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This guideline provides recommendations based on current evidence for best practice in the diagnosis and management of suspected bacterial lower urinary tract infection in adult women. It replaces SIGN 88: Management of suspected bacterial urinary tract infection in adults which was first published July 2006 and updated in July 2012. This guideline includes younger women aged 16–64 years; older women aged 65 years and over; and women of any age using an indwelling, intermittent or suprapubic catheter. It also includes the diagnosis and management of recurrent UTI in these groups.
The decision to focus on guidance for managing UTI symptoms in non-pregnant women of all ages was based on the burden of infection being in this population and the potential complicated nature of UTI in other populations.
The guideline is aimed primarily at healthcare professionals in primary-care settings, as the majority of non-pregnant women with symptoms of UTI will present in the community. Women with symptoms of UTI account for a significant proportion of acute presentations to GP practices and out-of-hours services, and evolution of services in Scotland means a proportion will also now be managed by community pharmacists.
For more information on background and aims see full guideline section Chapter 1.
The European Association of Urology categorises urinary tract infections based on the clinical presentation of the UTI, the anatomical level of the UTI, the grade of severity of the infection, the categorisation of risk factors and availability of appropriate antimicrobial therapy. Details of their classification of UTI is shown in the table below: 29
|Uncomplicated UTIs||Acute, sporadic or recurrent lower (uncomplicated cystitis) and/or upper (uncomplicated pyelonephritis) UTI, limited to non-pregnant women with no known relevant anatomical and functional abnormalities within the urinary tract or comorbidities.|
|Complicated UTIs||All UTIs which are not defined as uncomplicated, meaning UTIs in a patient with an increased chance of a complicated course: ie all men, pregnant women, patients with relevant anatomical or functional abnormalities of the urinary tract, indwelling urinary catheters, renal diseases, and/or with other concomitant immunocompromising diseases, for example diabetes.|
|Recurrent UTIs||Recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least three UTIs/year or two UTIs in the last six months.|
|Catheter-associated UTIs||Catheter-associated urinary tract infection (CA-UTI) refers to UTIs occurring in a person whose urinary tract is currently catheterised or who has had a catheter in place within the past 48 hours.|
Recurrent UTI may be due to relapse/persistence or reinfection.30
Empirical antimicrobial treatment occurs when the prescriber has not yet identified the bacteria causing the infection and does not know the suspected bacteria’s susceptibility to antibiotics.
Some recommendations can be made with more certainty than others. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the ‘strength’ of the recommendation).
The ‘strength’ of a recommendation takes into account the quality (level) of the evidence. Although higher-quality evidence is more likely to be associated with strong recommendations than lower-quality evidence, a particular level of quality does not automatically lead to a particular strength of recommendation.
Other factors that are taken into account when forming recommendations include: relevance to the NHS in Scotland; applicability of published evidence to the target population; consistency of the body of evidence, and the balance of benefits and harms of the options.
For ‘strong’ recommendations on interventions that ‘should’ be used, the guideline development group is confident that, for the vast majority of people, the intervention (or interventions) will do more good than harm. For ‘strong’ recommendations on interventions that ‘should not’ be used, the guideline development group is confident that, for the vast majority of people, the intervention (or interventions) will do more harm than good.
For ‘conditional’ recommendations on interventions that should be ‘considered’, the guideline development group is confident that the intervention will do more good than harm for most patients. The choice of intervention is therefore more likely to vary depending on a person’s values and preferences, and so the healthcare professional should spend more time discussing the options with the patient.
Good practice points
Recommended best practice based on the clinical experience of the guideline development group.
Systematic literature review
The evidence base for this guideline was synthesised in accordance with SIGN methodology. A systematic review of the literature was carried out using an explicit search strategy devised by a SIGN Evidence and Information Scientist. Databases searched include Medline, Embase, Cinahl, CENTRAL, PsycINFO and the Cochrane Library. The year range covered was 2003–2018. Internet searches were carried out on various websites for relevant guidelines. The main searches were supplemented by material identified by individual members of the development group. Each of the selected papers was evaluated by two Evidence and Information Scientists using standard SIGN methodological checklists before conclusions were considered as evidence by the guideline development group.
The search strategies are available on the SIGN website.
Literature search for patient issues
At the start of the guideline development process, a SIGN Evidence and Information Scientist conducted a literature search for qualitative and quantitative studies that addressed patient issues of relevance to diagnosis and management of suspected bacterial UTI. Databases searched include Medline, Embase, Cinahl and PsycINFO, and the results were summarised by the SIGN Patient Involvement Advisor and presented to the guideline development group.
Literature search for cost-effectiveness evidence
The guideline development group identified key questions with potential cost-effectiveness implications, based on the following criteria, where it was judged particularly important to gain an understanding of the additional costs and benefits of different treatment strategies:
A systematic literature search for economic evidence for these questions was carried out by a SIGN Evidence and Information Scientist covering the years 2008–2018. Databases searched include Medline, Embase and NHS Economic Evaluation Database (NHS EED). Each of the selected papers was evaluated by a Health Economist, and considered for clinical relevance by guideline group members.
Interventions are considered to be cost effective if they fall below the commonly-accepted UK threshold of £20,000 per QALY.
For recommendations for research, see section 9.2 of the full guideline.
SIGN is a collaborative network of clinicians, other healthcare professionals and patient organisations and is part of Healthcare Improvement Scotland. SIGN guidelines are developed by multidisciplinary groups of practising healthcare professionals using a standard methodology based on a systematic review of the evidence. Further details about SIGN and the guideline development methodology are contained in ‘SIGN 50: A Guideline Developer’s Handbook’.
This guideline was developed according to the 2015 edition of SIGN 50.
|BIA||budget impact assessment|
|CA-ASB||catheter-associated asymptomatic bacteriuria|
|CA-UTI||catheter-associated urinary tract infection|
|CDI||Clostridioides difficile infection|
|E. coli||Escherichia coli|
|eGFR||estimated glomerular filtration rate|
|GMC||General Medical Council|
|IDSA||Infectious Diseases Society of America|
|IRR||incidence rate ratio|
|LR-||negative likelihood ratio|
|LR+||positive likelihood ratio|
|LUTI||lower urinary tract infection|
|MHRA||Medicines and Healthcare Products Regulatory Agency|
|MIC||minimum inhibitory concentration|
|MRSA||methicillin-resistant Staphylococcus aureus|
|NHS||National Health Service|
|NHS EED||NHS Economic Evaluation Database|
|NICE||National Institute for Health and Care Excellence|
|NNT||number needed to treat|
|NSAID||non-steroidal anti-inflammatory drug|
|QALY||quality-adjusted life year|
|RCT||randomised controlled trial|
|SAPG||Scottish Antimicrobial Prescribing Group|
|SIGN||Scottish Intercollegiate Guidelines Network|
|SMC||Scottish Medicines Consortium|
|SUTIN||Scottish Urinary Tract Infection Network|
|UTI||urinary tract infection|
This guideline was issued in 2020 and will be considered for review in three years. The review history, and any updates to the guideline in the interim period, will be noted in the update report, which is available in the supporting material section for this guideline on the SIGN website: www.sign.ac.uk.
Comments on new evidence that would update this guideline are welcome and should be sent to the SIGN Executive, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB (email: firstname.lastname@example.org).
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