QuestionSBA
QuestionChoice
According to [NICE CKS guidelines](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/management/acute-uti-no-visible-haematuria-not-pregnant-or-catheterized/), this is the second-line antibiotic regimen where nitrofurantoin and trimethoprim are contraindicated (see other explanations), or where there is no improvement in symptoms.
10038320
a
PO Pivmecillinam 400mg initial dose, then 200 mg TDS for three days
QuestionChoice
The BNF advises that ciprofloxacin be used with caution in patients with G6PD deficiency. Furthermore, this medication would be more appropriate for patients with acute pyelonephritis managed in the community. The lack of additional symptoms in this patient i.e. flank pain or features of sepsis makes acute pyelonephritis unlikely. 
10038323
d
PO Ciprofloxacin 1g for seven days
QuestionChoice
Methotrexate is listed as a severe interaction with trimethoprim in the BNF, due to the increased risk of haematological side effects that can be fatal. This is a very important drug interaction to remember.
10038322
c
PO Trimethoprim 200mg BD for three days
QuestionChoice
G6PD deficiency is listed as a contra-indication to nitrofurantoin in the BNF.
10038321
b
PO Nitrofurantoin 100mg BD for three days
QuestionChoice
This would be appropriate for patients with suspected urosepsis. This patient does not present with any features of sepsis e.g. hypotension and therefore does not require a stat dose of gentamicin.
10038324
e
STAT dose IV gentamicin 5mg/kg
QuestionComment
So focussed on the G6PD stuff I didn't even see the methotrexate god
54304
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Shush
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bosh
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i did the exact opposite lol
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Defibrillator Dominant
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BradySclerosis
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PSA is the only reason i got this
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Still didn't get it :/
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anon
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Nightshift Bradykinin
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Got my finals tomorrow and still only getting 40% on mocks :/
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you got this!!
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Monoclonal Polyps
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Flutter Juice
Concept
Chapter
# Summary 

Lower urinary tract infections (LUTIs), often manifesting as cystitis, typically involve the infection of the bladder. Primarily caused by transurethral ascent of colonic commensals like E. coli, symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and suprapubic pain. Investigations are generally limited to a urine dipstick test for leucocytes and nitrites, while management involves oral nitrofurantoin or trimethoprim, and conservative measures. A key differential diagnosis is pyelonephritis, a urinary tract infection affecting the kidneys. Pyelonephritis exhibits more severe symptoms like fever, malaise, loin pain, and vomiting, and requires hospital admission and intravenous antibiotics.

# Definition 

A lower urinary tract infection (LUTI) is generally defined as an infection of the bladder, often manifesting as cystitis.

# Aetiology 

LUTIs are caused by the transurethral ascent of colonic commensals, most commonly **E. coli**.

# Signs and symptoms

Patients with LUTIs generally present with:

- Urinary frequency
- Dysuria
- Urgency
- Foul-smelling urine
- Suprapubic pain
- Clinical examination may be normal or reveal suprapubic tenderness.

Red flag symptoms such as haematuria, loin pain, rigors, nausea, vomiting, and altered mental state may indicate more serious infection, and these patients may have/are at risk of developing pyelonephritis (see below) and likely need referral to A&E.


# Investigations

For LUTIs:

- Urine dipstick is positive for leucocytes and nitrites in most cases.
- In uncomplicated cases, no further investigations are required.
- In children, men, and pregnant women a mid-stream urine sample should be sent.

NB: Urine dipstick is unreliable in women aged older than 65 years and those who are catheterised.

If being managed in secondary care due to red flag symptoms consider:

- If there are signs of systemic upset consider routine blood tests such as FBC, U+E, and CRP.
- For uncomplicated UTIs, imaging is rarely required, but if there are concerns over antecedents/complications such as urinary retention/obstruction, an USS bladder/kidney scan would be the first port of call.

# Management 

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[lightgallery1]

For LUTIs:

- First line management is with oral nitrofurantoin or trimethoprim. Antibiotic duration can vary (see below) however in women the standard course length is 3 days.
- The patient should be advised on conservative measures to reduce the risk of further infection e.g. regular fluid intake, post-coital voiding.

## Specific situations

**UTI in Men:**

- Empirical antibiotic drug treatment (if no cultures with sensitivities) with trimethoprim or nitrofurantoin for **7 days.**
- Refer to urology if there are ongoing symptoms despite treatment, if there is an underlying risk factor for UTIs (e.g. urinary calculi, suspected obstruction, previous GU surgery), or if there are recurrent episodes of UTI.

**UTI during Pregnancy (with no haematuria):**

- First-line antibiotics are nitrofurantoin (but *avoid at term),* for **7 days.**
- If nitrofurantoin is not suitable due to e.g. renal function, or there is no improvement in symptoms, consider second-choice antibiotics such as amoxicillin/cefalexin for 7 days.


# NICE Guidelines

[Click here for NICE CKS on urinary tract infection (lower) - women](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/)

[Click here for NICE CKS on pyelonephritis - acute](https://cks.nice.org.uk/topics/pyelonephritis-acute/)

1998
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UTI - choice of antibiotics (NICE).png
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3503
Urinary tract infection
Topic
60
General Practice
Condition
704
Urinary tract infection
UkmlaTopic
12
General practice and primary healthcare
20023
In women with urinary tract infections, pivmecillinam is a suitable second-line antibiotic when nitrofurantoin and trimethoprim are contraindicated.
Presentation
565
Urinary symptoms
UkmlaTopic
12
General practice and primary healthcare
A 55-year-old woman presents to the GP clinic with pain on passing urine for the past three days. She is otherwise well in herself. She has a past medical history of G6PD deficiency and rheumatoid arthritis, for which she takes methotrexate. She does not take any other medication and has no known drug allergies.

She has a temperature of 36.5 degrees Celsius, pulse 65 bpm, BP 125/86 mmHg.

Urine dipstick shows 2+ leukocytes and 3+ nitrites.

The GP decides to prescribe a course of antibiotics for this patient. Which is the most appropriate regimen to prescribe?
a