The Philippine Clinical Practice Guidelines on the

Diagnosis and Management of Urinary Tract

Infections in Adults
Update 2004

Merrill Van Yu

Case #1
Kim, 33 years old, female, married,
sexually active, with an
unremarkable health history, asks for
a house call for recent onset of pain
in urination, urinary frequency and
urgency. She has no costovertebral
tenderness on examination.

Acute Uncomplicated
Cystitis in Women

Definition
Non-pregnant women, 18-64 years old,
presenting with dysuria, frequency, or
gross hematuria, with or without back pain
No risk factors for complicated UTI

Hospital acquired infection

Indwelling urinary catheter
Recent urinary tract infection
Recent urinary tract instrumentation (in the past 2 weeks)
Functional or anatomic abnormality of the urinary tract
Recent antimicrobial use (in the past 2 weeks)
Symptoms for > 7 days at presentation
Diabetes mellitus
Immunosuppression

Case #1 contd
Kim brings you aside. Do I really
have to pee in a cup? That makes me
uncomfortable. Im not a big fan of
needles too.

Diagnostic Tests
Pre-treatment urine culture and
sensitivity is not recommended
Standard urine microscopy and
dipstick leukocyte esterase (LE) and
nitrite tests are not prerequisites
for treatment

 NOT ampicillin no
Treatment amoxicillin
Antibiotics
TMP-SMX
Ciprofloxacin
Ofloxacin
Norfloxacin
Levofloxacin
Gatifloxacin
Nitrofurantoin
Cefixime
Cefuroxime
Co-amoxiclav

Dose and
Frequency
800/160 mg BID
250 mg BID
200 mg BID
400 mg BID
250 mg BID
400 mg
100 mg QID
400 mg OD
125-250 mg BID
625 mg BID

Duration
3 days
3 days
3 days
3 days
3 days
Single dose
7 days
3 days
3-7 days
7 days

Response to Therapy
Patients whose symptoms worsen or do
not improve after 3 days should have a
urine culture and the antibiotic
should be empirically changed,
pending result of sensitivity testing
Patients whose symptoms fail to resolve
after the 7-day treatment should be
managed as a complicated urinary
tract infection

Case #1 contd
Kim was given Ciprofloxacin 250 mg
BID for 3 days with relief noted. She
brings up her anxiety about peeing in
a cup again.

Post-Treatment Urine
Culture
Routine post-treatment urine culture
and urinalysis in patients whose
symptoms have completely resolved
are not recommended

Case #2
Just as you were about to leave Kims
home, her sister Kylie asks to talk to
you outside the gate. She explains
that she has been having fever and
chills for the past 3 days,
accompanied by nausea and
vomiting. She wonders if shes
having a urinary tract infection too.

Acute Uncomplicated
Pyelonephritis in Women

Definition
Classical Syndrome

Fever (T > 38C)

Chills
Flank pain
Costovertebral
angle tenderness
Nausea and
vomiting
With or without
signs or symptoms
of lower urinary
tract infection

Laboratory
Findings
Pyuria (> 5
WBC/hpf of
centrifuged urine)
on urinalysis
Bacteriuria (>
100,000 CFU of a
uropathogen/mL on
urine culture

Diagnostic Tests
Urinalysis and Gram stain are
recommended
Urine culture and sensitivity should
also be performed routinely to facilitate
cost-effective use of antibiotics
Blood cultures are not routinely
recommended
Blood cultures done twice are
recommended for patients who present
with signs of sepsis

Case #2 contd
Unlike her sister Kim, Kylie has no
problems peeing in a cup. Urinalysis
and urine C/S revealed WBC > 10/hpf
and Gram negative coccobacilli,
respectively. She asks if she could
just take the medications at home
since she has to take care of her
children.

Treatment
Treated as Outpatients
Non-pregnant
No signs and symptoms
of sepsis
Likely to adhere to
treatment and return
for follow-up

*An initial parenteral

dose of ceftriaxone
may be given followed
by an oral antibiotic

Indications for Admission

Inability to maintain oral
hydration or take
medications
Concern about
compliance
Presence of possible
complicating conditions
Severe illness with high
fever
Severe pain
Marked debility and signs
of sepsis

Empiric Treatment
ORAL
Antibiotic and Dose
Ofloxacin 400 mg
Ciprofloxacin 500 mg
Gatifloxacin 400 mg
Levofloxacin 250 mg
Cefixime 400 mg
Cefuroxime 500 mg
Amoxicillin-Clavulanate 625
mg (Gram positive
organisms)

Frequency and
Duration
BID; 14 days
BID; 7-10 days
OD; 7-10 days
OD; 7-10 days
OD; 14 days
BID; 14 days
TID; 14 days

Empiric Treatment
PARENTERAL
Antibiotic and Dose
Ceftriaxone 1-2 gm
Ciprofloxacin 200-400 mg
Levofloxacin 250-500 mg
Gatifloxacin 400 mg
Gentamicin 3-5 mg/kg BW (+/Ampicillin)
Ampi-Sulbactam 1.5 gm (Gram
positive)
Piperacillin-Tazobactam 2.25-4.5
*Given until patient is afebrile
gm

Frequency and
Duration
Q 24
Q 12
Q 24
Q 24
Q 24
Q6
Q 6-8

Empiric Treatment
NOT recommended
Aminopenicillins (ampicillin or
amoxicillin)
1st generation cephalosporins
TMP-SMX (but can be used when
organism is susceptible on urine C/S)
Ampicillin + Aminoglycoside (except
when enterococcal infection is
suspected)

Case #2 contd
You gave Kylie Ciprofloxacin 500 mg
BID for 7 days with relief of
symptoms. Shes very happy and
sends you a box of chocolates to
show her appreciation.

Workup for Urologic

Abnormalities
Routine urologic evaluation and routine
use of imaging procedures are NOT
recommended
Consider urologic evaluation:
Patient remains febrile within 72 hours of
treatment
Recurrence of symptoms to rule out:

Nephrolithiasis
Urinary tract obstruction
Renal or perinephric abscesses
Other complications of pyelonephritis

Follow-up Urine Culture

NOT necessary in patients clinically
responding to therapy (usually apparent
in < 72 hours after initiation of treatment)
NOT recommended post-treatment in
those clinically improved
SHOULD BE PERFORMED in women
whose symptoms do not improve during
therapy and those whose symptoms recur
after treatment

Management of Recurrence
Antibiotic treatment based on urine
culture and sensitivity test results, in
addition to assessing for underlying
genitourologic abnormality
Duration of re-treatment in the absence of
a urologic abnormality is 2 weeks
For patients whose symptoms recur and
whose culture shows the same organism as
the initial infecting organism, a 4-6 week
regimen is recommended

Case #3
You received a call from another
sister, Khloe, who had abnormal
urinalysis and urine culture results
recently as she was applying for a
movie role. However, she does not
have any complaints nor problems
with urination. Shes anxious that
these may affect her career.

Asymptomatic Bacteriuria
in Adults

Definition and Diagnosis

Presence of > 100,000 CFU/mL of
one or more uropathogens in:
2 consecutive midstream urine
specimens
OR
1 catheterized urine specimen

in the absence of symptoms

attributable to urinary tract infection

Screening
Urine culture recommended
In the absence of facilities for urine
culture, significant pyuria (>10
WBC/hpf) or a positive Gram stain of
unspun urine (>2
microorganisms/OIF) in 2 consecutive
midstream urine samples can be
used to screen for ASB

Target for Screening

Patients who will undergo
genitourinary manipulation or
instrumentation
Post-renal transplant patients up to the
first 6 months
Patients with diabetes mellitus with
poor glycemic control, autonomic
neuropathy or azotemia
All pregnant women

Should NOT be Screened for

ASB
Healthy adults
Patients with diabetes mellitus with adequate
glycemic control, no autonomic neuropathy or
azotemia
Elderly patients
Patients with indwelling catheters
Immunocompromised patients
Other solid organ transplant patients
HIV patients
Spinal cord injury patients
Patients with urological abnormalities

Treatment
Antibiotics

Dose and
Frequency

Duration

TMP-SMX

800/160 mg BID

3 days

Ciprofloxacin

250 mg BID

3 days

Ofloxacin

200 mg BID

3 days

Norfloxacin

400 mg BID

3 days

Levofloxacin

250 mg BID

3 days

Gatifloxacin

400 mg

Single dose

Nitrofurantoin

100 mg QID

7 days

Cefixime

400 mg OD

3 days

Cefuroxime

125-250 mg BID

3-7 days

Co-amoxiclav

625 mg BID

7 days

*A 7- to 14-day course is recommended

Case #4
Another sister, Kourtney, 35 years
old, married, G2P1(1001), pregnant
at 5 weeks AOG, visited you for
dysuria. No fever nor costovertebral
angle tenderness noted.

Urinary Tract Infection in

Pregnancy
A. Asymptomatic Bacteriuria
in Pregnancy

Diagnosis
Presence of > 100,000 CFU/ml of one or
more uropathogens in two consecutive
midstream urine specimens or one
catheterized urine specimen, in the
absence of symptoms attributable to a
urinary tract infection
In settings where obtaining 2 consecutive
urine cultures are not feasible or difficult, 1
urine culture is an acceptable alternative
for the diagnosis of ASB in pregnancy

Screening
ALL pregnant women must be
screened for ASB on their first
prenatal visit between the 9th to 17th
weeks, preferably on the 16th week
age of gestation

Screening Test
TEST OF CHOICE: Urine culture of clean-catch midstream
In areas where urine culture is not available, the following
can be used for screening:
An initial gram stain of centrifuged urine (cut-off: same
morphology of bacteria seen in >6 of 12 hpfs in
centrifuged urine sample).
If positive, this must be followed by a urinalysis to determine
pyuria. A cut-off level of >5 wbc/hpf suggests ASB
To minimize multiple visits to the lab and/or clinic, both tests can
be requested simultaneously, but with the urinalysis being
performed after a positive gram stain result. (Please see
Algorithm section)

Urine dipsticks for leukocyte esterase and/or nitrite tests

are not recommended for screening for ASB in pregnancy.
Urinalysis alone is not recommended for screening

Treatment
Among the drugs that can be used are
nitrofurantoin (not for those near-term),
co-amoxiclav, cephalexin, and
cotrimoxazole (not in the 1st and 3rd
trimesters) depending on the sensitivity
results of the urine isolate
A 7-day course is recommended
A follow-up culture should be done one
week after completing the course of
treatment

Treatment
Category B,
L1, L2
Nitrofurantoin
AmoxicillinClavulanate
Cephalosporins

Category C, L3 Category D, L3
TMP-SMX
Avoid in 1st and
3rd trimester)

Aminoglycoside
s

Urinary Tract Infection in

Pregnancy
B. Acute Cystitis in Pregnancy

When to Suspect
Urinary frequency, urgency, dysuria
and bacteriuria without fever and
costovertebral angle tenderness
Gross hematuria may also be present

Diagnostic Tests
Urine culture and sensitivity test of a
midstream clean catch urine specimen
In the absence of a urine culture, the
laboratory diagnosis of acute cystitis can
be determined by the presence of
significant pyuria defined as
> 8 pus cells/mm3 of uncentrifuged urine OR
> 5 pus cells/hpf of centrifuged urine, and
a positive leukocyte esterase and nitrite test

Treatment
Antibiotics against E. coli
TMP-SMX and fluoroquinolones are
relatively contraindicated during
pregnancy because of their
potential teratogenicity and the third
trimester risk of kernicterus with
TMP-SMX.
A 7- day course is recommended

Post-Treatment Urine
Culture
Should be obtained to confirm
eradication of bacteriuria and
resolution of infection

Urinary Tract Infection in

Pregnancy
C. Acute Pyelonephritis in
Pregnancy

When Suspected
Shaking chills, fever (T>38 C), flank pain,
nausea and vomiting, with or without
signs and symptoms of lower urinary
tract infections and physical finding of
costovertebral angle tenderness
Urinalysis shows pyuria of > 5 WBC/hpf
of centrifuged urine and bacteriuria of >
10,000 CFU of a uropathogen/mL of urine

Diagnostic Tests
Gram stain of uncentrifuged urine is
recommended to differentiate gram
positive from gram-negative
bacteriuria
Urine culture and sensitivity test
should also be performed routinely
Blood cultures are not routinely
recommended for all pregnant
patients with acute pyelonephritis

Treatment
Should be hospitalized and
immediately treated
Patients without sepsis and able to
take oral medications can be treated
as outpatients
Treatment duration is 10-14 days
NOT fluoroquinolones and
aminoglycosides

Post-Treatment Urine
Culture
Should be obtained to confirm
resolution of the infection
Should be monitored at intervals
until delivery to confirm continued
urine sterility during pregnancy

Case #5
Another sister, Kendall, messages
you on Facebook. She says that she
has been having recurrent urinary
tract infections in that past year. She
is concerned because this might
affect her modeling career.

Recurrent Urinary Tract

Infection in Women

Diagnosis
Recurrent UTI is diagnosed when a
non-pregnant woman with no known
urinary tract abnormalities has
episodes of acute uncomplicated
cystitis documented by urine culture
occurring more than twice a year

Indications for Prophylaxis

Frequency of recurrence is not
acceptable to the patient in terms of
level of discomfort or interference
with activities of daily living
May be withheld if the frequency of
recurrence is tolerable to the patient

Prophylaxis
Antibiotic regimen
Continuous prophylaxis
Postcoital prophylaxis

Hormonal treatments in
postmenopausal women

Case #6
Their mother, Kris, calls you up
suddenly in the middle of the night.
She says that she is also having
problems with urination. She admits
to be taking steroids for an
undisclosed condition.

Complicated Urinary Tract

Infection

Definition
Significant bacteriuria (> 100,000
CFU/mL), which occurs in the setting
of functional or anatomic
abnormalities of the urinary tract or
kidneys

Conditions that Define Complicated

UTI
Presence of an indwelling catheter or
intermittent catheterization
Incomplete emptying of the bladder with
>100 mL retained urine post-voiding
Obstructive uropathy due to bladder outlet
obstruction, calculus and other causes
Vesicoureteral reflux and other urologic
abnormalities including surgically created
abnormalities

Conditions that Define Complicated

UTI
Azotemia due to intrinsic renal
disease
Renal transplantation
Diabetes mellitus
Immunosuppressive conditions
UTI caused by unusual pathogens or
drug-resistant pathogens
UTI in males except in young males
presenting with exclusively lower UTI
symptoms

Diagnostic Tests
Urine sample for Gram stain, culture
and sensitivity testing

Need for hospitalization

Marked debility
Signs of sepsis
Uncertainty in diagnosis
Unable to maintain oral hydration or
take oral medications

Treatment
Mild to moderate illness: Oral
fluoroquinolones
Severely ill patients: Broad-spectrum
parenteral antibiotics

Treatment Regimens
Oral Regimen
Ciprofloxacin 250-500 mg BID x 14 days
Norfloxacin 400 mg BID x 14 days
Ofloxacin 200 mg BID x 14 days
Levofloxacin 250-500 mg OD x 10-14 days
Parenteral Regimen
Ampicillin 1 gm q 6 hrs + gentamicin 3 mg/kg/day q 24 hrs
Ampicillin-sulbactam 1.5 gm to 3 gm q 6 hrs
Ceftazidime 1-2 gm q 8 hrs
Ceftriaxone 1-2 gm q 24 hrs
Imipenem-cilastatin 250-500 mg q 6-8 hrs
Piperacillin-Tazobactam 2.25 gm q 6 hrs
Ciprofloxacin 200-400 mg q 12 hrs
Ofloxacin 200-400 mg q 12 hrs IV
Levofloxacin 500 mg q 24 hrs IV

Follow-up Tests
Urine culture 1 to 2 weeks after
completion of medications
Further workup to identify and
correct the anatomical, functional or
metabolic abnormality

Specific Issues of Concern

in Complicated UTI

Catheter-Associated UTI
UTI in Diabetic Patients
UTI in Renal Transplant Patients
UTI in Patients with HIV/AIDS
Urinary Candidiasis

Case #7
Their brother, Rob, 24 years old,
male, with a very healthy
monogamous sexual relationship
with his girlfriend of 5 years, sought
consult at the OPD for dysuria and
frequency in urination.

Definition and Diagnostics

Urinalysis
> 5 WBC/hpf in a clean catch midstream
specimen

Urine culture
Growth of > 1000 CFU/mL

Urinary Tract Infection in

Men
A. Uncomplicated Cystitis in
Young Men

Case #7 contd
He was treated with TMP-SMX for 7
days with resolution of the condition

Case #8
6 months later, their father Bruce
arrived in your house after
experiencing chills, low back pain
and perineal pain. He also noted
dysuria, frequency, urgency, and
nocturia. Upon rectal examination
reveals a markedly tender, swollen
prostate.

Prostatitis Syndromes
Category

Characteristic Clinical Features

Acute
bacterial
prostatitis

Acute infection of the prostate gland characterized

by fever,
chills, low back pain and perineal pain. Irritative
voiding
symptoms (dysuria, frequency, urgency, nocturia)
are
characteristic. Rectal examination reveals a
markedly tender,
swollen prostate.

II

Chronic
bacterial
prostatitis

Recurrent infection of the prostate caused by

persistence of the same organism despite
treatment. Symptoms are irritative
voiding & pain of varying degrees. Rectal
examination reveals no characteristic finding.

III

Chronic
prostatitis /
Chronic

No demonstrable infection; primarily pain

complaints, plus
voiding complaints and sexual dysfunction

Prostatitis Syndromes
Category

Characteristic Clinical Features

IIIA

Inflammator Symptomatic patients without bacteriuria but with

y subtype
inflammation (white cells) in semen, expressed
prostatic secretions (EPS) or post-prostatic
massage urine

IIIB

NonNo white cells in semen, EPS or post-prostatic

inflammator massage urine
y subtype

IV

Asymptoma
tic
inflammator
y prostatitis

No subjective symptoms, inflammation detected

either by
prostate biopsy or the presence of white cells in
expressed
prostatic secretions or semen during evaluation of
other
genitourinary complaints

Diagnostic Tests
Acute Bacterial Prostatitis
Mid-stream urine sample for dipstick testing, culture for bacteria, and
antibiotic sensitivity
Prostatic massage should not be performed
Chronic Bacterial Prostatitis
Lower urinary tract localization procedure - standard
Recurrent UTI caused by the same pathogen are the hallmark of
chronic bacterial prostatitis
Chronic Prostatitis / Chronic Pelvic Pain Syndrome
No gold standard
SEMINAL FLUID ANALYSIS IS RECOMMENDED FOR ALL TYPES
OF PROSTATITIS

Treatment
Acute Bacterial Prostatitis
Start empiric treatment immediately
Adequate hydration, rest, and analgesics such as NSAIDs
Empiric therapy with TMP/SMX or oral fluoroquinolone
30-day treatment
Chronic Bacterial Prostatitis
First-line treatment:
Ciprofloxacin 500 mg BID for 28 days OR
Ofloxacin 200 mg BID for 28 days OR
Norfloxacin 400 mg BID for 28 days
For those allergic to quinolones:
Doxycycline 100 mg BID for 28 days
Minocycline 100 mg BID for 28 days OR
Trimethoprim 200 mg BID daily for 28 days OR
TMP-SMX 160/800 mg BID for 28 days

Treatment
Recalcitrant Chronic Bacterial Prostatitis
Radical transurethral resection of the prostate or total prostatectomy
For symptomatic relief: Sitz baths, anti-inflammatory agents,
prostatic massage, etc
Long-term, low-dose suppressive therapy for nonresponders to full
treatment
TMP-SMX 80/400 mg once daily for 4 to 6 weeks
Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Antibiotics or alpha-adrenergic blockers are not recommended
Heat treatment may be useful
Nonbacterial Prostatitis
Allopurinol not recommended

Case #8 contd
Bruce was inserted an antimicrobialimpregnated catheter attached to a
urine bag on May 2, 2015 for
difficulty urinating. Daily meatal care
was done and the catheter was
changed every 5 days. He was also
given levofloxacin 250 mg BID

Prevention of Catheter-Associated
Urinary Tract Infection

Case #9
Kim calls you up again and asks how
her family can prevent having
urinary tract infections. Shes trying
out alternative medicine/holistic
approach to health and does not
want to take medications but instead
wishes to use locally grown organic
fruits.

Nonpharmacologic
Interventions for UTI

TRUE OR FALSE
Cranberry juice and cranberry products
ARE NOT RECOMMENDED for the
prevention of urinary tract infections in
populations at risk
Cranberry juice and cranberry products
ARE RECOMMENDED for the treatment of
urinary tract infection
Lactobacilli both in oral form and vaginal
suppositories ARE RECOMMENDED in the
prevention of UTI

TRUE OR FALSE
Coconut juice IS NOT RECOMMENDED in
the prevention or treatment of urinary
tract infection
Oral water hydration IS RECOMMENDED
in the prevention or treatment of UTI
Drinking more water and voiding soon
after intercourse IS RECOMMENDED to
prevent urinary tract infection

Thank you!