Nitrofurantoin
100mg MR BD
Women all ages 3 days
Men 7 days
Trimethoprim
200mg BD
Women all ages 3 days
Men 7 days
Pivmecillinam
400mg stat then 200mg TDS
Women all ages 3 days
Men 7 days
Extended-spectrum Beta-lactamase E. coli are increasing. Trimethoprim (if low risk of resistance) and pivmecillinam are alternative first line agents.
Risk factors for increased resistance include: care home resident, recurrent UTI, hospitalisation >7days in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones.
If increased resistance risk, send culture for susceptibility testing & give safety net advice. If GFR<45 ml/min or elderly, consider pivmecillinam 400mg TDS or fosfomycin (3g stat in women plus 2nd 3g dose in men 3 days later).
Treat women with severe/or ≥ 3 symptoms;
Women <65 years with mild/or ≤ 2 symptoms AND
Urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors for infection. If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% positive predictive value; nitrite, leucocytes, blood all negative 76% Negative Predictive Value (NPV).
Consider a back-up / delayed antibiotic option along with analgesia
Men <65 years: Consider prostatitis and send pre-treatment MSU OR if symptoms mild/non-specific, use negative dipstick to exclude UTI.
Men >65 years: Treat if fever 380C or above or 1.50C above base in 12 hours and > 1 other symptom.
Always safety net.
Nitrofurantoin if GFR over 45ml/min; GFR 30-45: only use if resistance & no alternative.
In treatment failure: always perform culture.
People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity.
Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma (NICE). Take sample if new onset delirium, or one or more symptoms of UTI.