Comments from Expert Advisory Committee
- Always send pre-treatment MSU in males
- Consider chlamydia particularly in young people presenting with lower urinary tract symptoms
- Consider acute prostatitis in males > 50 with lower urinary tract symptoms
- It is advisable to refer men with recurrent UTI for specialist opinion. Antimicrobial prophylaxis should only be considered following specialist advice.
- Consider acute pyelonephritis/ upper UTI when:
- Pain in the loin which radiates to the iliac fossa and suprapubic area.
- Sudden onset general systemic disturbance with fever, rigors, vomiting.
- Tenderness and guarding over the kidney.
Treatment
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 available: nitrofurantoin 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.
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.
Patient Information
The HSE Health A-Z website provides patient information on many hundreds of conditions and treatments.
We recommend patients use the website developed by HSE/ICGP/IPU partnership www.undertheweather.ie for tips on how to get better from common infections without using antibiotics, what you can do for yourself or a loved one and when to seek help.
Visit HPSC Information Leaflets pages for the General Public, (MRSA, CRE, etc)
- Doses are oral and for adults unless otherwise stated
- Fluoroquinolone warning
- Penicillin allergy – tips on prescribing in penicillin allergy
- Renal impairment dosing table
- Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
- Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).
Reviewed September 2021
