Clinical Notes : Urology

156. Recurrent uncomplicated UTI

Recurrent uncomplicated UTI

 

Scope of this guideline

This guideline does not cover patients with acute uncomplicated UTI, who should be managed with a standard, 3-day course of narrow-spectrum antibiotics where possible, provided that their infection is uncomplicated.

This guideline also does not cover patients with complicated recurrent UTI, so specialist referral should be considered for the following according to local pathways: 

  • pregnant women

  • men 

  • patients with recurrent or severe pyelonephritis

  • patients infected with resistant bacteria

  • patients with recurrent UTI associated with structural or functional abnormalities of the urinary tract

  • patients with recurrent UTI associated with atypical infections, such as tuberculosis or schistosomiasis

  • catheterised patients, in whom misdiagnosis is common because of colonisation (treat only when symptomatic)

  • patients with immunity compromised as a result of drugs or diseases

  • patients with chronic renal failure with oliguria, who should be seen by the renal team because of the risk of renal deterioration

 

Diagnosis and management of uncomplicated recurrent UTI

Defining and diagnosing recurrent UTI

  • Recurrent UTI is defined as two UTIs within 6 months or three UTIs within 12 months 

  • Diagnosis of UTI should be based on a combination of:

    • clinical diagnosis based on typical symptoms 

      • Dysuria

      • Frequency

      • Suprapubic tenderness

      • Urgency

      • Haematuria

    • microbiological diagnosis by appropriate use of urine dipsticks and urine culture

    • past response to antibiotic treatment of isolated episodes of acute of UTI

 

  • A diagnosis of UTI can be considered if the patient has a strong symptom profile, even in the absence of culture‑positive urine or dipstick confirmation

    • fever can be useful to differentiate inflammatory and infective causes 

    • previous response to antibiotics for similar symptoms also supports this diagnosis

 

  • Use of urine dipsticks

    • urine samples should ideally be taken in the early morning, because these samples will have a higher yield

    • samples should be taken midstream to avoid urethral contamination

      • consider whether patients are physically able to take a sample, especially elderly patients 

    • overhydration can impact dipstick results by diluting urine, increasing the likelihood of false-negative results

    • please refer to manufacturer’s advice on appropriate storage for urine dipsticks; incorrect storage and use may result in inaccurate results, such as false‑positive results following prolonged exposure to air

    • the presence of leucocytes and nitrites in combination has a higher predictive value of UTI than leucocytes alone

    • provide full and accurate clinical details on request forms

 

  • A diagnosis of UTI should not be made in asymptomatic patients with a positive urine sample (asymptomatic bacteriuria)

    • dipsticks have a poor predictive value due to a high rate of false positives and false‑negatives; they may be useful in making a diagnosis when a combination of positive results including nitrites are detected in patients with classical symptoms, but a negative dipstick result, while making UTI less likely as a diagnosis, does not rule out UTI and thus must be interpreted in the light of symptoms/previous response to antibiotics

    • do not use dipsticks for asymptomatic or catheterised patients

    • diagnosis in elderly patients should not be based on positive microbiology alone, because asymptomatic bacteriuria is increasingly common with advancing age

      • use of urine dipsticks in elderly patients is associated with a high false-positive rate

      • elderly patients are often unable to provide a history of acute urinary symptoms for reasons such as delirium or dementia

      • asymptomatic bacteriuria is present in 3.6–19% of elderly patients and 15–50% of elderly individuals in long-term care

      • elderly institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of side-effects with no compensating clinical benefits

 

  • Consider referral for urinary tract ultrasound (including post-void residual volume) in patients: 

    • with very frequent infections

    • with recurrent Proteus infections (due to their association with renal calculi)

    • who do not respond to treatment

    • with post-micturition symptoms, such as a sensation of incomplete emptying, or those with a palpable bladder

 

  • Consider a non-urgent referral for suspected bladder cancer in people aged 60 years and over with recurrent or persistent unexplained symptoms of UTI

    • who do not respond to antibiotics 

    • with new storage symptoms where UTI is not confirmed

    • with rigors, systemic illness, and loin pain

  • Consider an urgent referral (within 2 weeks) for suspected bladder cancer in patients:

    • aged 45 years and over with unexplained visible haematuria without urinary tract infection or visible haematuria that persists or recurs after successful treatment of urinary tract infection

    • aged 60 years and over with unexplained non-visible haematuria and either dysuria or a raised white blood cell count

 

 

Behavioural and lifestyle modifications

  • Advise patients with inadequate fluid intake to increase their fluid intake to at least 1.5 litres per day

    • increasing fluid intake does not reduce the risk of UTIs in patients who already drink sufficient fluids, but it may reduce the frequency of recurrent infections in those who do not drink sufficiently

    • dehydration is a particular cause of recurrent UTI in elderly individuals and should be discussed with the patient

 

  • Optimise diabetic control

 

  • Treat constipation and diarrhoea, particularly in elderly patients—constipation is a common underlying cause of recurrent UTI in this population

 

  • Encourage post-coital voiding in women with intercourse‑triggered UTI

 

Prescribing

 
 
 
 
NICE.jpg
PHE.png

Diagnosis of urinary tract infections

Public Health England. 

November 2018

Access

 

Urological Infections

​EAU Urological Infections Guidelines Panel

2018

Access

Urinary tract infection (recurrent): antimicrobial prescribing

National Institute for Health and Care Excellence

NG112

October 2018

Access

Giesen, L. G. et al.

Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs.

BMC Family Practice. 2010;11(78).

Access

Michaels T, Sands J.

Dysuria: Evaluation and Differential Diagnosis in Adults.

American Family Physician. 2015;92(9)

Access

Management of suspected bacterial urinary tract infection in adults.

Scottish Intercollegiate Guidelines Network (SIGN).

July 2012

Access

Urinary tract infections in women

BMJ Best Practice

Last updated: January  2019

Last reviewed: March 2019

Access

Urinary tract infections in men

BMJ Best Practice

Last updated: September 2018

Last reviewed: March 2019

Access

 

CPD Quiz and Certificate

This activity attracts 1,0 CPD point

Scroll down the box above to view its entire content

All users who successfully complete the quiz are e-mailed a copy of their personalised CPD certificate.