Scope of this Guidance
This guidance refers to uncomplicated urinary tract infections in adult non-pregnant females under 65 years.
It does not apply to pregnant patients, male patients, patients with a catheter in-situ or acute pyelonephritis.
For information on these sub-groups, please see the following webpages.
Comments from Expert Advisory Committee
- Consider offering advice on hydration and pain relief (paracetamol and/ or ibuprofen if suitable)
- Consider delayed antibiotic prescription for use if symptoms worsen or do not improve over 48 hours.
- Use urine dipstick to exclude UTI in young women if there is a low index of suspicion.
- Send MSU if failing to respond to treatment (i.e. after 3 days of first line treatment) or if recent antimicrobial therapy where risk of antimicrobial resistance may be higher.
- Consider chlamydia, particularly in young people presenting with lower urinary tract symptoms.
Choice of empirical therapy should be governed by local resistance rates where available. Patterns can vary substantially across the country
- Nitrofurantoin is the preferred first choice if it is not contra-indicated. Nitrofurantoin resistance rates remain low in community E.coli UTIs throughout Ireland (including in ESBL-producing isolates) despite increasing resistance to other antibiotics. Nitrofurantoin concentrates well in the bladder but is only suitable for uncomplicated lower urinary tract infection.
- Nitrofurantoin precautions
- Tissue concentrations are too low for treatment of systemic infection, including pyelonephritis.
- Nitrofurantoin should not be used in patients with severe renal impairment (CKD Stage 4/5, eGFR <30 mL/min/1.73m2, Creatinine Clearance <30 mL/min) because of diminished urinary tract concentrations and increased risk of toxicity. Nitrofurantoin may be used with caution (as short-course therapy only) if there is a lesser degree of renal impairment (eGFR greater than 30 mL/min) to treat suspected or proven resistant pathogens, when the benefits are expected to outweigh the risks. In frail elderly patients with poor fluid intake and an infection, creatinine levels may deteriorate quickly so if a patient is dehydrated then established renal impairment may be further compromised.
- Two nitrofurantoin formulations are available: nitrofurantoin immediate release capsules (Macrodantin®) and nitrofurantoin prolonged release capsules (MacroBid®). For the treatment of infection the prolonged release capsules are dosed twice daily whilst the standard capsules are dosed four times daily. These products are not interchangeable.
- The rate of trimethoprim resistance in community E. coli UTIs exceed 30% in data from centres across Ireland. Empiric trimethoprim is therefore no longer recommended except where nitrofurantoin is unsuitable and the risk of resistance is low (e.g. where a previous urine culture has had a trimethoprim-susceptible isolate and trimethoprim has not been used, or in a young patient without a significant antibiotic exposure history).
- Cefalexin is a broad-spectrum systemic agent and should generally be avoided in uncomplicated UTI, unless there is no suitable alternative, to prevent the emergence of resistant organisms and C. difficile infection.
- Fosfomycin is suggested for use as a second-line agent e.g. for patients with symptoms not resolving on first-line agents. Many multi-resistant community UTI isolates (including ESBL-producing E. coli) remain susceptible to fosfomycin. To preserve the efficacy of this drug, its use should be limited to second-line treatment. Fosfomycin is not recommended in patients with creatinine clearance <10 mL/min.
- Amoxicillin is not recommended as empiric therapy, as resistance rates of approx. 60% in community E. coli UTIs have been described in recent Irish studies; only use if susceptibilities are available.
- Co-amoxiclav resistance is also increasing in Ireland. In addition, it is a systemic agent and should be avoided in uncomplicated cystitis if a locally acting agent (e.g. nitrofurantoin) could be used instead.
- Ciprofloxacin is a broad-spectrum systemic agent, associated with C. difficile infection and multiple adverse effects. It is not recommended for the empiric treatment of uncomplicated cystitis. It may be considered for targeted therapy of multi-resistant infections, where there are no other appropriate options
Reviewed September 2021