Urinary Tract Infections

Transcription

1 Urinary Tract Infections Written by: Dr Kavitha Gajee, Consultant Microbiologist Date: June 2016 Approved by: Drugs & Therapeutics Committee Date: July 2016 Implementation Date: August 2016 For Review: July 2018

2 URINARY TRACT INFECTIONS The diagnosis of urinary tract infection (UTI) is primarily based on symptoms and signs. Typical symptoms or signs of lower urinary tract infections (cystitis) include dysuria, urinary frequency, urgency, haematuria and suprapubic tenderness but no fever. Acute upper urinary tract infection (pyelonephritis) present with signs of loin pain, flank tenderness, nausea/vomiting, pyrexia, rigors with/without symptoms of a lower UTI Urosepsis is defined as sepsis whose source is the urogenital tract. It is most often related to an upper urinary tract infection Catheter associated UTI (CAUTI) is difficult to diagnose. Signs and symptoms compatible with CAUTI include new onset fever or worsening fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain, costo-vertebral angle tenderness, acute haematuria, pelvic discomfort and in those whose catheters have been removed, dysuria, urgent or frequent urination, or supra-pubic pain or tenderness. Investigations Dipstick screening test for nitrites and leucocyte esterase. DO NOT use dipstick testing to diagnose UTI in catheterised patients Mid-stream urine (MSU) to be taken before starting antimicrobial treatment Catheter specimen of urine (CSU) only if the patient has clinical sepsis, not because the appearance or smell of urine suggests that bacteriuria is present Blood culture in suspected acute pyelonephritis or clinical signs of sepsis or temperature > 38 0 C For epididymo-orchitis, send a urethral swab for N. gonorrhoeae culture and first pass urine or urethral swab for C.trachomatis NAAT Renal tract ultrasound for suspected sepsis secondary to acute pyelonephritis(please note that this investigation is not very sensitive) If previously or currently positive for Clostridium difficile - discuss with a Microbiologist

3 Asymptomatic bacteriuria Antibiotics are NOT appropriate for Antibiotic treatment is indicated majority of these patients. This includes: for pregnant women with premenopausal non- pregnant bacteriuria females Older patients (>65 years ) Catheterised patients Cystitis in a non-pregnant Trimethopim 200mg 12hrly Depends on susceptibility of Trimethoprim : female organism isolated * if egfr between 15-30ml use Nitrofurantoin 50mg 6 hrly half dose after 3 days Cystitis in Males Duration : 3 days Trimethoprim 200mg 12hrly If allergic to Nitrofurantoin or Trimethoprim - use amoxicillin if susceptibility results available or cephalexin * avoid if egfr < 15 ml or CKD * avoid in patients on methotrexate as increased risk of haematological toxicity Nitrofurantoin 50mg 6hrly Nitrofurantoin * do not use in chronic kidney disease Duration : 7 days * avoid if egfr < 45mls/min * avoid in males where prostatitis is suspected

4 Cystitis in Pregnant Females Nitrofurantoin 50mg 6hrly (except in 3rd trimester) Contact Microbiologist Trimethoprim : * teratogenic risk in first trimester (folate antagonist) Trimethoprim 200mg 12hrly (except in 1st trimester) Duration : 7 days Nitrofurantoin : * avoid in the third trimester, may produce neonatal haemolysis AKI Urosepsis including post IV Gentamicin 7mg/kg daily Oral alternative should be based * If U&E are not available or in prostatic biopsy sepsis (see trust policy) on culture results but avoid suspected AKI then give a stat (refer to sepsis IPOC) AND Acute pyelonephritis IV Cefuroxime 1.5g tds Nitrofurantoin dose of cefuroxime which can be switched to gentamicin if the renal function is subsequently found to be normal ( for patients with renal impairment ) Contact Microbiology * Contact Microbiology if patient has Duration : Pyelonephritis: days Urosepsis: 7-10 days had a previous 5-day course of Cephalosporins or Co-amoxiclav in the previous 2 weeks Please review all IV antibiotics at 48 hours

5 Catheter- associated UTI Catheters will invariably get colonised IV Gentamicin 7mg/kg daily (CAUTI) with bacteria which will continue to multiple over time ( see Trust policy) IV Cefuroxime 1.5g tds ( for patients with renal impairment ) Antibiotics only indicated signs and symptoms compatible with CAUTI - susceptibility results are available on request Do Not treat catheterised patients with asymptomatic bacteriuria with an antibiotic Duration : - 7 days if prompt resolution of symptoms - 10 days if delayed response - 3 days if catheter removed in Contact Microbiology if patient has had a previous 5-day course of Cephalosporins or Co-amoxiclav in the previous 2 weeks females 65yr and no fever Epididymo-orchitis Under 35 years Single dose of Ceftriaxone 500mg IM If allergic to cephalosporins then Usually sexually transmitted in the PLUS in the under 35 years use : under 35 years but in the over 35 Doxycycline 100mg bd Ofloxacin 200mg bd for 14 days years, it is usually due to enteric Duration : days organisms (It is vital that specimens for Over 35 years Ciprofloxacin 500mg bd sensitivity testing are taken first ) Duration 10 days Acute Prostatitis Ciprofloxacin 500mg bd Trimethoprim 200mg bd Duration: 28 days Duration: 28 days