Urine dipstick

• Positive for nitrite or leukocyte and RBC: UTI is likely.  Send urine MCS if previous antibiotic treatment has failed or there is a possibility of antibiotic resistance.

• Negative for nitrite and positive for leukocyte: UTI is equally likely to other diagnosis. Send urine culture to confirm diagnosis.

• Negative for all nitrite, leukocyte and RBC: UTI is less likely. No need to send sample for urine culture — consider other diagnoses.

UTI in adults

• Urinary tract infections in adults (NHS Choices)​, UTI - lower - women (CKS), Recurrent cystitis in women (patient.info), UTI - lower - men (CKS)

• Lower UTI: Nitrofurantoin MR 100mg BD 3/7 (7 days if M or pregnant). Alternative 1st-line: trimethoprim or pivmecillinam (F>16yrs). If GFR<45 or elderly consider pivmecillinam or fosfomycin. Pregnant/BF: nitro. Avoid trimeth if folate def, low folate intake, taking folate antagonist (antiepileptics/proguanil). Children: <3M: urgent referral. ≥3M: trimeth, nitro (GFR≤45). Amoxi if susceptible. 2nd-line: cefalexin.

• Recurrent UTI: post-menopausal F: vaginal E2, standby abx, prophylaxis (nitro>cipro>trimeth) . Pregnant/BF/male: seek specialist advice

• Catheter-associated: No upper UTI sx: nitro (if GFR≥45) OR trimeth OR amoxi. 2nd-line: pivmecillnam. Pregnancy/BF: cefalexin. Upper UTI sx: cefalexin OR co-amox OR trimeth OR cipro (trimeth or cipro if penicillin allergic)

• Primary Care Antibiotic Guideline 2019 (Lambeth & Southwark CCG, London)

​UTI in children

Question

A five-year-old girl has a three-day history of increased urinary frequency and dribbling with pain on passing urine. A urine culture shows:

Urine microscopy:

• White cells: +++ (>250 cells/ul)

• Red cells: Nil

Urine culture:

• Presence of normal urogenital flora, probable contamination. 

Which is the SINGLE MOST appropriate NEXT step? 

1. Arrange renal ultrasound 

2. Treat with oral trimethoprim

3. Treat with topical clotrimazole

4. Check inflammatory markers

5. No further action required

According to current guidance, if a child has signs or symptoms suggestive of a clinical urinary tract infection (UTI) where microscopy confirms pyuria (white cells in the urine) but urine culture is negative, antibiotic treatment should be started.

The clinical symptoms of urinary frequency, dribbling and dysuria are more suggestive of UTI than vulvovaginitis. Vulvovaginitis in pre-pubertal girls is rarely due to candida and is usually associated with bacterial infection, related to the increased susceptibility of the hypo-oestrogenic mucosa to infection.

• Upper UTI, children: refer. 

• Urinary tract infections in children (NHS Choices), UTI - children (CKS), Urinary tract infection in under 16s: diagnosis and management (NICE, 2007)

Pyelonephritis​

• Pyelonephritis - acute (CKS)

• Pyelonephritis: cefalexin OR co-amoxiclav (OR if MSU susceptible: trimeth OR cipro). Trimeth OR cipro if penicillin allergic. Pregnant/BF: cefalexin