N30.9/O23.4/N10
DESCRIPTION
UTIs include cystitis (infection of the bladder/lower urinary tract) and pyelonephritis (infection of the kidney/upper urinary tract). Pyelonephritis develops when pathogens ascend to the kidneys via the ureters. Uncomplicated UTIs involve either the lower urinary tract (bladder) and/or the upper urinary tract (kidney) in non-pregnant, pre-menopausal woman with no known relevant anatomical and/or functional abnormalities within the urinary tract or any comorbidities. UTIs in other groups of patients are complicated by definition.
Features of upper UTI include:
- flank pain/tenderness,
- temperature >38ºC,
- other features of sepsis, i.e. tachypnoea, tachycardia, confusion and hypotension, or
- nausea and vomiting.
In complicated, recurrent or upper UTIs, mid-stream urine should be sent for microscopy, culture and sensitivity.
MEDICINE TREATMENT
Women with recurrent UTIs should be advised to:
- void bladder after intercourse and before retiring at night
- not postpone voiding when urge to micturate occurs
- change from use of diaphragm to an alternative type of contraception
Empirical treatment is indicated only if:
- positive leucocytes and nitrites on urine test strips on freshly passed urine, or
- leucocytes or nitrites with symptoms of UTI, or
- systemic signs and symptoms indicating an upper UTI and/or urosepsis.
Alkalinising agents are not recommended, as many antibiotics require a lower urinary pH.
Uncomplicated community acquired cystitis N30.9
- Fosfomycin, oral, 3 g as a single dose.
OR
Gentamicin 5 mg/kg, IM as a single dose.
Note: Gentamicin should not be used in renal impairment or pregnancy (see GENTAMICIN, IV for guidance on prescribing)
OR
Nitrofurantoin, oral, 100 mg 6 hourly for 5 days.
Complicated community acquired cystitis N30.9
- Ciprofloxacin, oral, 500 mg 12 hourly for 7–10 days.
CAUTION
Concomitant use of fluoroquinolones with ACE-inhibitor/angiotensin receptor blocker is contraindicated in moderate to severe renal impairment (Creatinine Clearance ≤ 30 ml/minute) and in the elderly. Assess renal function before initiating treatment and monitor during treatment.
Evidence suggests a risk of developing acute kidney injury with concomitant use of fluoroquinolones and renin-angiotensin receptor blockers.
For pregnant women: O23.4
- Nitrofurantoin, oral, 100 mg 6 hourly for 5 days.
OR
Fosfomycin, oral, 3 g as a single dose.
Acute pyelonephritis N10
Admit all patients with vomiting, sepsis, diabetes or impaired/worsened renal function (eGFR <60 mL/minute).
Ensure adequate hydration with intravenous fluids.
If there is a poor response, perform an ultrasound on all hospitalised patients urgently as in-patients.
Adjust antibiotic according to sensitivity.
Duration of antibiotic therapy in uncomplicated pyelonephritis:
- fluoroquinolones 7 days
- other antibiotics 14 days.
Longer courses of therapy, 2–3 weeks, should be given for complicated pyelonephritis.
Patients who have features of severe sepsis or who are vomiting, initiate IV therapy and switch to oral therapy as soon as clinical condition improves:
If normal renal function:
- Gentamicin, IV, 6 mg/kg daily (see GENTAMICIN, IV for guidance on prescribing).
Switch to oral therapy as soon as the patient is able to take oral fluids, according to microscopy culture and sensitivity results:
- Ciprofloxacin, oral, 500 mg 12 hourly for 7–10 days.
If impaired renal function:
- Ceftriaxone, IV, 1 g daily.
Switch to oral therapy as soon as the patient is able to take oral fluids, according to microscopy culture and sensitivity results:
- Ciprofloxacin, oral, 500 mg 12 hourly for 7 days.
- CrCl: <10 mL/minute: 50% of normal dose.
REFERRAL/CONSULTATION
Urgent
- Acute pyelonephritis in pregnant women.
- Acute pyelonephritis with:
- vomiting
- sepsis
- diabetes mellitus
- urinary tract obstruction on ultrasound
Non-urgent
- Failure to improve within 72 hours.
- Women beyond reproductive age.
- >3 uncomplicated UTIs within a one-year period.
- >1 complicated UTI within a one-year period.