Questionnaire/history: Discomfort, pain, burning, tingling or stinging associated with urination (dysuria)? Passing urine more often than usual (frequency)? A strong desire to empty the bladder, which may lead to urinary incontinence (urgency)? Changes in urinary appearance or consistency? - Urine cloudy, colour change or odour? - Haematuria as red/brown discolouration of urine or as frank blood? Passing urine more often than usual at night (nocturia)? Suprapubic discomfort/tenderness? In elderly women or those with underlying cognitive impairment? Generalised non-specific clinical features such as delirium, debility, lethargy, reduced ability to carry out activities of daily living and anorexia? (Alternative sources of infection and causes of delirium other than UTI (eg pain, other infection, constipation, poor hydration and medication) must be excluded before a working diagnosis of UTI is made.) Fever? Rigors? Loin pain? Other symptoms (eg vaginal or urethral discharge, irritation or skin rash)? Red flags (eg haematuria, loin pain, rigors, nausea, vomiting, altered mental state)? Onset and evolution of symptoms? Possibility of pregnancy? PMH (eg RF for recurrent UTI (eg neurological conditions, diabetes, immunosuppression, urolithiasis, bladder catheterisation))? FH (eg urinary tract disease such as polycystic kidney disease)? DH (eg recent antibiotics)? Drug allergies? Examination: BP? HR? Temp.? RR? Flank or suprapubic tenderness? Pelvic or abdominal mass? Blockage if urinary catheter in situ? Other systems depending on suspected cause, eg genital examination if vulvovaginal atrophy or herpes simplex is a possibility? Investigations: If < 65 y + no RF for complicated UTI: urine dipstick? (Urine dipstick is unreliable in women aged older than 65 and those who are catheterised) Positive for nitrite or leucocyte and red blood cells UTI is likely -> Urine sample (morning sample most reliable) for culture and sensitivity if previous antibiotic treatment has failed or there is a possibility of antibiotic resistance Negative for nitrite and positive for leukocyte, UTI equally likely to other diagnosis -> Urine culture to confirm diagnosis Negative for all nitrite, leucocyte and red blood cells, UTI is less likely -> No need to send sample for urine culture - consider other diagnosis Urine culture (if pregnant, > 65 y, symptoms persistent or do not resolve with antibiotic treatment, recurrent UTI (2 episodes in 6 months or 3 in 12 months), urinary catheter in situ or recently been catheterised, RFs for resistance or complicated UTI (e.g. abnormalities of genitourinary tract, renal impairment, residence in a long term care facility, hospitalisation for more than 7 days in the last 6 months, recent travel to a country with increased resistance or previous resistant UTI, atypical symptoms, visible or non-visible haematuria)? Management: Advised: - Paracetamol (or if preferred and suitable, ibuprofen) can be used for pain relief - Enough fluids to avoid dehydration No visible haematuria, not pregnant or catheterized: Advised to consider the need for antibiotics depending on severity of symptoms, risk of complications, and previous urine culture results and antibiotic use and if immediate treatment to treat according to sensitivities from recent urine culture (if available), otherwise to treat empirically taking account of local antimicrobial resistance patterns 1st choice: Nitrofurantoin 100mg modified-release twice a day for 3 days (if eGFR ≥45ml/minute) or Trimethoprim 200mg twice a day for 3 days (if low risk of resistance) 2nd choice: Pivmecillinam (a penicillin) 400mg initial dose, then 200mg three times a day for a total of 3 days or Fosfomycin 3g single dose sachet Advised if prescribing a delayed (back-up) antibiotic as symptoms are mild and no risk factors for complicated infection — to start antibiotics if symptoms do not improve within 48 hours or worsen at any time Advised to seek urgent medical review if symptoms worsen rapidly or significantly at any time or fail to improve within 48 hours of starting antibiotics, then to send a urine sample for culture and susceptibility testing (if not already done) and to consider treatment with another agent while awaiting sensitivities Visible or non-visible haematuria: As above, advised re-test urine after completing treatment Recurrent UTI — no visible haematuria, not pregnant or catheterized: As above, advised referral or to seek specialist advice if underlying cause is unknown and to arrange an urgent 2-week wait referral if suspected underlying malignancy Advised to avoid douching and occlusive underwear, wipe from front to back after defaecation, to avoid delay of habitual and post-coital urination to maintain adequate hydration, to consider vaginal oestrogen in postmenopausal women if underlying cause has been investigated and behavioural/hygiene measures alone are ineffective or inappropriate with the lowest effective dose to be described with discussion of the risks and benefits of treatment including adverse effects of tenderness and vaginal bleeding (which may require investigation), and the uncertainty of endometrial safety with long-term or repeated use and to review treatment within 12 months Advised to consider antibiotic prophylaxis if underlying cause has been investigated and behavioural/personal hygiene measures and vaginal oestrogen (in postmenopausal women) are ineffective or inappropriate? 1st choice: Trimethoprim 200mg single dose when exposed to a trigger or Nitrofurantoin (if eGFR ≥45ml/ minute) 100mg single dose when exposed to a trigger 2nd choice: Amoxicillin 500mg single dose when exposed to a trigger (off label indication) or Cefalexin 500mg single dose when exposed to a trigger If no improvement after single-dose antibiotic prophylaxis or no identifiable triggers advised to consider trial of daily antibiotic prophylaxis? 1st choice: Trimethoprim 100mg at night or Nitrofurantoin (if eGFR ≥45ml/ minute) 50 to 100mg at night 2nd choice: Amoxicillin 250mg at night (off label indication) or Cefalexin 125mg at night Advised to arrange follow-up within 3–6 months and to seek urgent review if symptoms of acute UTI develop UTI in pregnancy — no visible haematuria: Advised to send a midstream urine sample for culture and sensitivities before antibiotics are taken 1st choice: Nitrofurantoin (avoid at term) 100mg modified-release twice a day for 7 days if eGFR ≥45ml/minute 2nd choice (no improvement in lower UTI symptoms on first-choice taken for at least 48 hours or when first-choice not suitable): Amoxicillin (only if culture results available and susceptible) 500mg three times a day for 7 days or Cefalexin 500mg twice a day for 7 days Asymptomatic bacteriuria in pregnancy: After confirmed with repeated sample offered immediate antibiotic as above Ensured antenatal services are made aware if group B streptococcal bacteriuria, as in addition to treatment at the time of diagnosis intrapartum antibiotic prophylaxis will be required With catheter — no haematuria, not pregnant: Advised not to routinely treat catheter-associated asymptomatic bacteriuria If the catheter has been in place for more than 7 days advised to consider to remove the catheter or, if this cannot be done, to change it as soon as possible and before antibiotics are taken to send a sample from mid-stream urine if the catheter has been removed or from the new catheter if changed and to ensure that the laboratory is aware of previous antibiotic use and that this is a suspected catheter associated UTI Reference(s): NICE CKS: UTI (lower) - women