Guidelines on Urological Infections. The Netherlands: European Association of Urology (EAU); 2013.
 Health Protection Agency (HPA). Management of infection. Guidance for primary care for consultation and local adaptation. London: HPA; 2010.
 Health Protection Agency (HPA). Diagnosis of UTI. Quick reference guide for primary care. London: HPA; 2011.
 British National Formulary (BNF). BNF 65. London: BMJ Group and RPS Publishing; 2013.
 National Institute for Health and Clinical Excellence (NICE). Referral guidelines for suspected cancer. Clinical guideline 27 (updated 2011). London: NICE; 2005.
Further information was provided by the following references including practice-based knowledge:
 Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews 2012; CD001321.
 Practice-informed recommendations, including contributors representing the Royal College of General Practitioners. 2013.
Symptoms of lower urinary tract infection (UTI):
lower abdominal pain [1,7]
restricted activities 
feeling unwell 
back pain 
systemic features of infection :
Signs of lower UTI:
cloudy urine 
urine smells offensive 
visible haematuria  − isolated haematuria without UTI symptoms is unlikely to be due to UTI [2,7]
suprapubic tenderness 
consider the possibility of upper UTI in patients presenting with symptoms or signs of UTI who have a history of fever or back pain 
nature, duration, and severity of symptoms 
previous urinary tract infections (UTIs) and use of antibiotics [2,7]
medical history − specifically diabetes [2,7]
genito-urinary symptoms suggestive of sexually transmitted disease (STD; important differential diagnosis and may co-exist with UTI):
discharge (urethral or vaginal) [3,7]
pelvic pain 
features that predispose to UTI, eg :
anatomical urinary tract abnormality
recent hospital stay or catheter
diabetes mellitus (DM)
Assess for features of pyelonephritis, such as [2,5]:
flank pain and tenderness
signs of dehydration
systemic features of sepsis, eg rigors, sweats, pallor, tachycardia
nausea and vomiting
high temperature (more than 38°C) 
costovertebral angle tenderness 
Examination − consider pelvic examination if symptoms of vaginal itch or discharge are present, and consider bladder cancer in the elderly [3,7].
Patients with indwelling catheters or intermittent catheterisation [3,7]:
look for associated localising or systemic features, eg:
exclude others sources of infection
In healthy pregnant women :
the diagnostic criteria of acute cystitis and pyelonephritis are similar to that of non-pregnant women
however, physical examination and urinalysis including urine culture are highly recommended in cystitis
If treatment failure always peform culture, second line treatment choice depends on sensitivity of organism isolated. When sending samples state antibiotics started empirically so sensitivities of isolated organisms can be checked.
Asymptomatic bacteriuria :
Do not treat non-pregnant women (of any age) with asymptomatic bacteriuria with an antibiotic
consider advising women with uncomplicated UTIs that they may use over-the-counter remedies such as paracetamol or ibuprofen to relieve pain
NB: do not advise the use of ibuprofen unless it is clear that the patient has normal kidney function and is not dehydrated, as acute kidney injury can result 
Considerations for catheterised patients:
do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters 
do not treat asymptomatic bacteriuria in those with indwelling catheters, as bacteriuria is very common and antibiotics increase side effects and antibiotic resistance [3,8,9].
do not rely on classical clinical symptoms or signs for predicting the likelihood of symptomatic UTI in catheterised patients 
do not use dipstick testing to diagnose UTI in patients with catheters 
do not use laboratory microscopy to diagnose UTI in patients with catheters 
only send urine for culture in catheterised patients if there are features of systemic infection to determine the infecting organism and susceptibility to antibiotics [3,9], not because the appearance or smell of the urine suggests that bacteriuria is present :
always exclude other sources of infection [3,8,9]
Symptoms that may suggest UTI in catheterised patients include :
new costovertebral tenderness
new onset delirium
fever greater than 37.9°C or 1.5°C above baseline on two occasions during 12 hours
Look for associated localising (loin or supra-pubic tenderness) or systemic features :
check that the catheter drains correctly and is not blocked [8,9]
consider need for continued catheterisation [8,9]
if the catheter has been in place for more than 7 days, consider changing it before/when starting antibiotic treatment [8,9]
when changing catheters, antibiotic prophylaxis should only be used for people with a history of catheter-associated urinary tract infection following catheter change  See the BNSSG antimicrobial guideline.
Consider antibiotic therapy taking into account the severity of the presentation and any comorbid factors . See the BNSSG antimicrobial guideline and the community IV antibiotic service criteria.
Consider referal to secondary care if symptoms are severe e.g. nausea, vomiting, reduced urine output. Consider undertaking the NEWS score as a screening tool.
Diagnosis in pregnant women [3,5]:
the gold standard method for diagnosis of bacteriuria is culture of urine obtained by suprapubic needle aspiration 
a catheter specimen of urine is less reliable than suprapubic needle aspiration, although more reliable than two midstream urine samples (MSU) samples 
do not use dipstick testing to screen for bacterial urinary tract infection (UTI) at the first or subsequent antenatal visits  – it is not sufficiently sensitive to be used as a screening test, and urine culture should be the investigation of choice 
standard quantitative urine culture should be performed routinely at first antenatal visit 
confirm the presence of bacteria in urine with a second urine culture 
asymptomatic bacteriuria is diagnosed in :
two consecutive voided urine specimens with grow of >105 colony forming units (CFU)/mL of the same bacterial species, or
a single catheterised specimen with grow of >105 CFU/mL of a uropathogen
if the woman is symptomatic, bacteriuria is considered relevant if a voided or catheterised urine specimen grows >103 CFU/mL of a uropathogen 
women who do not have bacteriuria in the first trimester should not have repeat urine cultures 
For pregnant women [3,9]:
treat symptomatic UTI and asymptomatic bacteriuria with an antibiotic 
take a single mid-stream urine sample for culture before empiric antibiotic treatment begins [3,9]
refer to local guidance for advice on the choice of antibiotic for pregnant women 
a 7-day course of treatment is normally sufficient 
perform a urine culture 7 days after completion of antibiotic treatment as a test of cure 
women with bacteriuria confirmed by a second urine culture should be treated and have repeat urine culture at each antenatal visit until delivery 
Considerations for the elderly (65 years or older):
the presence of bacteriuria does not always indicate disease [3,8]
asymptomatic bacteriuria is very common in the elderly and should not be treated with antibiotics [3,8]
Do not use a dipstick to diagnose
If signs of an infection (fever, hypothermia or non-specific symptons) no signs of non-urinary infection and at least two of:
dysuria, urgency, frequency, new or worsening urinary incontinence, rigors, pain in flank or superpubic, frank haematuria, new onset or worsening of pre-existing delirium or agitation. Send urine sanple and treat as per BNSSG Diagnosing and Treating Lower UTI Guidelines
is not routinely required if lower urinary tract infection (UTI) is uncomplicated
is required if haematuria was found:
retest the urine 
check that infection and haematuria have resolved otherwise refer urgently to urology cancer specialist 
in pregnancy, urine cultures should be obtained 1-2 weeks after completion of therapy for asymptomatic bacteriuria and symptomatic UTI 
Management of treatment failure [1,2,3]:
check compliance with treatment 
continue to relieve symptoms with paracetamol 
take urine for culture to guide change of antibiotic for patients who do not respond to trimethoprim or nitrofurantoin 
send urine sample for culture :
if troublesome symptoms persist, offer an alternative antibiotic whilst awaiting culture results:
antibiotic choice may vary depending on local microbiology input 
confirms infection, treat with appropriate antibiotics 
does not confirm infection, consider differential diagnoses
investigate for other causes 
Follow-up of patients with an indwelling catheter [1,3,5]:
review after 48 hours (or as clinically appropriate) to assess for:
response to treatment
culture results − if urine culture is resistant to current antibiotic:
and symptoms have not resolved, change to another antibiotic that the organism is sensitive to
and symptoms have resolved, consider continuing the current antibiotic
consider referring for assessment and investigations if patient fails to respond to two courses of antibiotic that are appropriate according to urine culture
patients with indwelling catheters should be admitted to hospital if systemic symptoms, such as fever, rigors, chills, vomiting, or confusion appear 
Consider antimicrobial prophylaxis in patients with [3,5]:
a high frequency of infections
severe infections that impact function and well-being
postcoital prophylaxis should be considered in pregnant women with a history of frequent UTIs before onset of pregnancy, to reduce their risk of UTI 
if patient does not respond to two courses of appropriate treatment, and compliance has been determined, refer for assessment and investigations [1,7]
Consider non-urgent referral for suspected bladder cancer for :
patients aged 60 years and older with recurrent or persistent unexplained urinary tract infection (UTI)
Consider two week wait referral for bladder and renal cancer:
of any age with painless macroscopic haematuria
50 years and older with unexplained microscopic haematuria
(positive two out of three tests, usually separated by two weeks between tests)
40 years and older with recurrent or persistent urinary tract infection associated with haematuria
abdominal mass identified clinically or on imaging thought to arise from urinary tract
Please see attached document on Assessment of Sterile pyuria in Primary Care
NB: consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 years and older with :
unexplained symptoms of vaginal discharge:
presenting for the first time; or
with thrombocytosis; or
visible haematuria and:
low haemoglobin levels; or
high blood glucose levels
2WW referral forms are available as EMIS templates
Patients with persisting haematuria, who do not meet the criteria for a urology referral for suspected cancer, may require nephrology referral .
Refer patients to a nephrologist if there is :
an albumin:creatinine ratio (ACR) of 30mg/mmol or more with haematuria 
isolated haematuria (in the absence of significant proteinuria) with hypertension (a blood pressure greater than 140/90mmHg) in patients age younger than age 40 years 
-Encourange relaxation of pelvic floor to ensure full bladder emptying
-Consider cranberry productions (avoid if on Wafarin) - these work for some women but good evidence is lacking
- For post-menopausal women with risk factors such as atropic vaginitis consider prescribing intr-vaginal or oral oestrogens. These should be trialled for 3-6 months. Estriol cream 0.1% (Ovestin) and Estradiol vaginal tablets 10 micrograms (Vagifem) are on formulary
If these first line measures fail to improve symptoms then:
1. Check MSU to confirm diagnosis and establish sensitivities during acute UTI episode
2. If continued problems consider renal tract ultrasound (to detect stones, cysts, tumours and other abnormalities) and post void bladder residual volume scan (to detect voiding dysfunction)
- If new presentation in post-menopausal women consider referral for cystoscopy to determine if symptoms are due to an intravesical lesion eg stone or tumour.
Red flags that would increase the importance of cystoscopy are persistent dysuria or storage problems despite antibiotic therapy, persistent non-visual haematuria despite treatment and significant smoking history.
3. If investigations normal and continued problems consider second or third line options.
Standby or post-coital antibiotics.
The choice of treatment should be based on recent sensitivities.
Post-coital antibiotics shouuld be taken as a single dose. For example
Nitrofurantoin 100mg or Trimethoprim 100mg.
Standby antibiotics would be a three day course of an antibiotic based on previous cultures and sensitivities. Ensure the PHE Urinary Tract Infection information leaflet is given this has details of possible urinary symptoms.
Antibiotic or Methenamine prophylaxis.
Counselling prior to initiation of prophylaxis
The patient should be counselled that antibiotic prophylaxis is not usually a lifelong treatment. Antibiotics are given in this way to allow a period of bladder healing which makes UTI much less likely. There is no evidence they have any additional benefit beyond 6-12 months treatment therefore the treatment should be discontinued ideally after 3-6 months.
Antibiotic choice should be based on previous urinary cultures and sensitivities.
Nitrofurantoin 100mg nocte
Trimethoprim 100mg nocte
Methenamine hippurate 1gram bd
This is a ‘non-antibiotic’ option which is suitable if there is no hepatic impairment. It is an option if a patient cannot have Trimethoprim or Nitrofurantoin prophylaxis. (Due to allergy, resistance or poor renal function for Nitrofurantoin). Methenamine can be used in mild to moderate renal impairment GFR >10ml/min.
On prescribing a review date of 3-6 months should be documented in the medical notes and on the prescription.
The patient should be reviewed with a view to stopping the treatment.
Counsel patients that antibiotic prophylaxis is not usually a life-long treatment. Antibiotics are given in this way to allow a period of bladder healing which makes UTIs much less likely.
Long term antibitoic prophyaxis is strongly associated with the developement of antimicrobial resistance.
or seek specialist help if measures to prevent recurrence are not successful
if risk factors for recurrent lower urinary tract infection (UTI) are present, eg:
urinary tract abnormalities
if there is a known abnormality on ultrasound of:
Consider non-urgent referral for suspected bladder cancer for :
patients aged 60 years and older with recurrent or persistent unexplained UTI
Further investigations include [2,7]:
CT-intravenous pyelogram (IVP) if indicated 
FROM 1st SEPTEMBER 2015
As part of the Planned Care programme it was agreed with the membership to run another pilot on ‘advice and guidance’ across Urology. This process will be carried out by Shire Health and will provide several benefits for referrers and patients.
What do practices need to do?
There is no change to the referral process for GP practices required to access the new advice and guidance service – urology referrals should continue to be sent to the Referral Support Service (RSS) as normal. Referrals will be directed by the RSS to the new advice and guidance service at Shire (2WW, Paediatric and vasectomy referrals should be sent directly to the Hospital as usual). Shire are happy to advise speedily as to whether 2ww is required, e.g. for PSA queries, haematuria queries etc.
Shire will respond within 72hrs (3 working days) with their recommendations and whether the patient could be managed in primary care with a management plan, or suggest that the patient needs to be seen/referred to the hospital.
The RSS will process the response to the advice and guidance request from shire and:
Forward to the hospital, on behalf of your GP practice, any patients where referral is recommended.
Return any referrals to the referring GP when there is a recommendation from Shire where the patient could be managed in primary care – the referring GP would be required to review this response and manage as appropriate.
Return the referral form asking for further details if Shire have not been given sufficient information to process the request.
For the few practices that do not use the RSS, the process will be discussed separately on an individual practice basis
For more information please see the Shire FAQ and flow chart below and use the Urology Referral Template to refer into this service.
NOTE: Please ensure the referral template is fully completed to help the advice team understand the issues, and decrease the need for requests for further information. Where appropriate, please add the referral template to your clinical system.