Urinary Tract Infections

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Asymptomatic Bacteriuria

Actively multiplying bacteria within the urinary tract of asymptomatic patients. This should only be treated in pregnant women as it is associated with a 20-30% risk of developing pyelonephritis in later pregnancy.

Antimicrobial 

Antibiotics are not recommended for most patients with asymptomatic bacteriuria.

During pregnancy, while waiting for urine culture and susceptibility results use:

Nitrofurantoin 100mg PO QID

Alternative:

Amoxicillin 500mg PO TID

OR

Cotrimoxazole 160/800mg BID (avoid in first and third trimester if alternative available)

If empiric treatment fails repeat urine culture.

Comments and Duration of Therapy 

Screening for bacteriuria is recommended at the first prenatal visit.

Take urine culture and where possible treat according to the results of this. If urine culture is unavailable perform urinary dipstick. Repeat urine culture 1-2 weeks after completion of antibiotics.

Duration:

Treat for 5-7 days.

Cystitis

Symptoms may include dysuria, urinary frequency or haematuria. Fever or renal angle tenderness represents upper urinary tract infection, see Pyelonephritis below.

In symptomatic infants <12 months old, have a low threshold for treating as for Pyelonephritis.

Antimicrobial 

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID (avoid in first and third trimester of pregnancy if alternative available).

Alternative:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Change antibiotic therapy based on results of cultures and susceptibility testing.

High fluid intake and complete bladder emptying may aid resolution of UTI.

Comments and Duration of Therapy 

Take urine culture. This is particularly important in patients with recurrent UTIs, recent antibiotic use, or in patients who have failed empiric treatment.

Men should be examined for evidence of prostatitis. If patient has a catheter it is important to remove or exchange this.

Duration:

Women and children > 12 months: Treat for 3-5 days

Men: Treat for 7 days

Children < 12 months: Treat for 5 days.

Pyelonephritis, Complicated Urinary Tract Infection

Pyelonephritis usually presents with fever, dysuria, and unilateral renal angle tenderness. In young children the symptoms and signs may be more non-specific, with fever, vomiting and poor feeding common in infants <12 months.

Complicated urinary tract infection is a urinary tract infection in the presence of:

  • Obstruction
  • Immunosuppression
  • Renal stones
  • Anatomical urinary tract abnormality

Antimicrobial

Mild to Moderate:

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID (avoid in first and third trimester of pregnancy if alternative available).

Alternative:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Severe:

Cefazolin 2g (child 50mg/kg) IV TID

PLUS

Gentamicin 4-5mg/kg (child <10 years old 7.5mg/kg) IV OD

Alternative:

Ceftriaxone 2g (child 50mg/kg) IV OD

OR

If cefazolin is not available replace this in the above regime with:

Ampicillin 2g (child 50mg/kg) IV QID

If patient is in septic shock replace gentamicin with:

Amikacin 28mg/kg IV OD as a first dose in patients with creatinine clearance >60ml/minute. Use 16-20mg/kg if creatinine clearance <60ml/minute. For subsequent doses see Aminoglycoside dosing section.

Child 15mg/kg IV OD.

If amikacin is not available and patient is likely to have normal renal function give above regime but increase Gentamicin to 7mg/kg IV for first dose.

If still requiring IV therapy after 48 hours, change ampicillin + gentamicin to:

Ceftriaxone 2g (child 50mg/kg) IV OD.

Comments and Duration of Therapy 

Take urine culture. If systemically unwell perform blood cultures prior to antibiotics. If patient is septic give antibiotics within 1 hour of presentation.

Consider imaging renal tract to define or exclude underlying anatomical or functional abnormality.

For children <12 months old with pyelonephritis, there should be a low threshold for treating initially with intravenous antibiotics, due to an increased risk of secondary bacteraemia.

Duration:

Change to oral antibiotics when improving. Treat for a total of 10-14 days.

See Urological procedure prophylaxis in Chapter 1: Antibiotic Prophylaxis

Epididymo-orchitis

Infection of the epididymis and/or testes. Presents with pyuria, scrotal pain and oedema, and swelling. Treatment depends on whether infection is sexually acquired or non-sexually acquired.

Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causative organisms in men under 35 years old.

Age cut-offs are suggestions only to help guide treatment where microbiology results are not available.

Antimicrobial 

Non-Sexually Acquired (>35 years):

Mild-Moderate:

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID

OR

Ciprofloxacin 500mg PO BID

Severe:

Ampicillin 2g (child: 50mg/kg) IV QID

PLUS

Gentamicin 4-5mg/kg (child <10 years old: 7.5mg/kg) IV OD

If still requiring IV therapy after 48 hours, change ampicillin + gentamicin to:

Ceftriaxone 2g (child 50mg/kg) IV OD.

Sexually Acquired (<35 years):

STI Pack.

See Genital Infections chapter.

Comments and Duration of Therapy

In all patients take a urine culture. For sexually active men perform an STI screen; first pass urine for gonorrhoea and chlamydia PCR, swab urethra and/or rectum with bacterial swab for culture, and with dry or viral swab for PCR.

Duration:

Non-Sexually Acquired: Change to oral antibiotics when well. Treat for total of 14 days.

Chronic Bacterial Prostatitis

Persistent infection of the prostate, usually with Gram-negative organisms. Presentation may include low-grade fever, urgency, or perineal discomfort. Most cases of what is thought to be ‘chronic’ prostatitis, characterised by chronic pelvic pain, are not due to infection and repeated courses of antibiotic treatment should be avoided. Chronic bacterial prostatitis is rare.

Antimicrobial 

Ciprofloxacin 500mg PO BID

Antibiotics should be guided by culture results however fluroquinolones and co-trimoxazole are preferred agents due to good prostate penetration.

Comments and Duration of Therapy 

Take urine culture in all patients. Consider performing prostate massage immediately prior to urine collection to improve sensitivity of culture.

Duration:

Treat for 4 weeks.

References

Cunningham F, Leveno K, Bloom S, Dashe J, Hoffman B, Casey B, et al. editors. Williams Obstetrics. 25th ed. New York: McGraw-Hill; 2018

eTG complete. Urinary Tract Infections. In: Therapeutic Guidelines [digital]. Melbourne: Therapeutic Guidelines Limited; 2019. http://www.tg.org.au

Gusmao dos Santos C, Francis J, Guterres J, Janson S, Lopes N, Marr I, et al. HNGV Antibiotic guidelines writing group. Antibiotic guidelines Hospital Nacional Guideo Valadares. Timor-Leste; 2016