There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
solution
Tablet
CAUTIONARY AND ADVISORY LABELS 8
▶Pyrazinamide (Non-proprietary)
Pyrazinamide 500 mg Pyrazinamide 500mg tablets |
30 tablet P £40.06 DT = £40.06
▶Zinamide (Genus Pharmaceuticals Ltd)
Pyrazinamide 500 mg Zinamide 500mg tablets | 30 tablet P
£31.35 DT = £40.06
Combinations available: Rifampicin with ethambutol,
isoniazid and pyrazinamide, p. 617. Rifampicin with isoniazid
and pyrazinamide, p. 618
2.6 Urinary tract infections
Urinary-tract infections
Description of condition
Urinary-tract infections (UTIs) are common infections that
can affect any part of the urinary tract. They occur more
frequently in women, and are usually independent of any
risk factor. UTIs are predominantly caused by bacteria from
the gastrointestinal tract entering the urinary tract, with
Escherichia coli being the most common cause. Infection due
to Candida albicans is rare, but may occur in hospitalised
patients who are immunocompromised or have an
indwelling catheter.
Lower UTIs are associated with inflammation of the
bladder (cystitis) and urethra (urethritis). In some patients
infection can ascend the urinary tract and lead to an upper
UTI. Upper UTIs affect the proximal part of the ureters
(pyelitis) or the proximal part of the ureters and the kidneys
(pyelonephritis), and can cause renal scarring, abscess or
failure, and sepsis. The most common signs and symptoms
of lower UTIs are dysuria, increased urinary frequency and
urgency, urine that is strong smelling, cloudy or contains
blood, and persistent lower abdominal pain. Upper UTIs
usually present with accompanying loin pain and fever.
In pregnant women, asymptomatic bacteriuria is a risk
factor for pyelonephritis and premature labour. UTIs in
pregnancy have been associated with developmental delay
and cerebral palsy in the infant, as well as fetal death.
Insertion of a catheter into the urinary tract increases the
risk of developing a UTI, and the longer the catheter is in
place for, further increases the risk of bacteriuria.
UTIs are considered recurrent after at least two episodes
within 6 months, or three or more episodes within
12 months.
Acute prostatitis is an infection of the prostate gland and
is usually caused by a UTI. It can occur spontaneously or
after certain medical procedures and can last for several
weeks. Common symptoms include sudden onset of fever,
acute urinary retention or irritative voiding symptoms.
Possible complications include prostatic abscess,
bacteraemia, epididymitis, and pyelonephritis. Chronic
prostatitis is a complication of acute prostatitis and is
defined as at least 3 months of urogenital pain usually
associated with lower urinary tract symptoms.
Aims of treatment
The aims of treatment are to relieve symptoms, treat the
underlying infection, prevent systemic infection, and to
reduce the risk of complications.
Non-drug treatment
g Patients with a UTI should be advised to drink plenty of
fluids to avoid dehydration, and to use self-care strategies to
reduce the risk of recurrent infections. These include wiping
from front to back after defaecation, not delaying urination,
and not wearing occlusive underwear.
D-mannose, cranberry or urine alkalinising products may
be used as self-care treatment strategies, however the
benefit of these products for the prevention and treatment of
UTIs has not been established. Patients should be advised to
consider the sugar content of these products. h
Drug treatment
g When prescribing antibacterial therapy the severity of
symptoms, risk of developing complications, previous urine
culture and susceptibility results, and previous antibacterial
use should be taken into consideration.
With the exception of pregnant women, asymptomatic
bacteriuria is not routinely treated with antibacterials. h
For other considerations such as for patients receiving
prophylactic antibacterial therapy, switching from
intravenous to oral antibacterials, and for advice to give to
patients, see Antibacterials, principles of therapy p. 527.
g Reassess patients if symptoms worsen at any time, or
do not start to improve within 48 hours of starting
treatment.
Refer patients to hospital if they have any symptoms or
signs suggestive of a more serious illness or condition.
Review choice of antibacterial when microbiological
results are available, and change treatment as appropriate if
susceptibility results indicate bacterial resistance.
Advise patients that paracetamol or ibuprofen can be used
for pain relief. Where appropriate codeine may be used in
patients with acute pyelonephritis or prostatitis. h
Lower urinary-tract infection
Non-pregnant women
g Consider a back-up antibacterial prescription for use if
symptoms worsen or do not improve within 48 hours or an
immediate antibacterial prescription. h
Choice of antibacterial therapy
. Oral first line :
▶g Nitrofurantoin p. 625, or trimethoprim p. 607 (if low
risk of resistance). h
. Oral second line (if no improvement after at least 48 hours,
or first line not suitable):
▶g Nitrofurantoin (if not used first line), fosfomycin
p. 603, or pivmecillinam hydrochloride p. 585. h
Men
g An immediate antibacterial prescription should be
given and a midstream urine sample obtained before
treatment is taken and sent for culture and susceptibility
testing. h
Choice of antibacterial therapy
. Oral first line :
▶g Nitrofurantoin, or trimethoprim. h
. Oral second line (if no improvement after at least 48 hours,
or first line not suitable):
▶Consider pyelonephritis or prostatitis. See pyelonephritis,
acute, or prostatitis, acute below for guidance.
Pregnant women
g An immediate antibacterial prescription should be
given and a midstream urine sample obtained before
treatment is taken and sent for culture and susceptibility
testing. h
Choice of antibacterial therapy
. Oral first line :
▶g Nitrofurantoin. h
. Oral second line (if no improvement after at least 48 hours,
or first line not suitable):
▶g Amoxicillin p. 579 (only if culture susceptible), or
cefalexin p. 551. h
. Alternative second line :
▶g Consult local microbiologist. h
. Asymptomatic bacteriuria:
▶g Amoxicillin, cefalexin, or nitrofurantoin. h
Prostatitis, acute
g An immediate antibacterial prescription should be
given and a midstream urine sample obtained before
treatment is taken and sent for culture and susceptibility
Infection
testing.
Refer patients to hospital if symptoms are not improving
after 48 hours of treatment, or if they have any signs or
symptoms suggestive of a more serious condition such as
sepsis, acute urinary retention, or prostatic abscess. h
Choice of antibacterial therapy
. Oral first line :
▶g Ciprofloxacin p. 590, or ofloxacin p. 593.
▶Alternative first line (if unable to take fluoroquinolones):
trimethoprim. h
. Oral second line (on specialist advice):
▶g Levofloxacin p. 592, or co-trimoxazole p. 594. h
. Intravenous first line (if severely unwell or unable to take
oral treatment). g Antibacterials may be combined if
concerned about sepsis.
▶Amikacin p. 544, ceftriaxone p. 556, cefuroxime p. 553,
ciprofloxacin, gentamicin p. 545, or levofloxacin. h
. Intravenous second line :
▶g Consult local microbiologist. h
Pyelonephritis, acute
g An immediate antibacterial prescription should be
given and a midstream urine sample obtained before
treatment is taken and sent for culture and susceptibility
testing.
Consider referring or seeking specialist advice for patients
with acute pyelonephritis who are significantly dehydrated
or are unable to take oral fluids and medicines, are pregnant,
or have a higher risk of developing complications. h
Non-pregnant women and men
Choice of antibacterial therapy
. Oral first line :
▶g Cefalexin p. 551, or ciprofloxacin p. 590. If sensitivity
known: co-amoxiclav p. 582, or trimethoprim p. 607. h
. Intravenous first line (if severely unwell or unable to take
oral treatment). g Antibacterials may be combined if
concerned about susceptibility or sepsis.
▶Amikacin p. 544, ceftriaxone p. 556, cefuroxime p. 553,
ciprofloxacin, or gentamicin p. 545. Co-amoxiclav may be
used if given in combination or sensitivity known. h
. Intravenous second line :
▶g Consult local microbiologist. h
Pregnant women
Choice of antibacterial therapy
. Oral first line :
▶g Cefalexin. h
. Intravenous first line (if severely unwell or unable to take
oral treatment):
▶g Cefuroxime. h
. Second line or combining antibacterials if concerned about
susceptibility or sepsis:
▶g Consult local microbiologist. h
Recurrent urinary-tract infection
g For patients with recurrent UTIs, refer or seek specialist
advice for men, pregnant women, patients with suspected
cancer, those presenting with recurrent upper UTI, and those
with recurrent lower UTI with an unknown cause.
For postmenopausal women experiencing recurrent UTIs,
consider a vaginal oestrogen [unlicensed indication] at the
lowest effective dose if behavioural and personal hygiene
measures alone are not effective or appropriate. Treatment
should be reviewed within 12 months. Oral oestrogens
(hormone replacement therapy) should not be given to
postmenopausal women specifically to reduce the risk of
recurrent UTIs.
In non-pregnant women, consider a trial of antibacterial
prophylaxis if behavioural and personal hygiene measures,
and vaginal oestrogen (in postmenopausal women) are not
effective or appropriate. Single-dose antibacterial
Infection
prophylaxis [unlicensed indication] should be considered for
use when exposed to an identifiable trigger. Daily
antibacterial prophylaxis should be considered in non-
pregnant women who have had no improvement after
single-dose antibacterial prophylaxis, or who have no
identifiable triggers.
With specialist advice, daily antibacterial prophylaxis
should be considered for men and pregnant women if
behavioural and personal hygiene measures alone are not
effective or appropriate.
Advise patients about the risk of resistance with long-term
antibacterial use, seeking medical help if symptoms of an
acute UTI develop, and to return for review within 6 months.
Review the success and ongoing need of prophylaxis at
least every 6 months. If antibacterial prophylaxis is stopped
ensure the patient has rapid access to treatment if they
develop an acute UTI. h
Women and men
Choice of antibacterial therapy
. Oral first line :
▶g Trimethoprim, or nitrofurantoin p. 625. h
. Oral second line :
▶g Amoxicillin p. 579 [unlicensed indication], or
cefalexin. h
Catheter-associated urinary-tract infection
g For people with a catheter-associated urinary-tract
infection, consider removing or changing the catheter as
soon as possible if it has been in place for longer than 7 days,
without delaying antibacterial treatment. An immediate
antibacterial prescription should be given and a urine sample
obtained before treatment is taken and sent for culture and
susceptibility testing.
Consider referring or seeking specialist advice for patients
with a catheter-associated UTI who are significantly
dehydrated or unable to take oral fluids and medicines, are
pregnant, have a higher risk of developing complications,
have recurrent catheter-associated UTIs, or have bacteria
resistant to oral antibacterials. h
Non-pregnant women and men
Choice of antibacterial therapy
. Oral first line (if no upper UTI symptoms):
▶g Amoxicillin (only if culture susceptible),
nitrofurantoin, or trimethoprim (if low risk of resistance).
h
. Oral second line (if no upper UTI symptoms and first-line
not suitable):
▶g Pivmecillinam hydrochloride p. 585. h
. Oral first line (upper UTI symptoms):
▶g Cefalexin, ciprofloxacin, co-amoxiclav (if culture
susceptible), or trimethoprim (if culture susceptible). h
. Intravenous first line (if severely unwell or unable to take
oral treatment). g Antibacterials may be combined if
concerned about susceptibility or sepsis.
▶Amikacin, ceftriaxone, cefuroxime, ciprofloxacin,
gentamicin, or co-amoxiclav (only in combination, unless
culture results confirm susceptibility). h
. Intravenous second line :
▶g Consult local microbiologist. h
Pregnant women
Choice of antibacterial therapy
. Oral first line :
▶g Cefalexin. h
. Intravenous first line (if severely unwell or unable to take
oral treatment):
▶g Cefuroxime. h
. Second line or combining if concerned about susceptibility or
sepsis:
▶g Consult local microbiologist. h
Useful Resources
Urinary tract infection (lower): antimicrobial prescribing.
National Institute for Health and Care Excellence. Clinical
Guideline 109. October 2018.
www.nice.org.uk/guidance/ng109
Prostatitis (acute): antimicrobial prescribing. National
Institute for Health and Care Excellence. Clinical Guideline
110. October 2018.
www.nice.org.uk/guidance/ng110
Pyelonephritis (acute): antimicrobial prescribing. National
Institute for Health and Care Excellence. Clinical Guideline
111. October 2018.
www.nice.org.uk/guidance/ng111
Urinary tract infection (recurrent): antimicrobial
prescribing. National Institute for Health and Care
Excellence. Clinical Guideline 112. October 2018.
www.nice.org.uk/guidance/ng112
Urinary tract infection (catheter-associated): antimicrobial
prescribing. National Institute for Health and Care
Excellence. Clinical Guideline 113. November 2018.
www.nice.org.uk/guidance/ng113
Patient decision aids: Urinary tract infection (lower);
Urinary tract infection (recurrent) National Institute for
Health and Care Excellence. November 2018.
www.nice.org.uk/about/what-we-do/our-programmes/nice-
guidance/nice-guidelines/shared-decision-making
ANTIBACTERIALS › OTHER
PDF pages 644, 645, 646
