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 Formulary Chapter 27: Antimicrobial guide - Full Chapter
Notes:

Coronavirus guidance

Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.

The list of resources will be updated as new material becomes available so please check back regularly for updates.

The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.

Antimicrobial guide

Self-care

Treatments marked as [OTC] are available to buy from pharmacies. Patients can be advised to purchase them as self-care where appropriate.

 

 Details...
27.08  Expand sub section  Urinary tract infections
 note 

 

Urinary tract infections

 

Non-pregnant women with uncomplicated lower UTI

Consider offering a back-up (delayed) antibiotic prescription for low severity symptoms and low risk of complications.

TARGET UTI leaflet

NICE UTI (lower) 3-page visual summary

First line: if eGFR ≥ 45 ml/minute, nitrofurantoin 100 mg MR BD for 3 days or
if there is low risk of resistance, trimethoprim 200 mg BD for 3 days.

Alternative: if not used 1st line, nitrofurantoin 100 mg MR BD for 3 days (if eGFR ≥ 45 ml/minute) or
pivmecillinam 400 mg STAT then 200 mg TDS for a total of 3 days or
fosfomycin 3 g single dose sachet.

Trimethoprim resistance and a liquid formulation is required: cefalexin 500 mg TDS for 3 days.

Last updated: Dec 2019

 
   
Non-pregnant women with complicated lower UTI

UTI may be complicated due to an abnormal genitourinary tract or impaired host defences:

  • Stent or splint (urethral, ureteral, renal) or nephrostomy.
  • Post-void residual urine of > 100 ml.
  • An obstructive uropathy of any aetiology (upper and lower urinary tracts), e.g., bladder outlet obstruction (including neurogenic urinary bladder), stones and tumour.
  • Vesicoureteric reflux or other functional abnormalities.
  • Urinary tract modifications/deviation, such as an ileal loop or pouch.
  • Chemical or radiation injuries of the uroepithelium.
  • Peri- and postoperative UTI, including renal transplantation.
  • Poorly controlled diabetes.
  • Immunosuppression.

TARGET UTI leaflet

NICE UTI (lower) 3-page visual summary

First line: cefalexin 500 mg TDS 7 days.

Alternative: with culture results and susceptibility, co-amoxiclav 500/125 mg TDS for 7 days or
with culture results and susceptibility, trimethoprim 200 mg BD for 14 days or
ciprofloxacin 500 mg BD 7 days.

Last updated: Dec 2019

 
   
Pregnant women with symptomatic lower UTI

Send urine for culture and review antibiotic choice with results; change antibiotic if bacteria are resistant regardless of treatment response.

TARGET UTI leaflet

NICE UTI (lower) 3-page visual summary

First line: avoid at term, * nitrofurantoin 100 mg MR BD for 7 days (if eGFR ≥ 45 ml/minute).

* May cause neonatal haemolysis. Avoid from 37 weeks of pregnancy.

Alternative: with culture results and susceptibility, amoxicillin 500 mg TDS for 7 days or
if eGFR < 45 ml/min and non-severe penicillin allergy, cefalexin 500 mg TDS for 7 days.

Last updated: Dec 2019

 
   
Pregnant women with asymptomatic bacteriuria

Screen for bacteriuria.

Confirm clearance of infection 7 days after completing treatment and request a follow-up MSU at each antenatal clinic appointment.

NICE UTI (lower) 3-page visual summary

Based on culture results and susceptible bacteria

Avoid at term, * nitrofurantoin 100 mg MR BD for 7 days (if eGFR ≥ 45 ml/minute) or
amoxicillin 500 mg TDS for 7 days or
non-severe penicillin allergy, cefalexin 500 mg TDS for 7 days.

* May cause neonatal haemolysis. Avoid from 37 weeks of pregnancy.

Last updated: Dec 2019 

 
   
Adult men with lower UTI

Send MSU for culture and susceptibility testing. Consider urology referral to screen out an underlying cause.

Consider alternative diagnoses including pyelonephritis or acute prostatitis if not responded to first choice antibiotic.

NICE UTI (lower) 3-page visual summary

First line: if eGFR ≥ 45 ml/minute, nitrofurantoin 100 mg MR BD for 7 days or
trimethoprim 200 mg BD for 7 days.

Alternative with culture results and susceptibility: pivmecillinam 400 mg STAT then 200 mg TDS for a total of 7 days or
non-severe penicillin allergy, cefalexin 500 mg TDS for 7 days.

Last updated: Dec 2019

 
   
Pyelonephritis (upper urinary tract), acute

Refer to hospital patients with severe systemic infection. Consider referring those who are: dehydrated or unable to take oral fluids; pregnant; at risk of complicated UTI.

NICE pyelonephritis 3-page visual summary

First line: cefalexin 500 mg TDS for 7 days or
with culture results and susceptibility, co-amoxiclav 500/125 mg TDS for 7 days or
with culture results and susceptibility, trimethoprim 200 mg BD 14 days or
ciprofloxacin 500 mg BD for 7 days.

In pregnancy: low threshold for hospitalisation, cefalexin 500 mg TDS for 7 days.

Last updated: Aug 2020 

 
   
Prostatitis, acute

Refer severe systemic infection (any of the high-risk criteria from the NICE guideline on sepsis), or complications, such as acute urinary retention or suspected prostatic abscess, or symptoms that are not improving 48 hours after starting the antibiotic.

Review antibiotic treatment after 14 days and either stop or continue for a further 14 days if needed based on history, examination findings, urine or blood tests.

If antibiotic choices are not suitable, discuss alternative options with a local microbiologist. Ofloxacin may be preferable if a sexually transmitted infection is suspected.

NICE prostatitis 2-page visual summary

First line: ciprofloxacin 500 mg BD for 14 days then review or
ofloxacin 200 mg BD for 14 days then review.

Alternative: with culture results and susceptibility, trimethoprim 200 mg BD for 14 days then review or
only after discussion with a specialist, co-trimoxazole 960 mg BD for 14 days then review.

Last updated: Dec 2019 

 
   
Catheter-associated urinary tract infection

Definition of catheter associated UTI
At least two of the following with no other recognised cause or
at least one of the following and a positive urine culture and no other recognised cause: fever (> 38 °C); suprapubic tenderness; altered mental status; malaise; lethargy; tenderness over the kidneys; pelvic pain; acute haematuria.

There is a high incidence of bacteriuria with long-term catheters. Antibiotics do not eliminate bacteria but leads to resistant organisms. Send urine culture and treat only if bacteriuria is associated with systemic symptoms (e.g. pyrexia, rigor) or pyelonephritis is likely.

Do not dipstick catheter urine.

Do not use the presence or absence of odorous or cloudy urine alone to differentiate catheter-associated asymptomatic bacteriuria from catheter associated UTI.

Do not use pyuria as an indicator for catheter associated UTI.

Refer patients with severe systemic infection to hospital. Consider referring those who are dehydrated or unable to take oral fluids, pregnant, at risk of complicated UTI, or suffering recurrent catheter associated UTIs.

Do not use prophylactic antibiotics for catheter changes unless there is a history of catheter change associated UTI or trauma.

Nitrofurantoin is not suitable and unlikely to be effective if there is clinical suspicion of upper UTI – treat with antibiotics used for pyelonephritis.

Laboratory diagnosis: intermittent self-catheterisation specimens should be labelled as “MSU”.

NICE catheter-associated UTI 2-page visual summary

Supportive measures

  • Check that the catheter drains correctly and is not blocked.
  • If the catheter has been in place for > 7 days, consider changing it before or when starting antibiotic treatment.
  • Ensure high fluid intake or when this cannot be assured perform regular bladder washout using 0.9% saline.
  • Review the need for continued catheterisation.

First line: no clinical suspicion of upper UTI, nitrofurantoin 100 mg MR BD for 7 days (if eGFR ≥ 45 ml/minute) or
if there is low risk of resistance, trimethoprim 200 mg BD for 7 days or
with culture results and susceptibility, amoxicillin 500 mg TDS for 7 days.

Alternative: pivmecillinam 400 mg STAT then 200 mg TDS for a total of 7 days.

Suspected upper UTI: follow antibiotic choices as pyelonephritis.

In pregnancy: cefalexin 500 mg TDS for 7 days.

Last updated: Dec 2019

 
   
Recurrent urinary tract infection

Recurrent UTI is two proven UTIs in six months or three in 12 months.

Consider urology referral to screen out an underlying cause.

Use single dose prophylaxis only where there is a well-defined trigger. Confirm eradication of previous uropathogen by a negative culture before starting long term prophylaxis.

Consider the risk of pulmonary, hepatic and neurological toxicity. Perform baseline spirometry, LFT and renal function tests before prescribing long-term nitrofurantoin.

Amoxicillin has higher resistance rates and is not licensed for preventing UTIs.

NICE recurrent UTI 2-page visual summary

Give advice on behavioural and personal hygiene measures and self-care to reduce the risk of UTI before considering prophylaxis.

Choose from these agents based on previous sensitivities.

If behavioural or self-care measure fail: if eGFR ≥ 45 ml/minute, nitrofurantoin 100 mg single dose when exposed to a trigger or 100 mg at night or
trimethoprim 200 mg single dose when exposed to a trigger or 100 mg at night.

Alternative: amoxicillin 500 mg single dose when exposed to a trigger or 250 mg at night (unlicensed) or
cefalexin 500 mg single dose when exposed to a trigger or 125 mg at night.

Review at three months and stop at six months.

Last updated: Aug 2020

 
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection. †Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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