Lower urinary tract infection/cystitis

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Diagnosis is clinical, based on two or more of:

  • New dysuria
  • New frequency
  • New urgency
  • New nocturia
  • Visible haematuria
  • Cloudy urine
  • Supra-pubic tenderness

In patients over 65 years new incontinence or delirium can also be caused by a UTI. Consider other causes of delirium before prescribing antibiotics and ensure urine culture and other investigations are sent to exclude other causes of delirium.

Required investigations

Urine culture: preferably midstream specimen or catheter specimen if catheterised.

  • A positive urine culture without symptoms (asymptomatic bacteriuria) in men & non-pregnant women should not be treated


Don't be a dipstick

Do not routinely use urinalysis/dipstick to diagnose a urinary tract infection.

  • Use of urinalysis results in antibiotic overprescribing.
  • Urine dipstick in men and women >65s has a high false-positive rate and a significant false negative rate and should not be used.
  • Urine dipstick in women <65’s only: nitrites indicate that a UTI is possible, but ONLY when symptoms are present.

Risk factors for bacterial resistance to trimethoprim

  • Hospital inpatient
  • Nursing/Care home resident
  • Patient >65 yrs
  • Received Trimethoprim in past 3 months
  • Trimethoprim resistant organism in any of the last 3 urine culture (up to 12 months ago)

Antibiotic recommendation

In the following scenarios follow alternative guidance:

Recommended total duration: Women - 3 days, Men - 7 days.

No risk factors for trimethoprim resistance Trimethoprim 200mg every 12 hours

Risk factor(s) for trimethoprim resistance AND eGFR >30

Nitrofurantoin M/R 100mg every 12 hours

If Risk factors for trimethoprim resistance identified and eGFR <30, options include:

  • Cefalexin 500mg every 12 hours
  • Pivmecillinam 400mg stat, then 200mg 12-hourly
  • Fosfomycin sachet 3g (once only for women; for men repeat after 72 hours)

If Penicillin allergy and eGFR <10, discuss with Microbiology (Antibiotic and clinical advice)


Likely organisms: E.coli, other Enterobacteriaceae, less commonly Enterococci.