UNCOMPLICATED URINARY TRACT INFECTION AUDIT
IN PRIMARY CARE
Aim
To evaluate the diagnosis of uncomplicated urinary tract infections using urine dipsticks
and/or urine cultures and to assess antibiotic prescribing using Public Health England
guidance on the diagnosis and antibiotic treatment.
Audit requirements
Search for consultation records with the following clinical conditions or Read code. At least
20 consultations should be analysed to determine overall compliance.
K15
K190
1J4
K190z
Cystitis
Urinary tract Infection
Suspected UTI
UTI, site not specified NOS
Method
Please view Figure 1: PHE Quick reference guide for primary care to assess your practice’s
or your individual compliance with the recommended algorithm or visit the website for more
information and the rationale behind the recommendations
https://www.gov.uk/government/collections/primary-care-guidance-diagnosing-and-managinginfections
Please view Table 2: PHE management for infection guidance in primary care to determine
the proportion of your patients who have been prescribed the recommended antibiotics,
including dose, frequency and duration. You can visit the website for more information and
the rationale behind the recommendations https://www.gov.uk/government/collections/primarycare-guidance-diagnosing-and-managing-infections
You may wish to use your local primary care organisation’s guidance as an alternative.
Results
Table 1 shows the results that should be recorded.
Table 1: Assessing Compliance with PHE guidance
Total number of patients being audited
Antibiotics: Use Figure 1 to determine the total number of patients in whom decision to
prescribe or not, was in line with guidance
Dipsticks: Use Figure 1 to determine the total number of patients in which urine dipsticks
were used or not, in line with guidance
A
B
Total number of patients prescribed an antibiotic
Use Table 2 to determine the total number of correct antibiotics chosen
Use Table 2 to determine the total number of correct doses
Use Table 2 to determine the total number of correct treatment frequencies
Use Table 2 to determine the total number of correct antibiotic course lengths
D
E
F
G
H
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C
UNCOMPLICATED URINARY TRACT INFECTION AUDIT
IN PRIMARY CARE
Calculations:
% compliance with PHE UTI diagnostic guide = (B+C/2A) x 100
% compliance with PHE antibiotic Primary Care guidance = ((E + F + G + H) / 4D) x 100
Actions:
1. Record actions required, especially when compliance with UTI diagnostic or primary
care guidance is less than 80%.
2. Identify a date when you will repeat the audit.
The TARGET Antibiotics Toolkit provides guidance and other support to clinicians and
commissioners to improve responsible antimicrobial prescribing in primary care. The Toolkit
can be accessed at: www.rcgp.org.uk/targetantibiotics
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UNCOMPLICATED URINARY TRACT INFECTION AUDIT
IN PRIMARY CARE
Table 1: Diagnosis of UTI quick reference guide for primary Care
Diagnosis of UTI
Quick Reference Guide for Primary Care
URINARY SYMPTOMS IN ADULT WOMEN <65 DO NOT CULTURE ROUTINELY
In sexually active young men and women with urinary symptoms consider Chlamydia trachomatis
Severe or ≥ 3 symptoms of UTI
 Dysuria
 Frequency
 Suprapubic tenderness
 Urgency
 Polyuria
 Haematuria
Mild or ≤ 2 symptoms of UTI
(as above)
AND
NO vaginal
discharge or
irritation
90% culture
positive
Give empirical
antibiotic
treatment
Obtain urine
specimen
Urine NOT
cloudy 97%
NPV
Consider other
diagnosis
URINE CLOUDY
Perform urine dipstick test with nitrite
When reading test WAIT for the time recommended by the manufacturer
Positive nitrite, leucocytes and
blood 92% PPV
or
positive nitrite alone
Positive leucocyte
Probable UTI
UTI or other diagnosis equally likely
Treat with first line agents on local or
PHE Guidance
Review time of specimen
(morning is most reliable)
Treat if severe symptoms or
consider delayed antibiotic
prescription and
send urine for culture
Negative nitrite
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Negative nitrite, leucocytes and
blood 76% NPV
or
Negative nitrite and leucocyte
Positive blood or protein
Laboratory microscopy for red cells
is less sensitive than dipstick
UTI Unlikely
Consider other diagnosis
Reassure and give advice on
management of symptoms
UNCOMPLICATED URINARY TRACT INFECTION AUDIT
IN PRIMARY CARE
Table 2: PHE management for infection guidance in Primary Care – March 2017. Please click
link for most recent updates.
URINARY TRACT INFECTIONS
Note: As antibiotic resistance and Escherichia coli bacteraemia in the community is increasing, use nitrofurantoin first line,1D always give safety net and
self-care advice, and consider risks for resistance.2D Give TARGET UTI leaflet,3D and refer to the PHE UTI guidance for diagnostic information.1D
UTI in adults
Treat women with severe/≥3 symptoms.1D,2D
First line: nitrofurantoin13A- 100mg m/r BD, OR 50mg i/r QDS25AWomen:
(lower)
All patients first line antibiotic:
If low risk of resistance:
(BD dose increases compliance)26D
3 days
PHE UTI
nitrofurantoin if GFR >45mls/min;3A+ if GFR 30-45,
trimethoprim14D,15A+
200mg BD27D
30A+,31B-,
only use if resistance and no alternative.4BIf first line unsuitable
32B-,33B+
1D
16A+
Women <65 years (mild/≤2 symptoms): pain
TARGET UTI
and GFR<45mls/min:
Men: 7
5A-,6A7D
17B+,18D,19B-,20A+
28B+,29B+
relief,
and consider delayed antibiotic.
pivmecillinam
400mg stat then 200mg TDS
days34B+,
RCGP UTI
If urine not cloudy, 97% NPV of no UTI.8AIf organism susceptible:
35A+,36A-,37AIf urine cloudy, use dipstick to guide treatment:9D
amoxicillin21A+
500mg TDS27D
8A27D
SIGN UTI
nitrite, leukocyctes, blood all negative 76% NPV;
If very high resistance risk:
Women: 3g stat
nitrite plus blood or leukocytes 92% PPV of UTI.8Afosfomycin22A+,23B-,24B+
Men: 3g dose 3 days later (unlicensed)38D
Men <65 years: consider prostatitis and send
NHS Scotland
Low risk of resistance: younger women with acute UTI and no risk.31B-,39C
UTI
MSU,1D,10D or if symptoms mild or non-specific, use Risk factors for increased resistance include: care-home resident;11A-,12Bnegative dipstick to exclude UTI.10D
recurrent UTI; hospitalisation for >7 days in the last 6 months; unresolving
>65 years:11A- treat if fever >38°C, or 1.5°C above
urinary symptoms; recent travel to a country with increased resistance;
12Bbase twice in 12 hours, and >1 other symptoms.
previous UTI resistant to trimethoprim, cephalosporins, or quinolones.31B-,39C,40D
1D
If treatment failure: always perform culture.
If risk of resistance: send urine for culture and susceptibilities; safety net. 31BUTI in patients with catheters: antibiotics will not eradicate asymptomatic bacteriuria;1D,2D only treat if systemically unwell or pyelonephritis likely.2D
Do not use prophylactic antibiotics for catheter change unless there is a history of catheter-change-associated UTI or trauma.3D,4A+
Take sample if new onset of delirium, or one or more symptoms of UTI.5A-,6B-,7D
UTI in
Send MSU for culture;1D start antibiotics in all with
Nitrofurantoin4D,5D
100mg m/r BD4D OR
pregnancy
significant bacteriuria, even if asymptomatic.1D
(avoid at term)4D,5D
50mg i/r QDS4D
SIGN UTI
Avoid trimethoprim if first trimester or low folate
Trimethoprim3D,4D
200mg BD (off-label)4D
7 days8D
status,2D,3D,4D or on folate antagonist.2D,3D
Short-term use of nitrofurantoin is appropriate.4D,5D
Give folate if first trimester2D
Avoid cephalosporins as high risk of C. difficile.6C
Cefalexin3D,4D,7D
500mg BD4D
1D
1D,3D
Acute
Send MSU for culture and start antibiotics.
Ciprofloxacin
OR
500mg BD1D
prostatitis
4 week course may prevent chronic prostatitis.1D,2D
ofloxacin1D,3D
200mg BD1D
28 days1D,2D
Quinolones achieve high prostate levels.1D,2D
Second line: trimethoprim1D 200mg BD1D
UTI in children
Child <3 months: refer urgently for assessment.1D
Lower UTI: nitrofurantoin1A- OR trimethoprim1A
Child >3 months: use positive nitrite to guide
NICE UTI in
Second line: cefalexin1D

3 days1A+,3A+
under 16s
antibiotic use;1A- send pre-treatment MSU.1D
If organism susceptible: amoxicillin1A
Imaging: refer if child <6 months, or recurrent or
Upper UTI: co-amoxiclav1A+

7-10 days1A+
atypical UTI.1D
Second line: cefixime2A+

Acute
If admission not needed, send MSU for culture and Ciprofloxacin5A-,6D OR
500mg BD5A-,6D,8D
 7 days5A-,7A+
pyelonephritis
susceptibility testing,1D and start antibiotics.1D
co-amoxiclav5A500/125mg TDS8D
 7 days5A-,7A+
If no response within 24 hours, seek advice.2D
If ESBL risk,3D and on advice from a microbiologist, If organism sensitive:
consider IV antibiotic via OPAT.4D
trimethoprim5A-,7A+
200mg BD8D
 14 days7A+
1D
11D
11D
At night or
Recurrent UTI in First line: advise simple measures, including
First line: nitrofurantoin
100mg m/r
3-6 months,1D,11D
post-coital
non-pregnant
hydration2D,3D and analgesia.4A-,5ACiprofloxacin8A+,11D
500mg11D
then review
stat (off-label) recurrence rate
women
Cranberry products work for some women.6A+,7A+
If recent culture sensitive:
1D,8A+,9D,11D
Second line: standby1D or post-coital antibiotics.8A+ trimethoprim11D
(2 in 6 months
100mg11D
and need1D,8A+
Third line: antibiotic prophylaxis.1D,8A+,9D Consider
or >3 in a year)
TARGET UTI
methenamine if no renal/hepatic impairment.10A+,11D Methenamine hippurate10A+ 1g BD11D
6 months11D
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