Urinary tract infections — appropriate diagnosis and antibiotic use for uncomplicated cystitis and pyelonephritis

Published on 17 Nov 2023
Last Updated on 08 Dec 2023

Resources

Dec 2023 update: practice tips in Table 4 for nitrofurantoin and fosfomycin for treatment of acute uncomplicated cystitis have been updated.

• UTI – appropriate diagnosis and antibiotic use for uncomplicated cystitis and pyelonephritis (Dec 2023) [PDF, 2.3 MB]

• UTI – appropriate diagnosis and antibiotic use references (Dec 2023) [PDF, 422 KB]

This ACE Clinical Guidance (ACG) highlights the importance of appropriate diagnosis and treatment of urinary tract infections (UTI) to reduce inappropriate antibiotic use. The ACG offers evidence-based recommendations on the treatment of UTI in adults, focusing on uncomplicated acute cystitis and pyelonephritis in healthy, non-pregnant pre-menopausal women. Principles of appropriate selection of antibiotics as well as patient education on antibiotic use and antimicrobial resistance awareness are also highlighted.

ACG Recommendations

1. Avoid routinely screening for and treating asymptomatic bacteriuria.

2. Diagnose uncomplicated cystitis based on history and presentation in patients with two or more typical signs or symptoms such as dysuria, frequency, urgency, or absence of vaginal discharge.

3. a. Conduct a urine dipstick test to confirm diagnosis of uncomplicated cystitis where there is uncertainty; and
   b. Conduct a urine culture and sensitivity test for unresolved or recurrent cystitis.

4. Suspect uncomplicated pyelonephritis in patients presenting with sudden-onset flank pain or tenderness, particularly when accompanied by other systemic symptoms such as fever, nausea or vomiting.

5. Conduct urine tests (dipstick or microscopy, plus culture and sensitivity) for all patients with suspected uncomplicated pyelonephritis to confirm diagnosis and guide management.

6. Prescribe nitrofurantoin empirically for uncomplicated cystitis; if nitrofurantoin is not suitable, prescribe amoxicillin-clavulanate or fosfomycin.

7. Prescribe amoxicillin-clavulanate empirically for patients with uncomplicated pyelonephritis and tailor antibiotic choice accordingly when urine culture and sensitivity results are available; if amoxicillin-clavulanate is not suitable, consider cefuroxime as an alternative.

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