1. Management of UTIs Chris Longstaff

2. Adult Non-Pregnant Women

3. When not to dipstick?  Do not dipstick if UTI highly likely  SIGN and HCA - more than 2 symptoms  CKS – moderate-severe symptoms  90% of these do have a UTI

4. When to Dipstick?  Dipstick if diagnosis uncertain  With only 1 symptom 20% false negative rate  SIGN advise to offer this group Abx even with negative dip  HPA advise only treat this group if nitrite or leukocyte positive dipstick  Looking for cloudiness is also reasonable (91% of non-cloudy urine in this group is not infected)

5. Urine Culture  Often results only available after symptoms settle  Relatively expensive lab investigation  Do not culture unless treatment failure (SIGN, CKS, EAU all agree)  If all possible UTIs were cultured  Cost per day of symptoms saved - £215  Reduction in duration – 0.04-0.32 days

6. Antibiotics  Acute Cystitis tends to be self- limiting in this group  If UTI likely, offer antibiotics with an explanation  Average duration  4-9 days without antibiotics  3-8 days with antibiotics

7. Pregnant Women

8. Asymptomatic Bacteriuria  20-40% of pregnant women with asymptomatic bacteriuria develop pyelonephritis in pregnancy  NNT is 7  Association with increased low birth weight low gestational age increased neonatal mortality

9. Asymptomatic Bacteriuria Screening  Needs MSU culture  Send at first booking appointment  Confirmed positive needs 2 positive cultures growing the same bacteria  (40% false positive for single positives)

10. What to do with Positive Results  Treat according to sensitivities  If there are options, CKS advises the following order of preference Amoxicillin Nitrofurantoin Trimethoprim (unless folate defic) Cefalexin  Recheck  At every subsequent antenatal visit (SIGN and CKS)

11. Treating Acute Cystitis  Insufficient evidence for short courses, so treat for 7 days  CKS advises empirical treatment with the following Abx in order of preference  Nitrofurantoin  Trimethoprim  Cefalexin  (not Amoxicillin as resistance is too high)

12. Men

13. Why do they have a UTI?  Often underlying complications  Consider Chlamydia  Refer if 2 or more episodes in 3/12

14. Concomitant Prostatitis  A significant proportion of males with UTI also have prostatitis  If inadequately treated this can lead to chronic prostatic infection or abscess  50% of all men with UTI also have prostatitis  90% of men with febrile UTI also have prostatitis  Only 9% of these actually had a tender prostate

15. To Treat Prostatitis or Not?  Treating Prostatitis Treat for 14 days Quinolone 1 st line Not Nitrofurantoin Recommended by EAU and SIGN for treatment of all male UTIs  Only treating UTI Treat for 7 days Nitrofurantoin or Trimethoprim 1 st line Recommended by CKS and HPA