Management of uncomplicated UTI in a woman

General Principles of management of UTI in adults (no fever or flank pain) (1)

• the diagnostic significance of symptoms is dependent on the age of the patient. See linked items for consideration of a possible UTI in woman under 65 years of age; possible UTI of woman over 65 years of age
  
  
• always safety net
  
  
• first line: nitrofurantoin if GFR over 45ml/min
  • GFR 30-45: only use if resistance & no alternative
  • in treatment failure: always perform culture

Guidance for management of UTI in an non-pregnant woman (2)

• consider a back-up antibiotic prescription or immediate antibiotic, noting that the evidence for back-up antibiotics was from women not needing immediate treatment
  • if urine sent for culture and susceptibility, and antibiotic given:
    • review antibiotic choice when results available, and
    • change antibiotic for pregnant women if bacteria resistant
    • change antibiotic for children and young people, men and non-pregnant women if bacteria resistant and symptoms not improving
    • a narrow spectrum antibiotic should be used when possible
      
      
  • with all antibiotic prescriptions, advise:
    • possible adverse effects of antibiotics include diarrhoea and nausea
    • seeking medical help if symptoms worsen at any time, do not improve within 48 hours of taking the antibiotic, or the person becomes very unwell
  • with a back-up antibiotic prescription, also advise:
    • antibiotic is not needed immediately
    • use prescription if no improvement in 48 hours or symptoms worsen at any time
      
      
  • reassess at any time if symptoms worsen rapidly or significantly or do not improve in 48 hours of taking antibiotics, sending a urine sample for culture and susceptibility if not already done. Take account of:
    • other possible diagnoses
    • any symptoms or signs suggesting a more serious illness or condition
    • previous antibiotic use, which may have led to resistance
      
      
  • Refer to hospital if a person aged 16 or over has any symptoms or signs suggesting a more serious illness or condition (for example, sepsis)

Choice of antibiotic: non-pregnant women aged 16 years and over (2)

For a first-choice antibiotic prescribe nitrofurantoin 100 mg modified-release twice a day for 3 days if estimated glomerular filtration rate (eGFR) ≥45 mL/minute. This is effective against Escherichia coli, the most common causative pathogen in uncomplicated UTIs (70%-95% of patients) with only 0.9% resistance. (3)

Trimethoprim 200 mg twice a day for 3 days may be used if there is a low risk of resistance. This risk is lower if not used in the previous 3 months, if previous urine culture suggests susceptibility (but trimethoprim was not prescribed), and in younger people where local data suggest resistance is low. (2) A higher risk of resistance is more likely with recent use and in older patients in residential facilities. (2)

For a second-choice antibiotic, where patients have shown no improvement in lower UTI symptoms after taking a first-choice antibiotic for at least 48 hours or if the first choice is not suitable, prescribe (2) nitrofurantoin (if eGFR ≥45 mL/minute and not used as a first choice) 100 mg modified-release twice a day for 3 days, pivmecillinam 400 mg initial dose, then 200 mg three times a day for a total of 3 days, or fosfomycin 3 g single dose sachet.

(Check BNF for use and dosing in specific populations, for example, hepatic impairment, renal impairment and breast-feeding.)

Risk factors for increased resistance include:

• care home resident,
• recurrent UTI,
• hospitalisation >7d 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

More extensive details of drug treatment are provided in the BNF.

Indwelling catheters always seem to result in white cells and bacteria which are very difficult to get rid of. Usually they are asymptomatic, and are only to be treated with the development of symptoms.

Reference:

1. Public Health England (June 2021). Managing common infections: guidance for primary care

2. Scottish Intercollegiate Guidelines Network. Management of suspected bacterial lower urinary tract infection in adult women. Sep 2020

3. Sanchez GV, Babiker A, Master RN, et al. Antibiotic resistance among urinary isolates from female outpatients in the United States in 2003 and 2012. Antimicrob Agents Chemother. 2016 May;60(5):2680-3.