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A national clinical guideline

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copiesofallsignguidelinesareaVailableonlineatWWW.sign.ac.uk

Scottish Intercollegiate Guidelines Network

SIGN

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thmmmh-mm

keytoeVidencestateMentsandgradesofrecoMMendations

leVelsofeVidence

1++ High quality meta-analyses, systematic reviews of randomised controlled trials(RCTs), or RCTs with a very low risk of bias

1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a lowrisk of bias

1 - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort studiesHigh quality case control or cohort studies with a very low risk of confounding orbias and a high robability that the relationshi is causal

2+ Well conducted case control or cohort studies with a low risk of confounding orbias and a moderate robability that the relationshi is causal

2 - Case control or cohort studies with a high risk of confounding or bias andasignifcantriskthattherelationshipisnotcausal

3 Non-analytic studies, eg case reorts, case series

4 Exert oinion

GRADES OF RECOMMENDATION

Note: The grade of recommendation relates to the strength of the evidence on which therecommendation is based. It does not reect the clinical importance of the recommendation.

a At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++

and directly alicable to the target oulation; or

A body of evidence consisting rincially of studies rated as 1+, directly alicableto the target oulation, and demonstrating overall consistency of results

b A body of evidence including studies rated as 2++

, directly alicable to the targetoulation, and demonstrating overall consistency of results; or

Extraolated evidence from studies rated as 1++ or 1+

c A body of evidence including studies rated as 2+, directly alicable to the targetoulation and demonstrating overall consistency of results; or

Extraolated evidence from studies rated as 2++

d Evidence level 3 or 4; or

Extraolated evidence from studies rated as 2+

GOOD pRACTICE pOINTS

Recommended best ractice based on the clinical exerience of the guidelinedeveloment grou

Sulementary material available on our website www...

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Scottish Intercoegite Guideines Network

Mngement o susected bcteriurinr trct inection in duts

A natinal clinical guideline

Jul 2006

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Scttish Intecllegiate Guidelines NetwkISBN 1 899893 79 2Fist published 2006

SIGN cnsents t the phtcping f this guideline f thepupse f ipleentatin in NHSSctland

Scottish Intercoegite Guideines Network28 Thiste Street, Edinburgh EH2 1EN

www.sign.c.uk

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1 INTRODUCTION

1 Introduction

1.1 THE NEED fOR a GUIDElINE

Uina tact infectin (UTI) is the secnd st cn clinical indicatin f epiicalantiicbial teatent in pia and secnda cae, and uine saples cnstitute the lagestsingle categ f speciens exained in st edical icbilg labaties. Healthcaepactitines egulal hae t ake decisins abut pesciptin f antibitics f uina tactinfectin. Citeia f the diagnsis f uina tact infectin a geatl in the UK, dependingn the patient and the cntext. Thee is cnsideable eidence f pactice aiatin in use fdiagnstic tests, intepetatin f signs spts and initiatin f antibitic teatent, 2-5with cntinuing debate egading the st apppiate diagnsis and anageent.,6

The diagnosis of UTI is particularly difcult in elderly patients, who are more likely to haveasptatic bacteiuia as the get lde.7 The pealence f bacteiuia a be s high thatuine cultue ceases t be a diagnstic test.8 Eldel institutinalised patients fequentl eceieunnecessa antibitic teatent f asptatic bacteiuia despite clea eidence f adese

effects with no compensating clinical benet.9,0

Existing eidence based guidelines tend t fcus n issues f antibitic teatent (dug selectin,dse, duatin and ute f adinistatin) with less ephasis n clinical diagnsis theuse f nea patient tests ae liited t adult, nn-pegnant wen with uncplicated,sptatic UTI.,2

F patients with spts f uina tact infectin and bacteiuia the ain ai f teatentis elief f spts. Secnda utces ae adese effects f teatent ecuence fspts. F asptatic patients the ain utce f teatent is peentin f futuesptatic episdes.

Unnecessa use f tests and antibitic teatent a be iniised b deelping sipledecisin ules, diagnstic guidelines the educatinal inteentins.3-6 Pudent antibitic

pescibing is a ke cpnent f the UKs actin plans f educing antiicbial esistance.7,8Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with signicantlyinceased isk f clinical adese eents.9,20

1.2 REMIT Of THE GUIDElINE

This guideline pides ecendatins based n cuent eidence f best pactice inthe anageent f adults with cunit acquied uina tact infectin. It includes adultwen (including pegnant wen) and en f all ages, patients with cathetes and patientswith cbidities such as diabetes. It excludes childen and patients with hspital acquiedinfectin. The guideline des nt addess pphlaxis t peent UTI afte instuentatin suge, teatent f ecuent UTI.

This guideline will be f inteest t healthcae pfessinals in pia and secnda cae,ofcers in charge of residential and care homes, antibiotic policy makers, clinical effectivenessleads, caes and patients.

Additinal epideilgical and statistical infatin t accpan this guideline is aailableas suppleenta ateial n the SIGN website www.sign.c.uk

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MaNaGEMENT Of SUSpECTED BaCTERIal URINaRy TRaCT INfECTION IN aDUlTS

1.3 DEfINITIONS

asymptomaticbacteriuria

pesence f bacteiuia in uine eealed b quantitatie cultue icscp in a saple taken f a patient withut an tpical sptsf lwe uppe uina tact infectin. In cntast with sptatic

bacteriuria, the presence of asymptomatic bacteriuria should be conrmedb tw cnsecutie uine saples.2

bacteraemia pesence f bacteia in the bld diagnsed b bld cultue.

bacteriuria pesence f bacteia in uine eealed b quantitatie cultue icscp.

empirical treatment treatment based on clinical symptoms or signs unconrmed by urinecultue.

haematuria bld in the uine eithe isible (acscpic haeatuia) inisible(icscpic haeatuia).

long term catheter an indwelling cathete left in place f e 28 das.

lower urinary tractinfection (LUTI)

eidence f uina tact infectin with spts suggestie f cstitis(dsuia fequenc withut fee, chills back pain).

medium termcatheter

an indwelling cathete left in place f 7-28 das.

near patient testing tests that ae dne at the pint f cnsultatin and d nt hae t be sentt a labat.

pyuria occurrence of 104 white bld cells (WBC)/l in a feshl idedspecien f uine.22 Highe nubes f WBC ae ften fund in healthasptatic wen. Puia is pesent in 96% f sptatic patientswith bacteiuia f >05 cln fing units (cfu)/l, but nl in

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1 INTRODUCTION

1.4 KEy MESSaGES aBOUT BaCTERIal UTI

Bcteriuri is not disese

The normal ora of the human body are extremely important as a key part of host defencesagainst infection and because of their inuence on nutrition.23

In peple less than 65 eas f age bacteiuia is abnal in the sense that st pepled nt suffe f it (see Table 1). Bacteiuia is cn in se ppulatins finstitutinalised wen24 and peple with lng te indwelling uina cathetes(see section 5).

Tests or bcteriuri or uri do not estbish the dignosis o UTI

The diagnsis f UTI is piail based n spts and signs (see section 2.1).

Tests that suggest pe the pesence f bacteia white cells in the uine a cntibuteadditinal infatin t inf anageent but ael hae iptant iplicatins fdiagnsis (see sections 2.2, 3.1.3, 4.1, 5.2).

Bcteriuri one is rre n indiction or ntibiotic tretment

Bacteiuia can nl be an abslute indicatin f antibitic teatent when thee is cnincingeidence that eadicatin f bacteiuia esults in eaningful health gain at acceptableisk (see sections 2.4, 5.3, 5.4). In paticula, in eldel patients, asptatic bacteiuia iscommon and there is evidence that treatment is more harmful than benecial.9,0 In cntast,duing pegnanc thee is eidence that teatent f bacteiuia des e gdthan ha.25

The ain alue f uine cultue is t identif bacteia and thei sensitiit t antibitics (seesections 2.3, 2.4.1, 3.1.2, 4.1, 5.4.1).

Indiect indicats f the pesence f bacteia (f exaple, uina nitites) ae likel t beuch less aluable than uine cultue (see sections 2.2.3, 3.1.3, 4.1, 5.2.2).

There is risk o se ositie resuts in tests or dignosis o bcteriuri other thn thegod stndrd

The gld standad test f diagnsis f bacteiuia is cultue f bladde uine btained bneedle aspiatin f the bladde as it iniises the isk f cntainatin f the uinespecien (see section 3.1.2).

All the techniques (uethal cathete and idstea speciens f uine) ca a highe iskf cntainatin and theefe pduce se false psitie esults (see section 3.1.2).

The signicance of false positive results is greatest when testing for bacteriuria in peoplewith lw pe-test pbabilit (f exaple, sceening f asptatic bacteiuia in therst trimester of pregnancy, see section 3.1.2).

Routine urine cuture is not required to mnge lUTI in women

Wen with sptatic LUTI shuld eceie epiical antibitic teatent

(see section 2.4.1).All uine saples taken f cultue will be f patients that ae nt espnding t teatentand will bias the esults f sueillance f antibitic esistance (see section 7.4).

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1.5 EpIDEMIOlOGy

.5. PrEvALENCE oF ASymPTomATIC BACTErIUrIA

In wen asptatic bacteiuia beces inceasingl cn with age. The liited data

abut health en shws that the pealence f bacteiuia als inceases with age, althughthe pealence in en is alwas lwe than f wen f the sae age 26-28 (see Table 1 andsupplementary material section S2.1.2).

Table 1: Prevalence of asymptomatic bacteriuria in adult men and women

Countr age (ers) Men (%) Women (%)

Japan26 50-59 0.6 2.8

60-69 .5 7.4

70+ 3.6 0.8

Sweden27 72 6.0 6.0

79 6.0 4.0

Sctland28 65-74 6.0 6.0

>75 7.0 7.0

.5.2 rISK FACTorS For ASymPTomATIC BACTErIUrIA

Table 2: Risk factors for asymptomatic bacteriuria

Risk ctor Eect on reence o smtomtic bcteriuri

Feale sex Inceases pealence (see Table 1).

Sexual actiit ma incease pealence (highe in aied wen than in nuns, 29see supplementary material section S2.1.1).

Cbid diabetes Inceases pealence in wen less than 65 eas f age withdiabetes f 2-6% t 7.9-7.7%.30-34

Age Inceases pealence in wen and en26-28,35-38 (see Table 1 andsupplementary material section S2.1.2).

Institutinalisatin Inceases pealence (in peple e 65 eas f age) f 6-6% t25-57% f wen9,39-42 and f-6% t 9-37% f en.40-43

Pesence f cathete 3-6% f peple acquie bacteiuia with ee da f catheteisatin.All patients with lng te cathetes hae bacteiuia.43,44

.5.3 PrEvALENCE oF SymPTomATIC BACTErIUrIA

Combined gures from nine studies show that women under 50 years of age with acute symptomssuch as dsuia, ugenc fequenc (suggesting lwe uina tact infectin) lin pain(suggesting uppe uina tact infectin) ae exteel likel t hae bacteiuia (see Table3 and supplementary material section S2.2)45-53 The pealence f sptatic bacteiuia inpegnant wen, en and catheteised patients is discussed in sectins 3., 4. and 5..

Table 3: Prevalence of bacteriuria in non-pregnant women under 50 years of age with acutesymptoms of UTI45-53

Tot numbero women

Number withbcteriuri

% withbcteriuri

lowercondence

inter (CI)

Uercondence

inter (CI)4,35 2,960 7.6% 70.2% 73.0%

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1 INTRODUCTION

1.6 STaTEMENT Of INTENT

This guideline is nt intended t be cnstued t see as a standad f edical cae.Standads f cae ae deteined n the basis f all clinical data aailable f an indiidualcase and are subject to change as scientic knowledge and technology advance and patterns of

cae ele. Adheence t guideline ecendatins will nt ensue a successful utce inee case, n shuld the be cnstued as including all ppe ethds f cae excludingthe acceptable ethds f cae aied at the sae esults. The ultiate judgeent egadinga paticula clinical pcedue teatent plan ust be ade b the apppiate healthcaepfessinal in light f the clinical data pesented b the patient and the diagnstic and teatentoptions available. It is advised, however, that signicant departures from the national guideline an lcal guidelines deied f it shuld be full dcuented in the patients case ntesat the tie the eleant decisin is taken.

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2++

2++

2++

2 Mngement o bcteri UTI in dut women

The anageent f sptatic bacteial UTI in adult nn-pegnant wen is suaised inAnnex (LUTI) and Annex 2 (UUTI).

2.1 DIaGNOSIS

Spts suggestie f acute uina tact infectin ae ne f the st cn easns fwen t isit healthcae pfessinals. Althugh the clinical encunte tpicall inles taking ahist and pefing a phsical exainatin, the diagnstic accuac f the clinical assessentf UTI eains uncetain.2,54

The pi pbabilit f bacteiuia in thewise health wen wh pesent t thei genealpactitine (GP) with spts f acute UTI is estiated at between 50-80%. 2

If dsuia and fequenc ae bth pesent, then the pbabilit f UTI is inceased t >90%and epiical teatent with antibitic is indicated.2

If aginal dischage is pesent, the pbabilit f bacteiuia falls. Altenatie diagnses such assexuall tansitted diseases (STDs) and ulaginitis, usuall due t candida, ae likel andpelic exainatin is indicated.2 rae causes include lcal aginal and ceical pathlgincluding esins and e ael cance.

C In otherwise heth women resenting with smtoms or signs o UTI, emirictretment with n ntibiotic shoud be considered.

C In women with smtoms o gin itch or dischrge, eore terntie dignosesnd consider eic emintion.

The pesence f back pain fee inceases the pbabilit f UUTI and uine cultue shuldbe cnsideed as the clinical isks assciated with teatent failue ae inceased. Inceasingbacterial resistance means that no antibiotic is sufciently reliable for empirical treatment ofUUTI.55,56

In patients pesenting with spts signs f UTI wh hae a hist f fee backpain the pssibilit f UUTI shuld be cnsideed. Epiical teatent with an antibiticshuld be stated and uine cultue pefed t guide the chice f antibitic.

2.2 NEaR paTIENT TESTING

Nea patient tests a include the appeaance f the uine saple, icscp and testing beans f dipsticks.

2.2. APPEArANCE oF UrINEUrine turbidity has been shown to have a specicity of 66.4% and sensitivity of 90.4% forpedicting sptatic bacteiuia. When exained against a bight backgund, a tubid sapleis psitie, wheeas a clea saple is negatie.57visual appeaance is pne t bsee e anda nt be a useful disciinat.

2.2.2 UrINE mICroSCoPy

There is wide variation in sensitivity (60-100%) and specicity (49-100%) of urine microscopyto predict signicant bacteriuria in symptomatic ambulatory women.58,59

Nea patient testing b icscp aises cncens abut health and safet at wk, aintenancef equipent and taining f staff which des nt justif its use.

Uine icscp shuld nt be undetaken in clinical settings in pia secnda cae.

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2++

+

2++

2 MaNaGEMENT Of BaCTERIal UTI IN aDUlT WOMEN

2.2.3 DIPSTICK TESTS

The qualit f eidence f nea patient testing with dipstick tests (eagent stip tests) wasp.2,60 The cae setting aied acss the studies, f exaple, accident and eegenc,genituina edicine and hspital inpatients. Indiidual eagent espnses wee epted ina aiable and incplete wa.

A eta-analsis f the accuac f dipstick testing t pedict UTI lked at fu categies ftests: nitite nl; leuccte estease (LE) nl; disjunctie paiing (dipstick psitie if eithe nitite LE bth ae psitie) and cnjunctie paiing (dipstick psitie nl if bth nitite and LEae psitie).60 The study found the disjunctive pair test to be signicantly more accurate thanthe LE test alne (p=0.000). 60 A uine saple psitie f dipstick tests f LE nitite is lesslikel t pedict bacteiuia than cbinatins f spts and signs, paticulal cbinatinsof conrmatory symptoms (dysuria, frequency) and absence of features that suggest alternativediagnses (aginal dischage and iitatin).2

Dipstick tests ae nl indicated f wen wh hae inial signs and spts andwhse pi pbabilit f UTI is in the inteediate ange (aund 50%). Whee nl nespt sign is pesent, a psitie dipstick test (LE nitite) is assciated with a high

pbabilit f bacteiuia (80%) and negatie tests ae assciated with uch lwe pbabilit(aund 20%).60

Negatie tests d nt exclude bacteiuia. A andised cntlled tial (rCT) f nea patienttesting in adult wen wh wee sptatic but had a negatie dipstick test shwed thatantibitics (tiethpi 300 g dail f thee das) iped spts with the edianduatin f cnstitutinal spts being educed b fu das. Althugh the pbabilit fUTI is educed t less than 20% b a negatie dipstick test, the eidence suggests that wenstill derive symptomatic benet from antibiotics, number needed to treat (NNT) of 4. 6 Fstatistical ethds see suppleenta ateial sectin S. These issues shuld be cnsideedand explained t sptatic wen with a negatie dipstick test. Clinical judgeent shuldbe used t decide whethe t btain uine f cultue inite the patient t etun if sptspesist wsen.60

B Distick tests shoud on be used to dignose bcteriuri in women with imitedsmtoms nd signs(no more than two symptoms).

Women with imited smtoms o UTI who he negtie distick urinsis (LE ornitrite) shoud be oered emiric ntibiotic tretment.

The risks and benets of empirical treatment should be discussed with the patientnd mnged ccording.

I womn remins smtomtic ter singe course o tretment, she shoud beinestigted or other otenti cuses.

No robust evidence was identied describing LE or nitrite testing in elderly, institutionalisedpatients.

In eldel patients (e 65 eas f age), diagnsis shuld be based n a full clinicalassessent, including ital signs.

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+

++

++

+

4

++

+

2.3 URINE CUlTURE

The quality of a urine sample will affect the ability to detect bacteria and conrm a diagnosisf UTI. Speciens can be diided int thse with high isk f cntainatin (clean catch idstea uine saples; mSU), lw isk (supapubic aspiate; SPA peatiel btained

urine from ureter or kidney). Standard laboratory processing of urine samples is conned toa single initial specien pe patient, which detects cnentinal aebic bacteia, nallat a alue f05 cfu/l. Thee is n bacteial cunt that can be taken as an abslute gldstandad f the diagnsis f UTI.

The criterion for the presence of signicant bacteria was established from early work comparingSPA against mSU speciens in wen suffeing eithe f acute UUTI wh hadasptatic UTI duing pegnanc. A single psitie mSU eliabl deteined the pesencef a UTI at 05 cfu/l in 80% f cases studied with tw saples iping this t 95%. 62-64

F wen expeiencing spts f uina tact infectin lwe nubes f clnforming units may also reect signicant bacteria. A study comparing SPA against MSUspeciens fund that the best diagnstic citein in wen was 02 cfu/l (sensitiit 95%,specicity 85%).65

The labat intepetatin f a uine cultue depends upn a cbinatin f facts. Theseinclude the nube f islates cultued and thei pedinance, the specien tpe, the clinicaldetails, the pesence absence f puia and the nubes f ganiss pesent. Cnentinallabat pactice in the UK detects aebic bacteia at a alue f04 cfu/l.22

2.4 aNTIBIOTIC TREaTMENT

2.4. SymPTomATIC BACTErIUrIA, LUTI

In a andised cntlled tial f nn-pegnant wen with dsuia, fequenc ugenc andpositive LE tests but no symptoms or signs of UUTI and no signicant comorbidity, 95% had105 bacteria per ml of urine. Treatment with a single dose of either cexime, co-trimoxazole

or ooxacin was equally effective.66

Anthe tial enlled nn-pegnant wen aged 5-54 with dsuia and fequenc, anddetected pyuria (method not specied) but no symptoms or signs of UUTI and no signicantcomorbidity. A three day regimen of nitrofurantoin signicantly shortened time to resolutionf spts.67

a Non-regnnt women with smtoms or signs o cute lUTI, nd either high robbiito or roen bcteriuri, shoud be treted with ntibiotics.

Thee t six das f antibitic teatent f uncplicated LUTI in wen aged 60 e isas effectie as teatent f 7-4 das. 68,69

Guidelines f the Infectius Diseases Sciet f Aeica (IDSA) and Health Ptectin

Agenc (HPA)55 ecend thee das teatent with tiethpi f LUTI. Thee is edirect evidence for three days treatment with co-trimoxazole but it is reasonable to infer thattrimethoprim is equally effective as co-trimoxazole.

Thee das f teatent with nitfuantin has been shwn t be effectie in nn-pegnantadult wen with uncplicated UTI.67 The IDSA ecends seen das teatent withnitfuantin. Thee is n diect eidence cpaing thee das nitfuantin with seendas nitfuantin.

B Non-regnnt women o n ge with smtoms or signs o cute lUTI shoud betreted with trimethorim or nitrourntoin or three ds.

Wen with enal ipaient shuld nt be teated with nitfuantin as:

an effectie cncentatin f antibitic in the uine is nt achieablea txic cncentatin f antibitic can ccu in the plasa.

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4

+

4

++

4

+


Uina pH affects the actiit f nitfuantin. Nitfuantin is effectie against E. coli ata cncentatin f 00 g/l as the cncentatin f antibitic geatl exceeds the iniuinhibit cncentatin (mIC lwest cncentatin f antibitic that egulal inhibits gwthf the bacteiu in it). The mIC inceases twent fld f pH5.5 t pH8.0 (see Table 4) 70

and at pH8.0 bacteial gwth ccus with 25 g/l f nitfuantin. A siila situatin is seen

with P. mirabilis althugh it has a highe mIC than st stains fE. coli.

D Women with lUTI, who re rescribed nitrourntoin, shoud be dised not to tkekinising gents (such as potassium citrate).

Table 4: The effect of pH on the MIC of nitrofurantoin on E. coli and P. mirabilis 70

Minimum inhibitor concentrtion o nitrourntoin (mg/)

H 5.5 H 7.0 H 8.0

E. coli 2.5 0.0 50.0

P. mirabilis 5.0 50.0 00.0

Resistance is increasing to all of the antibiotics used to treat UTI and there is no clear rst choicealtenatie t tiethpi nitfuantin.

B ptients who do not resond to trimethorim or nitrourntoin shoud he urine tkenor cuture to guide chnge o ntibiotic.

Quinlnes shuld nt be used f epiical teatent f LUTI.

2.4.2 SymPTomATIC BACTErIUrIA, UUTI

Uppe uina tact infectin can be accpanied b bacteaeia, aking it a life theateninginfectin.

Nitfuantin is an ineffectie teatent f UUTI because it des nt achiee effectiecncentatins in the bld. resistance t tiethpi is t cn t ecend thisdug f epiical teatent f a life theatening infectin.55

One week of treatment with ciprooxacin is as effective as two weeks treatment with co-trimoxazole.7

a Non-regnnt women with smtoms or signs o cute UUTI shoud be treted withciprooxacin for seven days.

As resistance to quinolones is increasing, the HPA suggests that patients started on ciprooxacinshuld hae uine sent f cultue and that patients shuld be aditted t hspital if thee isn espnse t teatent within 24 hus.55

D Urine shoud be tken or cuture beore immedite emiric tretment is strted ndtretment chnged i there is n indequte resonse to the ntibiotic.

Alternative treatments include co-trimoxazole, pivmecillinam, co-amoxiclav andcexime.

one week f teatent with piecillina is less effectie than tw weeks teatent.

Evidence about the effectiveness of less than two weeks treatment with co-amoxiclav, ceximeand co-trimoxazole is lacking.

Patients shuld be aditted t hspital if ssteic spts appea.

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++

+

+

+

++

++

2.4.3 ASymPTomATIC BACTErIUrIA

There is no evidence that treatment of asymptomatic bacteriuria in adult women signicantlyeduces the isk f sptatic episdes, eithe in wen withut cbidit withundeling diabetes pia bilia cihsis.20,72,73

In women with diabetes, antibiotic treatment of asymptomatic bacteriuria signicantly increasesthe risk of adverse events without signicant clinical benet, such as shortening duration ofspts.20

a Non-regnnt women with smtomtic bcteriuri shoud not receie ntibiotictretment.

In eldel wen (e 65 eas f age), teatent f asptatic bacteiuia des nteduce talit significantl educe sptatic episdes.9,74 Antibitic teatentsignicantly increases the risk of adverse events, such as rashes and gastrointestinal symptoms(number needed to harm; NNTH 3; condence interval; CI 2 10. For statistical methods seesupplementary material section S1).19

a Eder women (over 65 years of age) with smtomtic bcteriuri shoud not receientibiotic tretment.

2.5 NON-aNTIBIOTIC TREaTMENT

recuent UTIs ae a cn and debilitating pble. repeated plnged teatent withantibitics is likel t cntibute t the pble f antiicbial esistance. Effectie altenatiest antibitics hae the ptential t ipe public health.

Altenaties t antibitics ffe an pptunit f patients t self anage the peentin fecuent UTIs, which a ipe thei qualit f life.

2.5. CrANBErry ProDUCTS

Canbe pducts (juice, tablets, capsules) ae nt egulated and the cncentatin f actieingredients is not known. Concentrations may also uctuate between batches of the samepduct.

mst f the high stength pepaatins (tablet/capsule f) in the UK qute 200 g f canbeextact, equialent t 5,000 g f fesh canbeies (25: cncentatin).

Thee is gd eidence t suppt the effectieness f canbe pducts f peentingsptatic UTI in adult wen with a hist f ecuent UTI (NNT t peent nesptatic infectin in six nths 6.4, CI 3.7-25.9.75For statistical methods see supplementarymaterial section S1).The effectieness f canbe pducts in the patients is nt knwn.The ptial dse and ute f adinistatin has nt been addessed.

Thee has been n diect cpaisn between canbe pducts and antibitic pphlaxis fpeenting ecuent UTI. The NNTs f canbe pducts ae highe than f nightl antibiticpphlaxis f six nths,76 pstcital antibitic pphlaxis f six nths.77

a Women with recurrent UTI shoud be dised to tke crnberr roducts to reducethe requenc o recurrence.

Wen shuld be adised that canbe capsules a be e cnenient than juiceand that high stength capsules a be st effectie.

Thee is n eidence t suppt the effectieness f canbe pducts f teating sptaticepisdes f UTI.78

N seius adese effects t canbe pducts wee epted, althugh the high dp ut

ate in clinical tials suggests that lng te teatent with canbe pducts a nt be welltleated. The echanis f actin f canbe pducts is unclea.

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B 2003 the Cittee n Safet f medicines (CSm) eceied 2 epts f suspectedinteactins inling wafain and canbe juice. In eight f these cases thee was an inceasein International Normalized Ratio (INR) of the prothrombin time.79

In octbe 2004 the CSm adised that patients taking wafain shuld aid taking canbeproducts unless the health benets are considered to outweigh any risks.

D Patients taking warfarin should avoid taking cranberry products unless the health benetsre considered to outweigh n risks.

Inceased edical supeisin and INr niting shuld be cnsideed f an patienttaking wafain with a egula intake f canbe pducts.

one clinical tial addessed the cst effectieness f canbe pducts f peenting UTI innn-pegnant wen (see supplementarymaterialsection S4.1).80

Wen with ecuent UTI shuld be adised that canbe pducts ae nt aailablen the NHS, but ae eadil aailable f phaacies, health fd shps, hebalistsand supeakets.

2.5.2 mETHENAmINE HIPPUrATE

A systematic review of methenamine hippurate identied considerable heterogeneity betweentials and cncluded that intepetatin f these data shuld be dne cautiusl, due t thesmall sample sizes and poor methodology of the studies involved.8

methenaine hippuate a be effectie at peenting UTI in patients withut knwn uppeenal tact abnalities. Adese eents caused b ethenaine wee ae.8

Tw tials shw that ethenaine is less effectie at peenting sptatic UTI than nightlpphlaxis with eithe nitfuantin tiethpi.82

B Methenmine hiurte m be used to reent smtomtic UTI in tients without

known uer ren trct bnormities.

2.5.3 oESTroGEN

Genituina atph a incease the isk f bacteiuia and the le f estgen theap ineducing the isk f sptatic UTI has been inestigated.

Evidence for the efcacy of oestrogen in comparison with placebo is inconsistent. There is goodeidence that this teatent is less effectie than antibitic pphlaxis.83 A tial cpaingnine nths teatent with al nitfuantin esus estil pessaies in pst enpausalwomen reported a signicantly reduced risk of symptomatic UTI with nitrofurantoin.83 Twssteatic eiews f aginal estgen adinistatin bth epted cnsideable unexplainedheterogeneity of results with some studies reporting signicant reduction in risk of recurrent

UTI while others report no signicant effect or even a trend towards harmful effects.84,85

a Oestrogens re not recommended or routine reention o recurrent UTI inostmenous women.

Teatent with estgens a be apppiate f se wen.

2.5.4 ANALGESIA

N eidence was fund f the use f analgesics f sptatic elief f uncplicatedUTIs.

Wen with uncplicated UTIs a wish t use e the cunte eedies t t andeliee spts.

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2.6 REfERRal

recuent UTI is a cn easn f efeal f wen t ulgists but n eidence wasfund descibing citeia f efeal abut which inestigatins t undetake.

Thee is gd eidence t suppt peentin f ecuent bacteial UTI in wen with

antibitics82 and canbe pducts (see section 2.5.1). These stategies shuld be expledbefe efeal f specialist inestigatin.

2.7 COST-EffECTIvE TREaTMENT IN pRIMaRy CaRE

Thee ae tw ke issues in the ecnic ealuatin f stategies f anagingsuspected UTI:

Antibitics accunt f nl 3% f the ttal pia cae csts f patients with lweuina tact infectin and nl 2-8% f the csts f patients with uppe uina tactinfectin. visits t the GP accunt f the ajit f csts.86

manageent stategies that iniise healthcae csts a tansfe csts t the patient.A decisin analsis f anageent stategies f acute uncplicated lwe uina tact

infectin in pia cae cncluded that epiic antibitic teatent withut uine cultuewas the pefeed stateg.87 This stateg, hwee, plngs the aeage duatin fspts because it takes lnge t identif wen whse infectins ae caused b antibiticesistant bacteia.86

2.7. GP CoNSULTATIoN

Thee decisin analses cpaing epiic antibitic teatent with withut uine cultuecncluded that taking a uine cultue utinel f all patients will cst e but is likel teduce spt das b between 0.04 and 0.32 das.87-89This is achieed thugh a cbinatinf educing isk f adese effects, b stpping teatent if the cultue is negatie and ealidentication of infections caused by antibiotic resistant bacteria. There is considerable variationin the estiates f the inceental cst effectieness f uine cultue.

one stud estiated the cst pe spt da peented as 25.89The estiated cst pe QALy(qualit adjusted life ea) gained was 25,000.89 It is unlikel that utine cultue f uine willbe cst effectie unless the pealence f bacteiuia in sptatic wen is

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3 MaNaGEMENT Of BaCTERIal UTI IN pREGNaNT WOMEN

3 Mngement o bcteri UTI in regnnt

women

The anageent f sptatic bacteial UTI in pegnant wen is suaised in Annex 3.

3.1 DIaGNOSIS

3.. SymPTomATIC BACTErIUrIA

Symptomatic bacteriuria occurs in 1720% of pregnancies.25 Thee ae pathphsilgicalgunds t suppt a link t pe-labu, peatue uptue f ebanes (PProm) and pe-telabu.92 Unteated uppe uina tact infectin in pegnanc als caies well dcuentedisks f bidit, and ael, talit t the pegnant wan.92

Two to nine percent of pregnant women are bacteriuric in the rst trimester, a similar prevalencet nn-pegnant wen f the sae age.2,93 10-30% of women with bacteriuria in the rsttieste deelp uppe uina tact infectin in the secnd thid tieste.

3..2 THE GoLD STANDArD For DIAGNoSIS IN PrEGNANCy

The gld standad ethd f diagnsis f bacteiuia is cultue f uine btained b supapubicneedle aspiatin. A cathete specien f uine is less eliable than supapubic needle aspiatin,althugh e eliable than tw mSU saples.94man studies ept using single mSU saples.In women with acute symptoms of UTI the presence of 105 bacteia pe l f a single mSUsample has about 80% specicity in comparison with the gold standard while a single specimen(mSU CSU) has a false psitie ate f up t 40% f diagnsis f asptatic bacteiuiain pegnanc(see supplementary material section S3.1).94,95

3..3 NEAr PATIENT TESTING

A ssteatic eiew f studies cpaing uine cultue with nea patient tests epted thatn studies used the gld standad f diagnsis f asptatic bacteiuia in pegnanc.92 Inthe nl stud t establish the diagnsis f bacteiuia with tw cnsecutie uine saples atthe rst antenatal visit, 8.3% of pregnant women had asymptomatic bacteriuria while 12.1%had a positive dipstick test with sensitivity and specicity of 92.0% and 95.0%.96 Fie falsenegatie dipstick tests wee f patients wh had bacteiuia with ga-psitie bacteia (theegup B steptccci and tw enteccci) which d nt cause uppe UTI, but ae iplicatedin causing peatue delie.

Dipstick testing (LE or nitrate) is not sufciently sensitive to be used as a screening test. Urinecultue shuld be the inestigatin f chice.

a Standard quantitative urine culture should be performed routinely at rst antenatalisit.

a The presence of bacteriuria in urine should be conrmed with a second urinecuture.

a Dipstick testing should not be used to screen for bacterial UTI at rst or subsequentntent isits.

Dipsticks t test nl f pteinuia and the pesence f glucse in the uine shuld beused for screening at the rst and subsequent antenatal visits as a more cost-effectivealtenatie t ulti-eagent dipsticks that detect the pesence f nitite, leuccte esteaseand bld in additin t ptein and glucse.

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rCTs addessing teatent f UTI in pegnant wen fequentl include patients withasptatic bacteiuia and sptatic bacteiuia, uppe and lwe UTI. Thee is ftenpoor denition of long term outcomes.

3.2. SymPTomATIC BACTErIUrIA

In pegnant wen with spts f bth UUTI and LUTI thee is eidence that a ange fantibitic egiens achiee cue.97-0There is no clear evidence of benet by reduction of longte enal daage pe-te labu as st studies ae hetegeneus with espect t LUTIand UUTI and did not specically address these outcomes.

Thee is n clea eidence that an paticula antibitic dsage egien has an adantage.25

None of the studies addressed the risk of treatment, but apart from the hazards of adverseeactins anaphlaxis caused b an inapppiate antibitic, the isks ae likel t be sallcompared to the proven benet.25

B pregnnt women with smtomtic UTI shoud be treted with n ntibiotic.

A single uine saple shuld be taken f cultue befe epiic antibitic teatent isstated.

Nitfuantin is nt an effectie teatent f UUTI because it des nt achiee effectiecncentatins in the bld.55

refe t lcal guidance f the safest, cheapest, effectie antibitic f pegnantwen.

Gien se antibitics ae txic in pegnanc, efe t the Bitish Natinal Fula(BNF) f cntaindicatins.

Gien the isks f sptatic bacteiuia in pegnanc, a uine cultue shuld bepefed seen das afte cpletin f antibitic teatent as a test f cue.


A ssteatic eiew cncluded that antibitic teatent f asptatic bacteiuia in pegnanceduces the isk f uppe uina tact infectin, pe-te delie and lw bith weight babies(see supplementary material section S3.1).02

mst f the tials in this eiew wee f cntinuus antibitic theap f diagnsis fasptatic bacteiuia until the end f pegnanc.02 This is nt standad cae in the NHS inSctland, whee asptatic bacteiuia is usuall teated with a sht cuse (3-7 das) fantibitics. The eidence suggests that 3-7 das teatent is as effectie as cntinuus antibitictheap.02

There is insufcient evidence to compare the effectiveness of single dose treatment with a 3-7da cuse03 a thee da with a seen da cuse.

a asmtomtic bcteriuri detected during regnnc shoud be treted with nntibiotic.

refe t lcal guidance f the safest, cheapest, effectie antibitic f pegnantwen.

Thee is n need f epiical teatent in this gup f patients as all wen hae uine cultuebefe teatent.

The benets and risks of antibiotic treatment of symptomatic bacteriuria in pregnant womenappl equall t pegnant wen with asptatic bacteiuia.

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10 not repeated

& (57 not)

conrmed

Treated

bacteriuric:2.8% UUTI

Eradicationn=53 (75%)

Recurrencen=6 (8%)

Untreated

bacteriuric:28% UUTI

n=1575

Non-

bacteriuric:0.31% UUTI

UUTI (No) 2 0 0 2 5

Conrmed

n=77

Failuren=11 (16%)

Not treated

n=7

Treated

n=70

Negativen=1508

Positiven=144

Screeningn=1,652

3.3 SCREENING DURING pREGNaNCy

A lage bseatinal stud denstated the effectieness f a sceening pgaebased on diagnosis of asymptomatic bacteriuria with two urine cultures in the rst trimester(see Figure 2).95

Figure 2: Frequency of asymptomatic bacteriuria, response to treatment and subsequentdevelopment of upper urinary tract infection. Adapted from Gratacos et al 1994. 95

C Women with bacteriuria conrmed by a second urine culture should be treated andhe reet urine cuture t ech ntent isit unti deier.

Women who do not have bacteriuria in the rst trimester should not have repeat urinecultues.

Thee is incnsistent eidence egading the cst effectieness f sceening pegnant wenf asptatic bacteiuia (see supplementary materialsection S4.2).92,95,04-06

3 MaNaGEMENT Of BaCTERIal UTI IN pREGNaNT WOMEN

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4 Mngement o bcteri UTI in dut men

The anageent f sptatic bacteial UTI in en is suaised in Annex 4.

4.1 DIaGNOSIS

Uina tact infectins in en ae geneall iewed as cplicated because the esult fan anatic functinal anal instuentatin f the genituina tact.07

Cnditins like pstatitis, chladial infectin and epididitis shuld be cnsideed in thediffeential diagnsis f en with acute dsuia fequenc and apppiate diagnstic testsshuld be cnsideed.

Thee is n eidence t suggest the best ethd f diagnsing bacteial UTI in en. Eidencef studies f wen cannt be extaplated.

Uine icscp shuld nt be undetaken in clinical settings in pia secnda

cae.

In all en with spts f UTI a uine saple shuld be taken f cultue.

In patients with a hist f fee back pain the pssibilit f UUTI shuld be cnsideedand uine cultue shuld guide the chice f antibitic.

obtaining a clean-catch saple f uine in en is easie than in wen and a cln cuntof 103 cfu/ml may be sufcient to diagnose UTI in a man with signs and symptoms as longas 80% f the gwth is f ne ganis.08

A threshold of 103 cfu/l f diagnsing UTI is belw the theshld f detectin f secnl used labat ethds, which nl detect between 04 and 05 cfu/l.

methds f detecting lwe leels f bacteia in uine saples shuld be deelpedand ipleented.

The culture of expressed prostatic secretion and semen has no clinical benet and is no longercn pactice.09


No high quality evidence for the treatment of bacterial UTI in men was identied.

At least 50% f en with ecuent UTI0 and e 90% f en with febile UTI haepstate inleent, which a lead t cplicatins such as pstatic abscess chnicbacteial pstatitis.

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4 MaNaGEMENT Of BaCTERIal UTI IN aDUlT MEN


Given the difculty of excluding prostatitis in men with symptoms suggestive of UTI, the currentstandad f cae is a tw week cuse f antibitic likel t be effectie f pstatitis. Due ttheir ability to penetrate prostatic uid, quinolones rather than nitrofurantoin or cephalosporinsae indicated. A tw week cuse f teatent was shwn t be as effectie as a fu week cusef patients with febile UTI.

C Bcteri UTI in men shoud be treted emiric with two week course oquinoone.

Altenatie teatents include tiethpi, dexccline and c-axicla.

Eidence abut the effectieness f teatent with tiethpi, dexccline and c-axiclais lacking.

Patients wh d nt espnd t antibitic teatent shuld be inestigated fpstatitis.


In eldel en (e 65 eas f age), teatent f asptatic bacteiuia des nt educemortality or signicantly reduce symptomatic episodes.9,74 Antibiotic treatment signicantlyinceases the isk f adese eents, such as ashes and gastintestinal spts (NNTH 3;CI 2 - 0.9 For statistical methods see supplementary material section S1).

a Eder men (over 65 years of age) with smtomtic bcteriuri shoud not receientibiotic tretment.

4.3 REfERRal

recuent UTI is a cn easn f efeal t ulgists. Thee ae n tials abut theeffectieness f antibitics canbe pducts f peenting ecuent UTI in en. Thee aen eidence based guidelines f efeal abut which inestigatins t undetake.

Expet pinin suggests that en shuld be inestigated if the hae spts f uppe uinatact infectin, fail t espnd t apppiate antibitics hae ecuent UTI (tw eepisdes in thee nths).2

D Men shoud be reerred or uroogic inestigtion i the he smtoms o uerurinr trct inection, i to resond to rorite ntibiotics or he recurrentUTI.

Urodynamic techniques, such as pressure/ow videocystography revealed signicant underlyinglower urinary tract abnormalities (mainly involving bladder outow obstruction) in 80% of adult

ales pesenting with siple ecuent uina tact infectins, but withut pi uinaspts disdes.3

renal and pst-id bladde ultasund and a kidnes, uetes and bladde (KUB) plainX-a f the abden a be used t lk f eleant abnalities.

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5 Mngement o bcteri UTI in tients with

ctheters

5.1 DIaGNOSIS

Between 2% and 7% f patients with indwelling uethal cathetes acquie bacteiuia each da,een with the applicatin f best pactice f insetin and cae f the cathete.4 All patientswith a lng te indwelling cathete ae bacteiuic, ften with tw e ganiss.5,6

The catheter provides a focus for bacterial biolm formation. The majority of data comes fromstudies in eldel patients with lng te indwelling cathetes. Thee is n eidence t suggestthat the pealence in unge sht lng te catheteised patients, such as thse withultiple sclesis spinal cd inju, is an diffeent.7

Duatin f catheteisatin is stngl assciated with the isk f infectin. The lnge the catheteis in place the geate the likelihd f infectin.8 Inteittent catheteisatin is assciatedwith a lwe incidence f asptatic bacteiuia.7

The pesence f a sht lng te indwelling cathete is assciated with a geate incidencef fee f uina tact igin. Fee withut an lcalising signs is a cn ccuencein catheteised patients and uina tact infectin accunts f abut a thid f theseepisdes.7,9,20 In patients with sht lng te cathetes fee is assciated with a higheccuence f lcal uina tact and ssteic cplicatins such as bacteaeia.7,9,2,22

Althugh talit appeas t be highe in patients with lng te indwelling cathetes, theeis n causatie link with catheteisatin uina tact infectin.23

Uina tact infectin is the st cn hspital acquied infectin in the UK, accuntingf 23% f all infectins and the ajit f these ae assciated with cathetes. 24 Catheteassciated UTI is the suce f 8% f hspital acquied bacteaeia.25

In catheteised patients the cn ccuence f fee, the cnsistent pesence f bacteiuia,and the aiable pesence f a bad ange f the assciated clinical anifestatins (new nsetcnfusin, enal angle tendeness supapubic pain, chills/igs etc) akes the diagnsis fsymptomatic UTI difcult.24,26,27

Cuent suggested citeia f diagnsing UTI in catheteised patients ae nt eidence based.26

A clinical algith f suspected UTI in catheteised and nn-catheteised esidents in nusinghes suggests that the pesence f ne f the fllwing spts shuld stiulate antibitictheap:28

new cstetebal tendeness

igs

new nset deliiu

fee geate than 37.9C .5C abe baseline n tw ccasins duing 2 hus.

No particular constellation of symptoms or clinical signs, for example, fever or chills, new ank supapubic tendeness, change in chaacte f uine wsening f ental functinalstatus, appeas t incease the likelihd f a sptatic uina tact infectin in catheteisedpatients. The psitie pedictie alue (PPv) f bacteiuia f febile uina tact infectinidentied by clinical criteria has been measured as 11%.9The st cn spt, fee,is a non-specic presenting symptom in symptomatic urinary tract infection.7,9,2 The absencef fee des nt appea t exclude uina tact infectin.

D Cinic smtoms or signs re not recommended or redicting the ikeihood osmtomtic UTI in ctheterised tients.

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5 MaNaGEMENT Of BaCTERIal UTI IN paTIENTS WITH CaTHETERS

In catheteised patients wh pesent with fee:

lk f assciated lcalising (lin supapubic tendeness) ssteic featues

exclude the ptential suces f infectin

send ff an apppiatel taken uine saple f cultue t deteine the infecting

ganis and susceptibilitiescnside antibitic theap taking int accunt the seeit f the pesentatin andan cbid facts.

Uine saples shuld nl be sent f labat cultue if the patient has clinical sepsis,nt because the appeaance sell f the uine suggests that bacteiuia is pesent.

5.2 NEaR paTIENT TESTING

5.2. UrINE mICroSCoPy

The alue f icscp f uine saples f catheteised patients is liited in diagnsingsptatic UTI as all patients will hae bacteiuia. Thee is n elatinship between the leel

f puia and infectin in patients with indwelling cathetes, since the pesence f the catheteinaiabl induces puia withut the pesence f infectin.29

C lbortor microsco shoud not be used to dignose UTI in ctheterised tients.

5.2.2 DIPSTICK TESTS

Sptatic UTI cannt be diffeentiated f asptatic bacteiuia n the basis f uineanalsis with dipstick tests. Puia is cn in catheteised patients and its leel has npedictie alue.29,30

Thee is n eidence t suggest that detecting puia b uine analsis is f an aluein diffeentiating sptatic UTI f asptatic UTI (bacteiuia) in catheteised

patients.29-3

B Distick testing shoud not be used to dignose UTI in ctheterised tients.

5.3 aNTIBIOTIC pROpHylaxIS TO pREvENT CaTHETER RElaTED UTI

A eta-analsis f antiicbial pphlaxis f UTI in catheteised patients with spinal cddsfunctin included patients with acute (less than 90 das afte spinal cd inju) and nn-acute (geate than 90 das afte spinal cd inju) spinal cd dsfunctin and neugenicbladde.32 The ajit f patients had inteittent catheteisatin. Antiicbial pphlaxisdid not signicantly decrease symptomatic infections. Prophylaxis was associated with thereduction of asymptomatic bacteriuria among acute patients (p

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Symptoms that may suggest UTI in patients with catheters include fever, ank or suprapubic

discft, change in iding pattens, nausea, iting, alaise cnfusin.

26,28

No studies were identied that evaluated the prognostic value of individual or combinations ofsigns spts, with the exceptin f fee. The ccuence f febile episdes in patientswith lng te indwelling cathetes is assciated with the deelpent f abnalities suchas calculi and cplicatins in the kidne.33

Eidence f antibitic teatent f sptatic UUTI in nn-pegnant wen is applicablet catheteised patients with sptatic UTI and has been extaplated t gie the fllwinggd pactice pints (see section 2.4.2).

Catheteised patients with spts signs f acute UUTI shuld be teated withciprooxacin or co-amoxiclav for seven days.

Patients shuld be aditted t hspital if ssteic spts, such as fee, igs, chills,iting cnfusin appea.

Patients with lng te indwelling cathetes, wh hae the cathete changed befe statingantibitic teatent f sptatic UTI, hae a deceased duatin f fee, ae e likel tbe cued iped afte thee das and ae less likel t hae ecuence f acute sptswithin ne nth f teatent.34

B ptients with ong term indweing ctheters shoud he the ctheter chnged beorestrting ntibiotic tretment or smtomtic UTI.

Uine shuld be taken f cultue befe the cathete is changed and teatent is stated.Teatent shuld be changed if the ganis is esistant t the chsen antibitic.


Single dse antibitic teatent f wen with asptatic bacteiuia afte sht tecatheterisation signicantly reduces the risk of symptomatic episodes in the subsequenttwo weeks (number needed to benet; NNTB 7, CI 4-25.20 For statistical methods seesupplementary material section S1). Gien that the pealence f bacteiuia shuld be

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5.5 MaNaGEMENT Of BaCTERIal UTI IN paTIENTS WITH URINaRy STOMaS

Thee is n eidence t suppt the anageent f bacteial UTI in patients with uina stasbut issues that affect catheteised patients ae likel t appl. The pealence f bacteiuia islikel t be 00% in patients with uina stas. Cultue f uine f patients with spts

suggestie f UTI shuld nl be caied ut t test the susceptibilit f ptential pathgens. Uine saples shuld nl be sent f labat cultue if the patient has clinical sepsis,

nt because the appeaance sell f the uine suggests that bacteiuia is pesent.

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6 Inormtion or discussion with tients nd

crers

6.1 NOTES fOR DISCUSSION WITH paTIENTS aND CaRERS

The following points were drawn up by the guideline development group to reect the issuesst likel t be f cncen t patients and caes fllwing a diagnsis f suspected bacteialuina tact infectin in adult nn-pegnant wen. These pints ae pided f use b healthpfessinals when discussing bacteial UTI with patients and in guiding the pductin f lcallpduced patient infatin ateials.

6.2 KEy ISSUES

Thee is a need t balance the accuac f a diagnsis with the speed in which esults(and teatent, if necessa) ae delieed t the patient. Patients get e fustated waitingfor ofcial results to merit treatment of a painful, uncomfortable situation that is preventingnal dail actiities.

man pfessinals ae inteested in the accuac f the assessent, in de nt t pescibeinapppiate unnecessa teatent, which can plng spts.

Patients ae awae that dipsticks ae nt alwas accuate and that waiting f labatanalsis can dela tie t diagnsis and teatent.

Patients knw that facts such as thei d and cunicatin f discft als aeiptant in signalling infectin.

Patients peceie that the best healthcae pfessinals ae thse wh cnside the factsthat the patient nds signal infection.

man patients want infatin and clea explanatin f questins such as:

Why doesnt this treatment seem to be working?

How long until I feel better?

Can something alleviate my symptoms (and pain!) in the meantime, or at least ensure a level

of comfort so that I can resume normal daily activities (for example, go to work, sleep at

night)?

What could happen if I dont comply fully (for example, if I forget to take the full course of

treatment)?

Will this drug react/interact with any other drugs/medicines/herbal medicines I am taking?

6.3 GENERal aDvICE

Healthcae pfessinals shuld ffe:infatin n canbeies. Patients shuld be adised that futhe eseach is equied tdeteine the best wa t take canbeies, f exaple, juice, tablets, a cbinatin;in what cncentatin; utinel peentatiel; and hw ften (see section 2.5.1).

adice n cplicated esus uncplicated infectins. The distinctin between a3-da esus a 7-da cuse f pills and the easns f using ne the the shuld alsbe explained t the patient. These issues culd affect cncdance.

cntaceptin adice. This and the le f sexual actiit is a citical issue f wen, andne which a affect cncdance. This issue shuld be explicitl dealt with b healthcaepfessinals pescibing and dispensing teatent.

a einde t patients and caes that the pesence f bacteiuia des nt alwas indicatedisease. Especiall in eldel patients, asptatic bacteiuia is a nal cnditin and

shuld nt be teated with antibitics.

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6 INfORMaTION fOR DISCUSSION WITH paTIENTS aND CaRERS

Gien that thee is n cnclusie assciatin between lifestle facts, such as diet, hdatin,clthing, tileting actiit and sexual actiit, and susceptibilit t bacteial UTI in adult,nn-pegnant wen, thee is n eidence t suppt healthcae pfessinals giing utineadice t patients abut lifestle facts.40-43 Thee a be a link between secnd UTI andsexual actiit.40

rutine adice abut adpting discntinuing an paticula lifestle facts shuldnt be ffeed t patients with bacteial UTI.

F an indiidual with ecuent and/ cplicated uina tact infectin, healthcaepfessinals a wish t discuss the featues f the patients wn situatin which apaticulal cntibute t the pble.

6.4 SOURCES Of fURTHER INfORMaTION fOR paTIENTS aND CaRERS

age Concern Scotnd3 rse Steet, Edinbugh EH2 3DT

Tel: 03 220 3345 Feephne infatin line: 0800 00 99 66Website: www.agecncensctland.g.uk

assocition or Continence adicem Ji Tance, Chaian ACA Sctland, Bdes Pia Cae NHS TustNusing Seices, Dingletn Hspital, melse, Selkikshie TD6 9HNTel: 0896 750027 Fax: 0896 75949

A natinal ganisatin wking twads aising standads f cntinence cae with anpfessinal ebes ffeing adice and teatent.

Bdder pin Sndrome assocition54 Sutheland rad, Beledee, Kent DA7 6JrTel: 0208 30 8729

Website: www.b-p-s-a.g.uk

Pides infatin and suppt t suffees f bladde pain sndes (including intestitialcstitis and the elated disdes/sndes).

Continence foundtion307 Hattn Squae, 6 Baldwins Gadens, Lndn ECN 7rJTel: 020 7404 6875 Helpline: 020 783 983 Fax: 020 7404 6876Eail: [email protected] Website: www.cntinence-fundatin.g.uk

offes expet adice t peple with bladde and bwel pbles, thei caes and pfessinalsin the eld. The nurses who run the helpline also have details of all incontinence advice servicesand f all pducts n the UK aket.

Cstitis nd Oerctie Bdder foundtion76 High Steet, Stn Statfd, Buckinghashie mK AHTel: 090 856 969Website: www.cbfundatin.g

Provides information, leaets and support to people with all forms of lower urinary tract infectionand eactie bladdes.

fmi pnning nd Reroductie Heth CreThe Sandfd Initiatie, 6 Sandfd Place, Sauchiehall Steet, Glasgw G3 7NBTel: 04 2 8600

fmi pnning assocition ScotndUnit 0, Fihill Business Cente, 76 Fihill rad, Glasgw G20 7BATel: 04 576 5088 Helpline: 04 576 5088(mnda t Thusda 9a - 5p, Fida 9a - 4.30p)

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Incontct (Natinal Actin n Incntinence)ms Cath mcKeell, Pject manage (Sctland), 3 Bwnshill Aenue,Catbidge, Lanakshie mL5 5JFTel: 0870 770 3248 Fax 0870 770 3248Eail: [email protected] Website: www.incntact.g

Ais t pide infatin and suppt t peple affected b bladde and bwel cntinenceproblems, to increase awareness about incontinence difculties and encourage those affectedt seek pfessinal help.

Ntion Chidbirth TrustAlexanda Huse, oldha Teace, Actn, Lndn W3 6NHTel: 0870 7703236 Enqui Line: 0870 444 8707 Fax: 0870 770 3237Eail: [email protected] Website: www.nctpegnancandbabcae.c

Ntion Kidne federtionHelpline: 0845 60 02 09

A chait un b kidne patients f kidne patients, it pides patient suppt seices tpatients and thei failies.

NHS24Tel: 0854 24 24 24 Textphne: 800 0854 24 24 24Website: www.nhs24.c

NHS 24 is a nurse-led helpline providing condential healthcare advice and information.

pRODIGyWebsite: www.pdig.nhs.uk

A suce f eidence based clinical knwledge abut the cn cnditins and sptsmanaged by primary healthcare professionals. Patient information leaets form an integral part

f ProDIGy.

Urostom associtionHazel Pixley, National Secretary, Central Ofce, 18 Foxglove Avenue, Uttoxeter,Staffdshie ST4 8UNTel: 0870 770 793 Fax: 0870 770 7932Eail: [email protected] Website: www.uagbi.g

Womens Heth Concern ltd.Whitehall Huse, 4 Whitehall, Lndn SWA 2ByTel: 020 745 377Eail: [email protected] Website: www.wens-health-cncen.g

Womens Heth52 Feathestne Steet, Lndn ECy 8rTHelpline: 020 7251 6333 (9.30am 1.30pm weekdays) Fax: 020 7250 4152Eail: [email protected] [email protected]: www.wenshealthlndn.g.uk

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7 RECOMMENDaTIONS fOR IMplEMENTaTION, aUDIT, SURvEIllaNCE aND RESEaRCH

7 Recommendtions or imementtion, udit,

sureince nd reserch

7.1 lOCal IMplEMENTaTION

Ipleentatin f natinal clinical guidelines is the espnsibilit f lcal NHS ganisatinsand is an essential pat f clinical genance. It is acknwledged that nt ee guideline canbe ipleented iediatel n publicatin, but echaniss shuld be in place t ensue thatthe cae pided is eiewed against the guideline ecendatins and the easns f andiffeences assessed and, whee apppiate, addessed. These discussins shuld inle bthclinical staff and anageent. Lcal aangeents a then be ade t ipleent the natinalguideline in indiidual hspitals, units and geneal pactices, and t nit cpliance. Thismay be done by a variety of means including patient-specic reminders, continuing educationand taining, and clinical audit. Ipleenting the new geneal pactice cntact will pidepptunities t intduce such eleents f gd pactice.

7.2 KEy aREaS fOR aUDIT

7.2. KEy ArEAS For AUDIT IN PrImAry CArE

The anageent f patients with acute uina spts shuld be audited against theapppiate algith (see Annexes 1 to 4).

7.2.2 KEy ArEAS For AUDIT IN SECoNDAry CArE

Audit f clinical eidence f infectin in patients with lng te cathetes wh hae beenteated with antibitics had cathete uine saples sent f cultue.

Audit f eldel patients (tpicall cnfused, with a cugh, wh ae psitie f nitite in

the uine) teated with augentin equialent and fuseide (s called eldel cailfusegien) with n dcuented eidence f spts f UUTI LUTI.

7.3 IMplEMENTaTION aND aUDIT Of THE RECOMMENDaTIONS

7.3. mANAGEmENT oF BACTErIAL UTI IN ADULT WomEN

Recommendtion Imementtion or udit

2. C In otherwise heth women resentingwith smtoms or signs o UTI, emirictretment with n ntibiotic shoud beconsidered.

Ipleentatin f cae pathwas in

pia and secnda cae includinginiu data t be ecded inassessing a wan with spts fLUTI.

Audit f pactice against cae pathwa.

2. C In women with smtoms o gin itch ordischrge, eore terntie dignoses ndconsider eic emintion.

2. In patients pesenting with spts signs f UTI wh hae a hist f fee back pain the pssibilit f UUTI shuldbe cnsideed. Epiical teatent with anantibitic shuld be stated and uine cultuepefed t guide the chice f antibitic.

2.2.2 Uine icscp shuld nt be undetakenin clinical settings in pia secnda

cae.

Eninental infectin cntl auditsin pia and secnda cae shuld

ensue that uine icscp is ntbeing undetaken.

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2.2.3 B Distick tests shoud on be used todignose bcteriuri in women with imitedsmtoms nd signs (no more thn two

smtoms).

Ipleentatin f cae pathwas inpia and secnda cae includinginiu data t be ecded inassessing a wan with spts fLUTI.

Audit f pactice against cae pathwa

2.2.3 B Women with imited smtoms o UTI whohe negtie distick urinsis (lE ornitrite) shoud be oered emiric ntibiotictretment.

2.2.3 B The risks and benets of empirical treatmentshoud be discussed with the tient ndmnged ccording.

2.2.3 B I womn remins smtomtic ter singe course o tretment, she shoud beinestigted or other otenti cuses.

2.2.3 In eldel patients (e 65 eas f age),diagnsis shuld be based n a full clinicalassessent, including ital signs.

2.4. a Non-regnnt women with smtomsor signs o cute lUTI nd either highrobbiit o or roen bcteriuri shoudbe treted with ntibiotics.

2.4. B Non-regnnt women o n ge withsmtoms or signs o cute lUTI shoud betreted with trimethorim or nitrourntoinor three ds.

measueent f length f teatentwith tiethpi nitfuantinn PrISmS f Pactices pject,cpaisn f lcal pacticespecentage f thee da cuses with

natinal data.

Pecentage f pescibed cuses ftiethpi nitfuantin f LUTIthat ae f thee das

2.4. B ptients who do not resond to trimethorimor nitrourntoin shoud he urine tken orcuture to guide chnge o ntibiotic.

Audit f anageent f patientswith epeat isits within 28 das fpesciptin f tiethpi f LUTI.

2.4. Quinlnes shuld nt be used f epiicalteatent f LUTI.

Pecentage f LUTI teated withquinlnes with n pi episde fUTI in the past 28 das and n uinecultue sent.

2.4.2 a Non-regnnt women with smtoms orsigns o cute UUTI shoud be treted withciprooxacin for seven days. Ipleentatin f cae pathwa

f UUTI in pia and secndacae with audit f pactice againstecendatins.

2.4.2 D Urine shoud be tken or cuture beoreimmedite emiric tretment is strted ndtretment chnged i there is n indequteresonse to the ntibiotic.

2.4.3 a Non-regnnt women with smtomticbcteriuri shoud not receie ntibiotictretment.

Pecentage f wen teated insecnda cae f UTI with ndcuented eidence f spts fUUTI LUTI.

2.4.3 a Eder women (oer 65 ers o ge) withsmtomtic bcteriuri shoud not receientibiotic tretment.

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7.3.2 mANAGEmENT oF BACTErIAL UTI IN PrEGNANT WomEN


3..3 a Stndrd quntittie urine cuture shoud beperformed routinely at rst antenatal visit

Cae pathwa f detectin andanageent f asptaticbacteiuia f pegnanc with auditagainst tagets.

3..3 a The resence o bcteriuri in urine shoudbe conrmed with a second urine culture.

3..3 a Distick testing shoud not be used to screen orbacterial UTI at rst or subsequent antenatalisits.

3..3 Dipsticks t test nl f pteinuia and thepesence f glucse in the uine shuld beused for screening at the rst and subsequentantenatal isits as a e cst-effectiealtenatie t ulti-eagent dipsticks thatdetect the pesence f nitite, leuccteestease and bld in additin t ptein andglucse.

real f dipsticks f leucctes andnitites f antenatal clinics.

3.2. B pregnnt women with smtomtic UTIshoud be treted with n ntibiotic.

Cae pathwa f detectin andanageent f asptatic

bacteiuia f pegnanc with auditagainst tagets.

3.2. Gien se antibitics ae txic in pegnanc,efe t the Bitish Natinal Fula (BNF)f cntaindicatins.

3.2. A single uine saple shuld be taken f

cultue befe epiic antibitic teatent isstated.

3.2. Gien the isks f sptatic bacteiuiain pegnanc, a uine cultue shuld bepefed seen das afte cpletin fantibitic teatent as a test f cue.

3.2.and3.2.2

refe t lcal guidance f the safest,cheapest, effectie antibitic f pegnantwen.

Audit f antibitics pescibedt pegnant wen against lcalguidance.

3.2.2 a asmtomtic bcteriuri detected duringregnnc shoud be treted with n

ntibiotic.Cae pathwa f detectin andanageent f asptaticbacteiuia f pegnanc with auditagainst tagets.

3.3 C Women with bacteriuria conrmed by asecond urine cuture shoud be treted ndhe reet urine cuture t ech ntentisit unti deier.

3.3 Wen wh d nt hae bacteiuia in therst trimester should not have repeat urinecultues.


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7.3.3 mANAGEmENT oF BACTErIAL UTI IN PATIENTS WITH CATHETErS


5. D Cinic smtoms or signs re notrecommended or redicting the

ikeihood o smtomtic UTI inctheterised tients.

Cae pathwa f diagnsis fsptatic UTI in catheteisedpatients with audit against pactice.

5. In a catheteised patient wh pesentswith a fee:

lk f assciated lcalising (lin supapubic tendeness) ssteicfeatues

exclude the ptential suces finfectin

send ff an apppiatel taken uinesaple f cultue t deteine the

infecting ganis and susceptibilitiescnside antibitic theap takingint accunt the seeit f thepesentatin and an cbidfacts.

5.

and

5.5

Uine saples f patients with cathetes ueteic stas shuld nl be sentf labat cultue if the patienthas clinical sepsis, nt because theappeaance sell f the uine suggeststhat bacteiuia is pesent.

Audit f clinical eidence f infectinin patients with lng te cathetes ueteic stas wh hae been teatedwith antibitics had uine saplessent f cultue.

5.2. C lbortor microsco or dignosingUTI in ctheterised tients is notrecommended.

Cae pathwa f diagnsis fsptatic UTI in catheteisedpatients with audit against pactice.5.2.2 B Distick testing shoud not be used to

dignose UTI in ctheterised tients.

5.3 a antibiotic rohis is notrecommended or the reention osmtomtic UTI in ctherised tients.

Pecentage f patients with lng tecathetes wh eceie antibitics withn clinical eidence f sptaticUTI.

5.4. Catheteised patients with spts signs f acute UUTI shuld be teatedwith ciprooxacin or co-amoxiclav for

seen das. Antibitic selectin f patients withsptatic UTI cpaed with lcalplic ecendatins.5.4. Uine shuld be taken f cultue befe

teatent is stated, teatent shuld bechanged if the ganis is esistant t thechsen antibitic.

5.4. B ptients with ong term indweingctheters shoud he the ctheterchnged beore strting ntibiotictretment or smtomtic UTI.

Audit f cathete change pi tcencing antibitic.

5.4.2 B Ctheterised tients with smtomticbcteriuri shoud not receie ntibiotic

tretment.

Audit f clinical eidence f infectinin patients with lng te cathetes

ueteic stas wh hae been teatedwith antibitics had uine saplessent f cultue.

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7.4 RECOMMENDaTIONS fOR SURvEIllaNCE

Thee shuld be utine sapling f uine f cultue f all patients pesenting with acuteuina spts in se selected pactices t establish the tue leel f esistance in bacteiacausing acute UTI in geneal pactice. Pia eseach a be equied t pide eidence

to support details of surveillance (for example, sample sizes, frequency of surveillance studiesand gegaphical lcatin f pactices).

Thee shuld be sueillance f cathete assciated uina tact infectin (CAUTI) using theScttish Sueillance f Healthcae Assciated Infectin Pgae (SSHAIP) deelped audittl (www.shw.sct.nhs.uk/scieh/) t allw easueent f catheteisatin and cathete caepactice against the best pactice stateent Uina Catheteisatin and Cathete Cae 44 whichwas deelped and ipleented b the Scttish ministeial Healthcae Assciated Infectin(HAI) Task Fce.

7.4. USEFUL WEBSITES For SUrvEILLANCE AND INFECTIoN CoNTroL

NHS Scotnd e-ibrr HaI Mnged Knowedge Network ort: www.elib.sct.nhs.uk

British Societ or antimicrobi Chemother (BSaC): www.bsac.g.uk/SaCaR (Depatent f Healths Specialist Adis Cittee n Antiicbial resistance):www.adisbdies.dh.g.uk/saca

Ntion Eectronic librr o Inection: www.neli.g.uk

7.5 RECOMMENDaTIONS fOR RESEaRCH

What is the isk f isdiagnsis, including STDs, afte patients with suspected UTI haetelephne cnsultatin and antibitic pescibing b nuse pactitines?

Hw effectie ae nea patient tests when cpaed t a eliable ethd f diagnsingasptatic bacteiuia in pegnant wen?

Which antibitics ae st effectie f peentin and teatent f ecuent UTI inen?

Ae canbe pducts effectie f peentin and teatent f ecuent UTI in en?

Is ethenaine pphlaxis effectie f the peentin f sptatic UTI in eldel,institutinalised, catheteised patients?

What ae the st effectie was f questining patients t elicit the st eleant infatint aid diagnsis and teatent?

What ae the st effectie ethds f cunicatin between healthcae pfessinalsand patients abut spts and facts that elate t a ptential infectin?

What is the ipact f UTI and its teatent (including side effects) n patients qualit flife?

What ae patients attitudes and expectatins twads teatent and what pesnal stategies

d the hae f self cae?


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8 Deeoment o the guideine

8.1 INTRODUCTION

SIGN is a cllabatie netwk f clinicians, the healthcae pfessinals and patientganisatins and is pat f NHS Qualit Ipeent Sctland. SIGN guidelines ae deelpedb ultidisciplina gups using a standad ethdlg based n a ssteatic eiew f theeidence. Futhe details abut SIGN and the guideline deelpent ethdlg ae cntainedin SIGN 50; A Guideline Deelpes Handbk, aailable at www.sign.c.uk

8.2 THE GUIDElINE DEvElOpMENT GROUp

Pfess Pete Dae Professor of Pharmoeconomics, Medicines Monitoring Unit,(Chai) Ninewells Hospital and Medical School, Dundee

D Deek Bne Consultant Surgeon and Urologist,Ninewells Hospital and Medical School, Dundee

ms Na Caig Lead Nurse - Continence, Whitehills HealthandCommunity Care Centre, Forfar

D Daid Eans Consultant Obstetrician, Dr Grays Hospital, Elgin

Pfess T Fahe Professor of General Practice, University of Dundee

D Ian Guld Consultant in Clinical Microbiology,Aberdeen Royal Inrmary

m rbin Habu Quality and Information Director, SIGN

ms Kaen Hakness Principal Pharmacist, Ninewells Hospital andMedical School, Dundee

D rbeta Jaes Programme Manager, SIGN

ms Bin Jadine Lay representative, Edinburgh

D rss Langlands General Practitioner, Newton Port Surgery, East Lothianms Helen macdnald Health Protection Nurse Specialist,

Highland NHS Board, Inverness

D rbet mastetn Medical Director, Crosshouse Hospital, Kilmarnock

Pfess Dilip Nathwani Consultant Physician, Infection Unit,Ninewells Hospital and Medical School, Dundee

D Eica Petes Special Registrar in Infectious Diseases,Brownlea Centre, Gartnavel Hospital, Glasgow

ms valeie Sillit Community Pharmacist, Woodend Hospital, Aberdeen

ms Deen Sipsn Community Staff Nurse, Green Street Surgery, Forfar

The membership of the guideline development group was conrmed following consultation

with the ebe ganisatins f SIGN. All ebes f the guideline deelpent gupade declaatins f inteest and futhe details f these ae aailable n equest f the SIGNExecutie. Guideline deelpent and liteatue eiew expetise, suppt and facilitatin weepided b the SIGN Executie.

8.3 aCKNOWlEDGEMENTS

SIGN is gateful t the fllwing fe ebes f the guideline deelpent gup andthes wh hae cntibuted t the deelpent f this guideline.

ms Fina Bandt Practice Nurse, Aberlour

D Ali El-Gh Programme Manager, SIGN

D michael Pwe Clinical Knowledge Author, Guideline Developerand Informatician, Prodigy Knowledge, Newcastle

D Kate Wdan Lay representative, Edinburgh

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8 DEvElOpMENT Of THE GUIDElINE

8.4 SySTEMaTIC lITERaTURE REvIEW

The eidence base f this guideline was snthesised in accdance with SIGN ethdlg.A ssteatic eiew f the liteatue was caied ut using an explicit seach stateg deisedby the SIGN Information Ofcer in collaboration with members of the guideline development

gup.Liteatue seaches wee initiall cnducted in medline, Ebase, Cinahl, and the CchaneLiba using the ea ange 994-2002. The liteatue seach was extended f 966-2003f rCTs and diagnstic studies. The Natinal Ecnic Ealuatin Database (NEED) wasseached f ecnic studies t ce the peid up t Janua 2004. Ke websites n theIntenet wee als seached. These seaches wee suppleented b the efeence lists f eleantpapers and group members own les. The Medline version of the main search strategies canbe fund n the SIGN website.

8.5 CONSUlTaTION aND pEER REvIEW

8.5. NATIoNAL oPEN mEETING

A natinal pen eeting is the ain cnsultatie phase f SIGN guideline deelpent, atwhich the guideline development group presents its draft recommendations for the rst time.The natinal pen eeting f this guideline was held n 30 Apil 2004 and was attended bepesentaties f all the ke specialties eleant t the guideline. The daft guideline was alsaailable n the SIGN website f a liited peid at this stage t allw thse unable t attendthe eeting t cntibute t the deelpent f the guideline.

8.5.2 SPECIALIST rEvIEW

This guideline was als eiewed in daft f b the fllwing independent expet efeees,wh wee asked t cent piail n the cpehensieness and accuac f intepetatinf the eidence base suppting the ecendatins in the guideline. SIGN is e gateful

t all f these expets f thei cntibutin t the guideline.

D Jaes Beattie Director of Guidelines Development, Royal College ofGeneral Practitioners/General Practitioner, Aberdeenshire

m Gaee Cnn Consultant Urological Surgeon,Southern General Hospital, Glasgow

ms Beatice Gant Lay Reviewer, Larbert

D ma Hansn Consultant Microbiologist,Western General Hospital, Edinburgh

D Diana Hltn Hospital Practitioner, Roodlands Hospital, East Lothian

ms Cath mcKeell Project Manager (Scotland), Incontact, Lanarkshire

D Allan me General Practitioner, South Beach Surgery, Ardrossan

D Dth mi Director of Public Health, NHS LanarkshirePfess Sigad mlstad Professor of General Practice,

Primrvardens FoU-enhet, Sweden

D Lindsa Niclle Professor of Internal Medicine and Medical Microbiology,University of Manitoba, Canada

D Ewan olsn Consultant Microbiologist, Royal Inrmary of Edinburgh

Professor Raul Raz Director, Infectious Diseases Unit,Haemek Medical Centre, Israel

D maueen Sipsn General Practitioner, Townhead Practice, Montrose

Pfess Fancisc Sian Professor of Microbiology, Fundacion Jimenez Diaz, Madrid

D Chales Swainsn Medical Director, Lothian NHS Board, Edinburgh

D Alex Watsn General Practitioner, West Gate Health Centre, DundeeD Caig Willias Consultant Medical Microbiologist,

Yorkhill NHS Trust, Glasgow

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8.5.3 SIGN EDITorIAL GroUP

As a nal quality control check, the guideline is reviewed by an editorial group comprisingthe eleant specialt epesentaties n SIGN Cuncil t ensue that the specialist eiewescents hae been addessed adequatel and that an isk f bias in the guidelinedeelpent pcess as a whle has been iniised. The editial gup f this guidelinewas as fllws:

Pfess Gdn Lwe Chair of SIGN; Co-Editor

D Daid Alexande General Practitioner, Nethertown Surgery, Dunfermline

D Bill reith Royal College of General Practitioners,General Practitioner, Aberdeen

Dr Saa Qureshi SIGNProgramme Director; Co-Editor

D Saa Twaddle Director of SIGN; Co-Editor

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abbreitions

BNf Bitish Natinal Fula

BSaC Bitish Sciet f Antiicbial ChetheapCaUTI cathete assciated uina tact infectin

CBa cntlled befe and afte stud

cu cln fing units

CI condence interval

CSM Cittee n Safet f medicines

CSU cathete specien f uine

Gp geneal pactitine

HaI healthcae assciated infectin

Hpa Health Ptectin Agenc

IDSa Infectius Diseases Sciet f Aeica

INR International Normalized Ratio

KUB kidnes, uetes and bladde

lE leuccte estease

lUTI lwe uina tact infectin

MIC iniu inhibit cncentatin

MSU idstea specien f uine

NelI Natinal electnic Liba f Infectin

NNT nube needed t teat

NNTB number needed to benet

NNTH nube needed t ha

ppROM pe-labu, peatue uptue f ebanes

ppv psitie pedictie alue

Qaly qualit adjusted life ea

RCT andised cntlled tial

SaCaR Depatent f Healths Specialist Adis Cittee n Antiicbialresistance

SIGN Scttish Intecllegiate Guidelines Netwk

Spa supapubic aspiate

SSHaIp Scttish Sueillance f Healthcae Assciated Infectin Pgae

STD sexuall tansitted disease

UTI uina tact infectin

UUTI uppe uina tact infectin

WBC white bld cells

aBBREvIaTIONS

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MaNaGEMENT Of SUSpECTED lUTI IN WOMEN (not regnnt)

In women with symtoms of vgin

itch or dischrge, exore terntivedignoses nd consider evic

exmintion.

CyESNO vgin itch

or dischrge?

Mutie

smtoms

feer &

bck in?

yES

Conside the possibility of UUTI.

limited (no more thn

two) smtoms

Distickositie

Distick negtieor equioc

Distick tests shoud ony be used to

dignose bcteriuri in women with

imited symtoms nd signs.

C

NO, lUTI robbe

Non-regnnt

women of nyge with

symtoms or

signs of cute

lUTI shoud betreted with

trimethorim or

nitrofurntoin

for three dys.

ptients who do

not resond to

trimethorimor nitrofurntoin

shoud hve

urine tken forcuture to guide

chnge of

ntibiotic.

B Offer emiricntibiotictretment.

The risks nd

benefits ofemiric

tretment shoud

be discussed

with the tient

nd mngedccordingy.

If womnremins

symtomtic

fter singecourse of

tretment,

investigte other

otenti cuses.

B

Quinolones should not be used fo empiical

teatment of LUTI.

Smtoms nd signs o UTI?

dsuri urgenc

requenc

ouri

surubic tenderness

eer

ank or back pain

Women with enal impaiment should not beteated with nitofuantoin.

Women rescribed nitrofurntoin shoud not

tke knising gents (potassium citrate).D

anne 1

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MaNaGEMENT Of SUSpECTED UUTI IN WOMEN (not regnnt)

Signs nd smtoms o UUTI:

oin in

ank tenderness

eer

rigors

other mniesttions o sstemic

inammatory response

Admit to hospital

Non-regnnt women with symtoms or signs of

cute UUTI shoud be treted with cirofoxcin for

seven dys.

a

NO yES

Uine should be taken fo cultue befoe immediate

empiical teatment is stated and teatment changed if

thee is an inadequate esponse to the antibiotic.

D

UUTI cn be ccomnied b bcteremi,

mking it ie-thretening condition

I no resonse to

tretment in 24 hours

Sstemic smtoms?

aNNExES

anne 2

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MaNaGEMENT Of SUSpECTED lUTI IN pREGNaNT WOMEN

Tret with n ntibiotic.B

Sptatic bacteiuia(ccus in 7-20% f pegnancies)

NO

Sceening fasptatic bacteiuia

The resence of bcteriuri in urine

should be confrmed with a second

urine cuture.

a

Cuture ositie?

Tret with n ntibiotic.a

Reet urine cuture t ech ntent

visit unti deivery.a

Stndrd quntittive urine cuture

shoud be erformed routiney t

frst antenatal visit.

a

a single uine sample

should be taken fo

cultue befoe empiic

antibiotic teatment is

stated efe to local guidance

fo the safest, cheapest,

effective antibiotic

efe to the Bitish

National Fomulay

(BNF) fo

containdications inpegnancy

a uine cultue should

be pefomed sevendays afte completion

of antibiotic teatment as

a test of cue.

refe to local guidance fo the safest,cheapest, effective antibiotic.

Women who do not

have bacteiuia in

the frst trimester

should not have

epeat uine

cultues.yES

Distick testing shoud not be usedto screen for bcteri UTI.

a

anne 3

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MaNaGEMENT Of SUSpECTED UTI IN aDUlT MEN

Histor o eer or bck in

Smtoms nd signs o UTI?

dsuri urgenc

requenc

ouri

surubic tenderness

eer

ank or back pain

Dierenti dignosis shoud incude

rosttitis, chmidi inection, eididmitis

Refer for uroogic

investigtion

Tret emiricy with two week course

of quinoone.

In all men with symptoms of UTI

a uine sample should be taken focultue.

Conside the possibility of UUTI

Uine cultue should guide the

choice of antibiotic.

I no resonse

to ntibiotic

Tret emiricy with two week course

of quinoone.

Recurrent UTI?

Edery men with symtomtic

bcteriuri shoud not receive ntibiotictretment.

NO

yES

C

Investigate fo

postatitis.

D

a

B

anne 4

aNNExES

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42/4638


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