Symptoms occurring in both upper UTI (UUTI) and lower UTI (LUTI):

• dysuria
• urinary frequency
• haematuria
• lower abdominal tenderness
• the presence of dysuria and frequency in women indicates a probability of UTI of over 90%.

Additional symptoms indicative of UUTI:

• pyrexia
• loin pain
• systemic symptoms

Urinalysis

Diagnosis of UTI : primarily based on symptoms and signs,
However, urinalysis may contribute additional information to inform management. Dipstick tests are only indicated for women who have minimal signs and symptoms.
Where only one symptom or sign is present, a positive dipstick test (LE or nitrite) is associated with a high probability of bacteriuria (80%) and negative tests are associated with much lower probability (around 20%)

Mid Stream Sample of Urine (MSSU)

• Send an MSSU before starting treatment, if there are symptoms or signs of upper UTI
• No need to await the MSSU result before commencing treatment
• In women consider possibility of pregnancy prior to treatment
• Consider the possibility of STIs and PID and screen/treat appropriately
• An MSSU should be sent from symptomatic pregnant women and from those in whom symptoms have persisted after empirical treatment
• Narrow range antibiotics remain first line choice: broad spectrum drugs increase the risk of clostridium difficile, MRSA and resistant UTIs.

In uncomplicated lower UTI in non-pregnant women, treat with:-
trimethoprim 200mgs twice daily for 3 days
Alternative nitrofurantoin 50mg 4 times daily for 3 days
i.e. there is no need to send an MSSU at this point

In pregnant women, treat with:-
Nitrofurantoin 50mg 4 times daily7 days (theoretical risk neonatal haemolysis
at term)
(second-line:Amoxycillin amoxicillin 50mg 4 times daily for 7 days)
(Trimethoprim 200mg po bd 7 days – off-label because folate metabolism)

If signs or symptoms of upper UTI are present, obtain an MSSU and treat
with:.
ciprofloxacin 500mg BD for 7 days (not if pregnant)
Alternative co-amoxiclav 625mg tds for 14 days (for pregnancy or if allergy
cephalexin 500mg tds po 14 days)
Or trimethoprim 200mg po bd 7 days

lower UTI – MEN: trimethoprim 200mg twice daily 7days or nitrofurantoin
50mg 4 times daily for 7 days
upper UTI(ciprofloxacin 500mg po bd 7 days should be used for tissue
penetration – consider longer courses if signs of prostate involvemen

• Urinary tract infection is rare in young men. All men with proven UTI should be referred to their GP for referral for imaging of the renal tract (ultrasound or IVP). Men with recurrent UTI should be referred to a urologist.
• Women with recurrent UTI may benefit from imaging of the renal tract and consideration of prophylactic antibiotics. This is best managed by urologists, following referral by the woman’s GP

• Cranberry products – evidence shows prevention of symptomatic UTI in young adult women with recurrent UTI is almost as good as trimethoprim. Cranberry is available as tablets, capsules and juice. High strength is more convenient and efficacious. Less benefit in older men, women, and those requiring catheterisation. These products are not available on the NHS. N.B: Warfarin should not be taken with Cranberry products owing to pharmacokinetic interaction.

• Oestrogen replacement locally has not been shown consistently to reduce the frequency of recurrent UTIs in women.

NHS GGC Adult Therapeutics Handbook. www ggcmedicines.org.uk (accessed online Feb 2018