Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Management of Urinary Tract Infection (UTI) in Adult Women
Diagnosis
C - In otherwise healthy women presenting with symptoms or signs of urinary tract infection (UTI), empirical treatment with an antibiotic should be considered.
C - In women with symptoms of vaginal itch or discharge, explore alternative diagnoses and consider pelvic examination.
Near Patient Testing
Dipstick Tests
B - Dipstick tests should only be used to diagnose bacteriuria in women with limited symptoms and signs (no more than two symptoms).
- Women with limited symptoms of UTI who have negative dipstick urinalysis (leucocyte esterase or nitrite) should be offered empirical antibiotic treatment.
- The risks and benefits of empirical treatment should be discussed with the patient and managed accordingly.
- If a woman remains symptomatic after a single course of treatment, she should be investigated for other potential causes
Antibiotic Treatment
Symptomatic Bacteriuria, Lower Urinary Tract Infection (LUTI)
A - Non-pregnant women with symptoms or signs of acute LUTI, and either high probability of or proven bacteriuria, should be treated with antibiotics.
B - Non-pregnant women of any age with symptoms or signs of acute LUTI should be treated with trimethoprim or nitrofurantoin for three days.
D - Women with LUTI, who are prescribed nitrofurantoin, should be advised not to take alkalinising agents (such as potassium citrate).
B - Patients who do not respond to trimethoprim or nitrofurantoin should have urine taken for culture to guide change of antibiotic.
Symptomatic Bacteriuria, Upper Urinary Tract Infection (UUTI)
A - Non-pregnant women with symptoms or signs of acute UUTI should be treated with ciprofloxacin for seven days.
D - Urine should be taken for culture before immediate empirical treatment is started and treatment changed if there is an inadequate response to the antibiotic.
Asymptomatic Bacteriuria
A - Non-pregnant women with asymptomatic bacteriuria should not receive antibiotic treatment.
A - Elderly women (over 65 years of age) with asymptomatic bacteriuria should not receive antibiotic treatment.
Non-Antibiotic Treatment
Cranberry Products
A - Women with recurrent UTI should be advised to take cranberry products to reduce the frequency of recurrence.
D - Patients taking warfarin should avoid taking cranberry products unless the health benefits are considered to outweigh any risks.
Methenamine Hippurate
B - Methenamine hippurate may be used to prevent symptomatic UTI in patients without known upper renal tract abnormalities.
Oestrogen
A - Oestrogens are not recommended for routine prevention of recurrent UTI in postmenopausal women.
Management of Bacterial UTI in Pregnant Women
Diagnosis
Near Patient Testing
A - Standard quantitative urine culture should be performed routinely at first antenatal visit.
A - The presence of bacteriuria in urine should be confirmed with a second urine culture.
A - Dipstick testing should not be used to screen for bacterial UTI at first or subsequent antenatal visits.
Antibiotic Treatment
Symptomatic Bacteriuria
B - Pregnant women with symptomatic UTI should be treated with an antibiotic.
Asymptomatic Bacteriuria
A - Asymptomatic bacteriuria detected during pregnancy should be treated with an antibiotic.
Screening During Pregnancy
C - Women with bacteriuria confirmed by a second urine culture should be treated and have repeat urine culture at each antenatal visit until delivery.
Management of Bacterial UTI in Adult Men
Antibiotic Treatment
Symptomatic Bacteriuria
C - Bacterial UTI in men should be treated empirically with a two week course of quinolone.
Asymptomatic Bacteriuria
A - Elderly men (over 65 years of age) with asymptomatic bacteriuria should not receive antibiotic treatment.
Referral
D - Men should be referred for urological investigation if they have symptoms of upper urinary tract infection (UUTI), fail to respond to appropriate antibiotics, or have recurrent UTI.
Management of Bacterial UTI in Patients with Catheters
Diagnosis
D - Clinical symptoms or signs are not recommended for predicting the likelihood of symptomatic UTI in catheterised patients.
Near Patient Testing
Urine Microscopy
C - Laboratory microscopy should not be used to diagnose UTI in catheterised patients.
Dipstick Tests
B - Dipstick testing should not be used to diagnose UTI in catheterised patients.
Antibiotic Prophylaxis to Prevent Catheter Related UTI
A - Antibiotic prophylaxis is not recommended for the prevention of symptomatic UTI in catheterised patients.
Antibiotic Treatment
Symptomatic Bacteriuria
B - Patients with long term indwelling catheters should have the catheter changed before starting antibiotic treatment for symptomatic UTI.
Asymptomatic Bacteriuria
B - Screening of women with asymptomatic bacteriuria after short term catheterization is not recommended.
B - Catheterised patients with asymptomatic bacteriuria should not receive antibiotic treatment.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
