Antibiotic Guidelines f URINARY TRACT/ UROLOGY infections CLINICAL CONDITION USEFUL INFORMATION RECOMMENDATIONS ALTERNATIVE (suitable in serious penicillin allergy) Asymptomatic Bacteriuria (in the absence of a catheter) Defined as: >10 5 cfu/ml MSSU/CSU (2 cultures with the same ganism in women) in the absence of clinical signs symptoms of UTI. Do not treat unless pregnancy urology procedures planned. In males asymptomatic bacteriuria is unusual and merits further investigation. Treatment not required DURATION Uncomplicated Lower UTI / cystitis dysuria frequency suprapubic pain/ tenderness urgency haematuria. MSSU pri to treatment See Diagnosis of UTI in Adults Elderly patients: symptoms may be atypical e.g. new onset incontinence/confusion. Initial antibiotic therapy should be guided by recent urine culture results, especially if a histy of multi-drug resistant ganisms. Change antibiotic accding to culture and susceptibility results of urine. Trimethoprim: o avoid if egfr <30 and on concurrent ACE inhibits/ angiotensin-ii recept antagonists / spironolactone / eplerenone / amilide therapy. o avoid in patients on methotrexate due to increased risk of haematological toxicity. Nitrofurantoin: o contraindicated if egfr<45. Trimethoprim 200mg 12 hourly PO OR Nitrofurantoin 100mg 6 hourly PO If trimethoprim nitrofurantoin unsuitable: Pivmecillinam 400mg PO stat, followed by 200mg 8 hourly PO Trimethoprim 200mg 12 hourly PO OR Nitrofurantoin 100mg 6 hourly PO If trimethoprim nitrofurantoin unsuitable: Contact microbiology f advice Females: Trimethoprim 3-5 days Nitrofurantoin 5 days Pivmecillinam 3-5 days Males: 7 days.
Antibiotic Guidelines f URINARY TRACT/ UROLOGY infections CLINICAL CONDITION USEFUL INFORMATION RECOMMENDATIONS ALTERNATIVE (suitable in serious penicillin allergy) Complicated UTI UTI with sepsis dysuria frequency suprapubic pain/ tenderness urgency haematuria. F sepsis, 2 me additional symptoms required: Temperature >38 0 C <36 0 C Tachycardia >90 bpm RR >20/min WCC <4 >12 X 10 9 /L. Risks f complicated UTI include: o recent urinary tract instrumentation o diabetes o immunosuppression o symptoms >7 days at presentation o structural abnmality of the renal tract Initial antibiotic therapy should be guided by recent urine culture results, especially if a histy of multi-drug resistant ganisms. Change antibiotic accding to culture and susceptibility results of urine. Gentamicin 5mg/kg* Piperacillin/Tazobactam 4.5g 8 hourly IV Gentamicin 5mg/kg* Aztreonam 2g 8 hourly IV DURATION 5-10 days Shter duration e.g. 5-7 days is reasonable if patient not severely ill and demonstrates rapid clinical response. MSSU pri to treatment Blood culture if temp >38 0 C *Refer to Moniting of antimicrobial agents guidelines and aminoglycoside prescription f prescribing infmation
Antibiotic Guidelines f URINARY TRACT/ UROLOGY infections CLINICAL CONDITION USEFUL INFORMATION RECOMMENDATIONS ALTERNATIVE (suitable in serious penicillin allergy) Pyelonephritis temperature >38 0 C chills rigs flank pain costovertebral angle tenderness. MSSU pri to treatment** Blood culture Catheter- associated UTIs New onset temperatures Altered mental state haematuria. flank pain & tenderness rigs pelvic discomft f which no other cause has been identified. Catheter in situ <7days: CSU pri to treatment Catheter in situ >7days: sample from 1 st urine Initial antibiotic therapy should be guided by recent urine culture results, especially if a histy of multi-drug resistant ganisms. Change antibiotic accding to culture and susceptibility results of urine. Most patients with catheters develop asymptomatic bacteriuria; do not treat unless pregnancy urology procedures planned. Initial antibiotic therapy should be guided by recent urine culture results, especially if histy of multi-drug resistant ganism. Change antibiotic accding to culture and susceptibility results of urine. Assess need f catheter: o Remove if possible o If CA-UTI suspected and catheter is in situ > 7 days; removal and insertion of new catheter should be done and the first urine drained sent f culture pri to the initiation of empirical treatment. drained from new catheter *Refer to Moniting of antimicrobial agents guidelines and aminoglycoside prescription f prescribing infmation ** Please phone and infm lab to test ciprofloxacin in urine sample as this will not be routinely tested in the sensitivity panel Piperacillin/Tazobactam 4.5g 8 hourly IV Piperacillin/Tazobactam 4.5g 8 hourly IV Aztreonam 2g 8 hourly IV Aztreonam 2g 8 hourly IV DURATION 7-14 days Duration depends on patient facts and antibiotic prescribed on al switch - contact microbiology f advice. 5-7 days Shter duration e.g. 5 days is reasonable if patient not severely ill and demonstrates rapid clinical response, especially if catheter removed changed early in treatment course.
Antibiotic Guidelines f URINARY TRACT/ UROLOGY infections CLINICAL CONDITION USEFUL INFORMATION RECOMMENDATIONS DURATION Epididymitis scrotal swelling (unilateral in majity) scrotal erythema pain +/- UTI symptoms All patients <35yrs MSSU pri to treatment** 1 st void of urine f chlamydia/gonrhoea PCR All patients 35yrs MSSU pri to treatment** If STI suspected- 1 st void of urine f chlamydia/gonrhoea PCR Seek urgent urology advice. Abscess fming epididymitis requires surgical management. Change antibiotic accding to culture and PCR results of urine. Risk facts f infection with enteric ganisms include: o benign prostatic hyperplasia (in the elderly) o risk of UTI o Bladder outlet obstruction o Urogenital malfmations Men at risk of infection by both enteric ganisms and STI include men who practice insertive anal intercourse. If STI confirmed-refer to GUM clinic. All patients <35 high risk of STI: Doxycycline 100mg 12 hourly PO AND GIVE Ceftriaxone 500mg IM Patients 35 and not sexually transmitted: Ciprofloxacin 500mg 12 hourly PO Patients at risk of enteric and STIs: Ofloxacin 200mg 12 hourly PO AND GIVE Ceftriaxone 500mg IM If severe cephalospin allergy, alternative agent: Azithromycin 2g PO. 10-14 days SINGLE dose 10 days 14 days SINGLE dose SINGLE dose Prostatitis Intense local pain +/- UTI symptoms Seek urgent urology advice. Change antibiotic accding to culture and PCR results of urine. If STI confirmed-refer to GUM clinic. Ciprofloxacin 500mg 12 hourly PO If high suspicion of STI: contact microbiology f advice. 2-4 weeks f acute 4-6 weeks f chronic In chronic cases, symptoms will be present f >3 months. MSSU pri to treatment** If <35yrs STI suspected- 1 st void of urine f chlamydia/ gonrhoea PCR *Refer to Moniting of antimicrobial agents guidelines and aminoglycoside prescription f prescribing infmation ** Please phone and infm lab to test ciprofloxacin in urine sample as this will not be routinely tested in the sensitivity panel
Antibiotic Guidelines f URINARY TRACT/ UROLOGY infections CLINICAL CONDITION USEFUL INFORMATION RECOMMENDATIONS DURATION Prophylaxis f recurrent infections in women Diagnosis 3 confirmed uncomplicated UTI per year ( symptomatic reinfection based on urinary pathogens isolated in MSSU) Relapse is recurrent UTI with the same strain of ganism. Relapse is the likely cause if infection recurs within a sht period (f example within 2 weeks) after treatment. Reinfection is the likely cause if UTI recurs me than 2 weeks after treatment. Prophylactic use at night - take befe going to bed, after emptying bladder. Repeat MSSU after 1 month of treatment. Trimethoprim: o avoid if egfr <30 and on concurrent ACE inhibits/ angiotensin-ii recept antagonists / spironolactone / eplerenone / amilide therapy. o avoid in patients on methotrexate due to increased risk of haematological toxicity. Nitrofurantoin: o contraindicated if egfr<45. Trimethoprim 100mg nocte PO OR Nitrofurantoin 50-100mg nocte PO If trimethoprim nitrofurantoin unsuitable: Contact microbiology f advice Treat f 3 months, then review.
References: 1. 2010 United Kingdom national guideline f the management of epididymo-chitis. Clinical Effectiveness Group, British Association f Sexual Health and HIV. 2. United Kingdom National guideline f the management of prostatitis (2008). Clinical Effectiveness Group, British Association of Sexual Health and HIV. 3. SIGN 88. Management of suspected bacterial urinary tract infection in adults. July 2012. 4. European Association of Urology Guidelines, 2014 edition. Title: CLINICAL GUIDELINES ID TAG Antibiotic Guidelines f Urinary Tract/ Urology infections Auth: Speciality / Division: Directate: Date Uploaded: Consultant Microbiologists: Dr Martin Brown, Dr Melanie Pathiraja Lead Antimicrobial Pharmacist: Mrs A McCry Microbiology/ Pharmacy Acute Review Date September 2018 Clinical Guideline ID CG0172(1)