Urinary Tract Infection (UTI)

Description 

General Measures

Medicine Treatment 

Referral

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N10/N30.9/N39.0/O23.4

DESCRIPTION

Urinary tract infections may involve the upper or lower urinary tract. Infections may be complicated or uncomplicated. Uncomplicated UTI is a lower UTI, where there are no functional or anatomical anomalies in the urinary tract, no kidney impairment, or no concomitant disease that would promote the UTI.

Complicated UTIs exist in patients with an increased chance of a complicated course, i.e. all men, pregnant women, patients with relevant anatomical or functional abnormalities of the urinary tract, indwelling urinary catheters, kidney diseases, and/or other concomitant immunocompromising diseases for example, diabetes.

Differentiation of upper from lower urinary tract infection in young children is not possible on clinical grounds.

Upper UTI is a more serious condition and requires longer, and sometimes intravenous, treatment.

Features of upper UTI (pyelonephritis) that may be detected in adults and adolescents include:

• Flank pain/ tenderness
• Temperature 38^oC or higher
• Other features of sepsis, i.e.:
  - Tachypnoea
  - Tachycardia
  - Confusion
  - Hypotension
• Vomiting

In complicated, recurrent or upper UTIs, urine should be sent for microscopy, culture and sensitivity.

LoE:IVb⁶

Features of urinary tract infections in children

Signs and symptoms are related to the age of the child and are often non-specific.

Uncomplicated urinary tract infections may cause very few signs and symptoms, while complicated infections may present with a wide range of signs and symptoms.

Neonates may present with:

• Fever
• Poor feeding
• Vomiting
• Failure to thrive
• Hypothermia
• Sepsis
• Prolonged jaundice
• Renal failure

Infants and children may present with:

• Failure to thrive
• Persisting fever
• Abdominal pain
• Diarrhoea
• Frequency
• Dysuria
• Enuresis or urgency

In any child with fever of unknown origin, the urine must be examined to assess whether a urinary tract infection is present

Perform a dipstix test on a fresh bag urine specimen.

Dipstix result	Action
No leukocytes/ nitrites	UTI unlikely
Leukocytes only	Repeat dipstix on a second specimen. If leucocytes on second specimen, suspect UTI and treat empirically. Collect urine aseptically if possible for urine MC&S.
Leukocytes or nitrites with symptoms of UTI	Treat empirically for UTI. Collect urine aseptically if possible for urine MC&S.
Leukocytes and nitrites	Collect urine aseptically if possible for urine MC&S. Treat empirically for UTI.

GENERAL MEASURES

• Women with recurrent UTIs should be advised to:
  • Void bladder after intercourse and before retiring at night
  • Not postpone voiding when urge to micturate occurs
  • Change from use of diaphragm to an alternative type of contraception

MEDICINE TREATMENT

Empirical treatment is indicated only if:

• Positive leukocytes and nitrites on freshly passed urine, or
• Leucocytes or nitrites with symptoms of UTI, or
• Systemic signs and symptoms.

Alkalinising agents are not advised.

Uncomplicated cystitis

Adults

• Gentamicin, IM, 160 mg, as a single dose.                                                                                    

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Note:

Gentamicin should not be used in patients with known chronic kidney disease or pregnancy.

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LoE:IIb⁷

If gentamicin is unavailable/ contraindicated:

• Fosfomycin, oral, 3 g as a single dose.

LoE:IIb⁸

If fosfomycin is unavailable:

• Nitrofurantoin, oral, 100 mg 6 hourly for 5 days

LoE:IIb⁹

Complicated cystitis

Adults

• Ciprofloxacin, oral, 500 mg 12 hourly for 7 days.

For pregnant women: O23.4

• Fosfomycin, oral, 3 g as a single dose.

LoE:IIb¹⁰

OR

• Nitrofurantoin, oral, 100 mg 6 hourly for 5 days.

LoE:IIb¹¹

Children ≤35 kg who do not meet criteria for urgent referral:

• Amoxicillin/ clavulanic acid oral, 15–25 mg/kg/dose of amoxicillin component, 8 hourly for 7 days.

Weight kg	Dose mg (amoxicillin component)	Use one of the following			Age months/years
		Susp. 125/31.5 mg/5 mL	Susp. 250/62.5 mg/5 mL	Tablet 500/125 mg/tab
>5–7 kg	100 mg	4 mL	2 mL	-	>3–6 months
>7–9 kg	150 mg	6 mL	3 mL	-	>6–12 months
>9–11 kg	200 mg	8 mL	4 mL	-	>12–18 months
>11–14 kg	250 mg	10 mL	5 mL	-	>18 months–3 years
>14–17.5 kg	300 mg	12 mL	6 mL	-	>3–5 years
>17.5–25 kg	375 mg	15 mL	7.5 mL	-	>5–7 years
>25–35 kg	500 mg	20 mL	10 mL	1 tablet	>7–11 years

LoE:IIIb¹²

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ACUTE PRELONEPHRITIS

N10

Outpatient therapy is only indicated for women of reproductive age, who do not have any of the manifestations requiring referral (see referral criteria below). All other patients should be referred.

• Ciprofloxacin, oral, 500 mg, 12 hourly for 7–10 days.
  • It is essential to give at least a 7-day course of therapy.

REFERRAL

Urgent

• Acute pyelonephritis with:
  • Vomiting
  • Sepsis
  • Diabetes mellitus
• Acute pyelonephritis in:
  • Pregnant women
  • Women beyond reproductive age
  • Men
• Children ≥3 months of age who appear ill.
• Children ≤3 months of age with any UTI.

Ill patients awaiting transfer

• Ensure adequate hydration with intravenous fluids.
• Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See: dosing tables.
  • Do not inject more than 1 g at one injection site.

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN   - If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced. - Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone: - If ≤28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone administered. - If >28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after. - Preferably administer IV fluids without calcium contents. - Always include the dose and route of administration of ceftriaxone in the referral letter.

Non-urgent

• All proven UTIs (positive culture) in children after completion of treatment.
• No response to treatment.
• UTI >3 times within a one-year period in women, and more than once (at any point in time) in men.
• Recurrent UTI in children for assessment and consideration of prophylaxis.

Click here to access the pdf

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_17 October 2024

Chapter 8: Kidney and Urological Disorders_8.4 Urinary tract infection (UTI)