Clinical Topic A-Z Clinical Speciality

Urinary tract infection (lower) - men

Urinary tract infection (lower) - men
D014552Urinary Tract Infections
D003556Cystitis
D001437Bacteriuria
D006417Hematuria
Infections and infestationsKidney disease and urologyMen's health
2010-01-25Last revised in January 2010

Urinary tract infection (lower) - men - Summary

Urinary tract infection (UTI) is infection of any part of the urinary tract, usually by bacteria. The commonest organism causing UTI in adults is Escherichia coli — about 90% of cases.

UTI in men is generally uncommon, but incidence rates are higher in elderly men, and if risk factors are present for example:

Abnormalities of urinary tract function or structure (e.g. indwelling catheter, neurogenic bladder, vesicoureteric reflux, anatomical abnormalities).

Incomplete bladder emptying (e.g. prostatic enlargement, or a blocked indwelling catheter).

Previous urinary tract surgery.

Immunocompromised state.

Ascending infection can occur, leading to pyelonephritis, perinephric and intrarenal abscess, hydronephrosis, pyonephrosis, renal failure, and septicaemia.

A lower UTI should be suspected if the man has:

Dysuria, frequency, urgency, nocturia, suprapubic discomfort.

Suprapubic tenderness, and cloudy, bloody, or foul-smelling urine.

UTI can present with atypical symptoms in men who are frail and elderly, or institutionalized, or who have an indwelling urinary catheter.

Diagnosis of a UTI should be confirmed with a urine culture. Urine dipstick tests or microscopy should not be relied on to confirm the diagnosis.

Considerable clinical judgement is required to diagnose UTI in men with an indwelling urinary catheter.

Other conditions which present similarly to lower UTI include pyelonephritis, urethritis, acute prostatitis, drug-induced cystitis, and epididymitis.

To manage lower UTI in men, local guidelines should be followed, if available.

In the absence of local guidelines, management of lower UTI involves:

Arranging hospital admission if symptoms are severe (e.g. there is severe nausea and vomiting, confusion, tachypnoea, tachycardia, or hypotension).

Assessing the need for referral and referring with the appropriate urgency. Referral for urological assessment is not routinely required for men who have had a UTI.

Obtain a urine sample for culture and microscopy before starting antibiotic treatment.

Offering paracetamol or ibuprofen for symptom relief.

Obtaining a urine sample for culture and microscopy before starting antibiotic treatment.

Starting empirical treatment with trimethoprim or nitrofurantoin. Trimethoprim should not be used for empirical treatment if the man has a history of recurrent infections or has taken trimethoprim within the past 12 months.

Arranging a follow up after 48 hours (or according to the clinical situation) to check response to treatment and the urine culture results. Antibiotic should be changed if the organism is resistant to the current antibiotic.

Management of recurrent UTI involves:

Culturing the urine (whatever the results of urine dipstick tests).

Treating each episode as for acute lower UTI.

Ruling out chlamydial infection, if applicable.

Referral for urological assessment should be made for men who:

Have failed to respond to appropriate antibiotic treatment.

May have an underlying cause for the UTI.

Have frequent episodes of UTI (for example two or more episodes in a 3-month period).

Have a history of pyelonephritis, calculi, or previous genitourinary tract surgery.

Are younger than 50 years of age and have persistent microscopic haematuria with otherwise normal renal function tests (urinary protein and serum creatinine).

Urgent referral should be made if cancer is suspected.

Have I got the right topic?

192months3060monthsMale

This CKS topic incorporates recommendations from the Scottish Intercollegiate Guidelines Network (SIGN) guideline Management of suspected bacterial urinary tract infection in adults [SIGN, 2006].

This CKS topic covers the management of lower urinary tract infection (UTI) in men, as well as UTI in men with urethral catheters.

This CKS topic does not cover the prevention of UTI following surgery or instrumentation, or the treatment of UTI in hospital. This CKS topic also does not cover the treatment of prostatitis, urethritis, or epididymitis, or infection of the upper urinary tract.

There are separate CKS topics on LUTS in men, age-related (prostatism), Prostatitis - acute, Prostatitis - chronic, Pyelonephritis - acute, Renal colic - acute, Urethritis - male, Urinary tract infection - children, and Urinary tract infection (lower) - women.

The target audience for this guidance is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in January 2010

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic [NICE, 2013].

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic [NPC, 2012].

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.

March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

March 2011 — minor update. Minor clarification to the text. Issued in March 2011.

December 2010 — minor update. Nitrofurantoin capsules have been added as an alternative option to nitrofurantoin tablets in the Prescriptions. Issued in December 2010.

April 2010 — minor update. The advice regarding when prophylactic antibiotics should be used when changing an indwelling catheter has been corrected. Issued in May 2010.

August 2009 to January 2010 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

There have been no major changes to the recommendations.

Previous changes

September 2008 — minor correction to the Changes section. Issued September 2008.

April 2008 — minor update. Guidance updated to be in line with the SIGN guideline on the Management of Suspected Bacterial Urinary Tract Infection in Adults. Issued in May 2008.

January to March 2006 — reviewed. Validated in June 2006 and issued in July 2006.

October 2005 — minor technical update. Issued in November 2005.

January 2002 — written, replacing sections of previous guidance on UTI (lower) — acute and UTI (lower) — recurrent. Validated in March 2002 and issued in April 2002.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 September 2009.

HTAs (Health Technology Assessments)

No new HTAs since 1 September 2009.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2009.

Systematic reviews and meta-analyses

Systematic reviews published since the last revision of this topic:

Schmiemann, G., Kneihl, E., Gebhardt, K., et al. (2010) The diagnosis of urinary tract infection: a systematic review. Deutsches Arzteblatt International 107(21), 361-367. [Abstract] [Free Full-text]

Wang, C-H., Fang, C-C., Chen, N-C., et al. (2012) Cranberry-containing products for prevention of urinary tract infections in susceptible populations. A systematic review and meta-analysis of randomized controlled trials. Archives of Internal Medicine 172(13), 988-996. [Abstract]

Primary evidence

No new randomized controlled trials published in the major journals since 1 September 2009.

Observational studies published since the last revision of this topic:

Drekonja, D.M., Rector, T.S., Cutting, A., and Johnson, J.R. (2013) Urinary tract infection in male veterans: treatment patterns and outcomes. Archives of Internal Medicine 173(1), 62-68. [Abstract]

New policies

No new national policies or guidelines since 1 September 2009.

New safety alerts

No new safety alerts since 1 September 2009.

Changes in product availability

No changes in product availability since 1 September 2009.

Goals and outcome measures

Goals

To promptly recognize urinary tract infection (UTI)

To accurately diagnose UTI

To appropriately treat UTI

To safely avoid the unnecessary use of antibiotics

To provide symptomatic relief

To eradicate infection

To prevent recurrence of UTI

To prevent complications

To detect and manage predisposing and associated conditions

Outcome measures

Outcome measures for management of lower urinary tract infection (UTI) in men

Rate of cure.

Rate of re-attendance for the same symptoms.

Rate of antibiotic prescribing for urinary symptoms.

Patterns of antibiotic prescribing for urinary symptoms (for example choice of antibiotic, duration of treatment).

Proportion of urine samples meeting standards for urine collection, storage, and transport.

QIPP - options for local implementation

QIPP - options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs)

Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).

If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).

Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008b].

Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008b; NICE, 2009a; NICE, 2009b].

Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.

Antibiotic prescribing — especially quinolones and cephalosporins

Review and, where appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing is in line with Health Protection Agency (HPA) guidance.

Review the total volume of antibiotic prescribing against local and national data.

Review the use of quinolones and cephalosporin prescribing against local and national data.

Three-day courses of trimethoprim for uncomplicated urinary tract infection:

Review and, where appropriate, revise current prescribing practise and use implementation techniques to ensure prescribing of three-day courses of trimethoprim is in line with HPA guidance.

[NICE, 2013]

Background information

Definition

What is it?

Urinary tract infection (UTI) is infection of any part of the urinary tract, usually by bacteria, but rarely by other micro-organisms or viruses.

Lower UTI is infection of the bladder (although technically, urethritis and prostatitis are also lower UTIs). In this CKS topic the term 'lower UTI' implies infection of the bladder with no clinical evidence of urethritis, prostatitis, epididymitis, or orchitis.

Cystitis is often used as a synonym for lower UTI (particularly for women) although technically it means 'inflammation of the bladder' and there are rare non-infectious causes of cystitis, such as radiation and chemicals.

Upper UTI includes pyelitis (infection of the proximal part of the ureters) and pyelonephritis (infection of the kidneys and the proximal part of the ureters).

Recurrent UTI is repeated UTI, which may be due to relapse or reinfection.

Relapse is a recurrent UTI with the same strain of organism. Relapse is the likely cause if infection recurs within a short period after treatment (for example within 2 weeks).

Reinfection is a recurrent UTI with a different strain or species of organism. Reinfection is the likely cause if UTI recurs more than 2 weeks after treatment.

Causes

What causes it?

Urinary tract infection (UTI) is usually caused by bacteria from the gastrointestinal tract. The spectrum of organisms that cause UTI is similar in men and women [European Association of Urology, 2009].

Common organisms causing UTI include:

Escherichia coli — about 90% of cases [Krieger et al, 1993].

Staphylococcus saprophyticus.

Proteus mirabilis.

UTI caused by Proteus mirabilis is a cause for concern due to the risk of urosepsis, and should raise suspicion of urinary stones. The motility and adherence to the uroepithelium of this organism facilitates movement up the urinary tract and invasive infection; urease production promotes stone formation.

Less common organisms causing UTI include:

Proteus vulgaris, Klebsiella species, Enterobacter species, Enterococcus species, Citrobacter species, Serratia marcescens, Acinetobacter species, Pseudomonas species, and Staphylococcus aureus.

Candida albicans

UTI infection due to Candida albicans is rarely found in the community, but is common in hospitalized people who have risk factors such as indwelling catheters, immunosuppression, diabetes mellitus, or antibiotic treatment.

Pathophysiology

How does the urinary tract become infected?

For the urinary tract to become infected, bacteria must gain entry to the urinary tract, avoid being flushed away, adhere to the epithelial surface, and multiply.

Entry of bacteria into the urinary tract may be:

Retrograde, ascending through the urethra into the bladder.

Via the blood stream, which is more likely in people who are immunosuppressed.

Direct, for example upon insertion of a catheter into the bladder, instrumentation, or surgery.

Incomplete emptying of the bladder during micturition is a key factor predisposing to urinary tract infection.

Many bacteria, to avoid being flushed away, adhere to the surface of the urinary tract with the aid of fimbriae.

Bacteria adhering to the urothelium use poorly understood methods to make their micro-environment suitable for rapid reproduction.

Urinary tract infection is much less common in men than in women because in men there is a greater distance between the usual source of uropathogens (the anus) and the usual entry point (the urethral meatus). In addition, the environment surrounding the male urethra is drier, the urethra is much longer, and prostatic fluid has antibacterial activity [European Association of Urology, 2009].

Prevalence

How common is it?

Urinary tract infection (UTI)

UTI in men is generally uncommon, but incidence rates are higher in elderly men (who are likely to have additional risk factors) and in men with an indwelling urinary catheter.

Few studies have documented UTI rates in men.

In one study, men presenting with symptoms indicative of UTI were predominantly elderly (median 61 years of age) and 41% had additional risk factors [Hummers-Pradier et al, 2004]. This study was conducted in 36 German general practices. The location of infection (that is, upper or lower urinary tract) was not determined.

In generally healthy male undergraduate and graduate university students, the mean incidence of symptomatic urinary infections was five per 10,000 men per year [Krieger et al, 1993]. Men with symptomatic infections were older than other students (p = 0.001).

Males accounted for 39% of the hospital admissions for UTI (undifferentiated) in England during 2007/2008 [Hospital Episode Statistics, 2008].

The incidence of UTI is similar in men and women who are elderly or who have a long-term indwelling urinary catheter [European Association of Urology, 2009].

Asymptomatic bacteriuria (bacteria present in the urine without symptoms or signs of UTI)

In men, as with women, asymptomatic bacteriuria is more common with co-existing illnesses, institutional care, and advancing age.

The reported prevalence of asymptomatic bacteriuria in men older than 70 years of age ranges from about 4–7% [SIGN, 2006].

Asymptomatic bacteriuria is common in the institutionalized elderly, with reported rates in the range 19–37% [SIGN, 2006].

Most people with long-term urinary catheters experience episodes of asymptomatic bacteriuria [SIGN, 2006; European Association of Urology, 2009].

Risk factors

What are the risk factors?

Most urinary tract infections (UTIs) in men are not associated with any risk factor. However, the following risk factors need to be excluded or managed (especially in recurrent UTI) [SIGN, 2006; European Association of Urology, 2009]:

Abnormalities of urinary tract function or structure (for example indwelling catheter, neurogenic bladder, vesicoureteric reflux, anatomical abnormalities).

Incomplete bladder emptying (for example caused by obstruction in men with prostatic enlargement, or a blocked indwelling catheter).

Previous urinary tract surgery.

Immunocompromised state.

Diabetes mellitus is a risk factor for UTI in women, but CKS found no studies of this association in men. 

Complications

What are the complications?

Ascending infection can occur, leading to pyelonephritis, perinephric and intrarenal abscess, hydronephrosis, pyonephrosis, renal failure, and septicaemia.

Prostatic involvement could lead to complications such as prostatic abscess, chronic bacterial prostatitis, and recurrent urinary tract infection (UTI) [SIGN, 2006].

However, the risk seems to be small, and evidence of serious complications is lacking. Subclinical infection of the prostate may occur in a high proportion of men with UTI. Subclinical prostatitis in men with UTI is suggested by studies finding that:

Prostate-specific antigen was transiently increased in about 90% of men with UTI [Ulleryd et al, 1999; Ulleryd, 2003].

Bacteria were present in prostatic secretions in 52% of men with recurrent UTI [Smith et al, 1979].

Prognosis

What is the prognosis?

Most men with urinary tract infection (UTI) respond well to appropriate antibiotics [Ulleryd, 2003; Hummers-Pradier et al, 2004].

Severe morbidity is more likely in men with [Emmons and Tamminga, 2004]:

Indwelling catheter.

Urinary obstruction.

Infection with urease-splitting bacteria (which are associated with stone formation in the renal collecting ducts).

Congenital renal tract anomalies.

Diabetes.

Neurogenic bladder with chronically high pressure.

Renal papillary necrosis.

Diagnosis

Diagnosis of urinary tract infection (lower) - men

Diagnosis

How do I know my patient has it?

Suspect lower UTI

Suspect lower urinary tract infection (UTI) if the man has:

Symptoms of UTI: dysuria (painful urination), frequency, urgency (the desire to pass urine immediately), nocturia (having to urinate during the night more frequently than usual), and suprapubic discomfort — these symptoms are usually present.

Signs of UTI: suprapubic tenderness, and cloudy, bloody, or foul-smelling urine — although typical of UTI, these signs may be absent.

Diagnosis can be difficult in men who are frail and elderly, or institutionalized, or who have an indwelling urinary catheter. UTI can present with atypical symptoms, and bacteriuria can be present when there are no specific urinary symptoms and signs. Therefore, considerable clinical judgement is required in this situation. Suspect UTI if any of the following are present:

Change in urinary symptoms, for example urine becoming very smelly, cloudy, or bloody.

Suprapubic or urethral discomfort.

Feeling generally unwell.

Fever.

Increased confusion or new onset of confusion.

Exclude other causes

If the man also has fever or loin pain (or both), suspect and manage as upper UTI — see the CKS topic on Pyelonephritis - acute.

Consider other possible causes for the symptoms, in particular urethritis.

Confirm the diagnosis

Confirm the diagnosis with a urine culture.

Because empirical treatment will usually need to be started immediately, it is important to obtain a urine sample for culture before starting treatment.

Do not rely on urine dipstick tests or microscopy to confirm the diagnosis.

When symptoms are moderate or severe, or suggestive of UTI, neither dipstick tests nor microscopy can reliably confirm or exclude the diagnosis of UTI.

If the man has mild or non-specific symptoms of UTI, a negative urine dipstick test (both nitrite and leukocyte esterase tests negative) can safely exclude UTI.

Collection and storage of urine samples

Collection and storage of urine samples

Careful collection, storage, and transport of urine samples minimizes the chance of false positive or false negative test results.

Collection

A clean-catch, mid-stream urine (MSU) sample is ideal and can usually be collected with little difficulty.

This requires the man to start urinating then, about half way through and without interrupting the flow, collecting a sample of approximately 10 mL urine into a sterile specimen container [HPA, 2008a]. A fresh-voided specimen is probably adequate if an MSU is not practical [Hummers-Pradier and Kochen, 2002].

Uncircumcised men are usually advised to withdraw the prepuce and clean the glans penis before collecting the sample. However, if this is not done, the sample is probably adequate [Lipsky et al, 1984].

In frail elderly men, a clean condom catheter with a sterile collection bag attached may be necessary to obtain a urine sample.

If the man has a chronic indwelling urinary catheter, drain and discard a few millilitres of urine from the catheter or sampling port, and then collect the urine sample. Use an aseptic technique. Do not take the specimen from the collection bag, as this is more likely to be contaminated [NICE, 2003].

Containers

If the container contains boric acid (as a preservative), fill it to the marked line — with a lesser volume of urine, the concentration of boric acid can be high enough to be bactericidal [HPA, 2008a].

Storage

If the urine sample cannot be transported and processed within 4 hours, it should be refrigerated at 4°C. If the sample is preserved with boric acid, it can be stored at room temperature prior to transport.

Urine that has been refrigerated at 4°C for 48 hours remains suitable for culture — but not for microscopy, because most cells will have disintegrated [Sanderson, 1998].

Urine preserved with boric acid remains suitable for culture and microscopy for up to 96 hours [HPA, 2008a].

Basis for recommendation

Basis for recommendation

These recommendations are based on guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) and from the European Association of Urology [SIGN, 2006; European Association of Urology, 2009].

Interpreting urine culture results

How do I interpret urine culture results?

Diagnosis of significant bacteriuria

Generally, the threshold for reporting significant bacteriuria is 105 colony-forming units (CFU) per millilitre (CFU/mL). However, if the man is acutely symptomatic, counts higher than 102 CFU/mL can be regarded as significant when there is a single isolate. In many laboratories, the routine culture methods can detect bacteriuria only above 10CFU/mL .

The Health Protection Agency regard the following colony counts as significant:

At least 104 CFU/mL of a single organism, when there are urinary symptoms.

At least 103 CFU/mL of Escherichia coli or Staphylococcus saprophyticus.

Clinical judgement is required to assess the clinical significance of urine culture results from people with a long-term indwelling urinary catheter, as there is a high probability of culturing bacteria which are not causing symptoms or signs of urinary tract infection .

False-positive culture results are common, and are caused by contamination of the urine.

The laboratory report will mention the possibility of contamination when there are copious epithelial cells, multiple organisms, or bacteria but no leucocytes (unless the man is immunocompromised).

False-negative culture results can be caused by:

The person having started an antibiotic before the urine sample was collected. 

Boric acid (used as a preservative in the specimen bottle) — when the volume of urine is small compared with that of the preservative.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidelines from the Health Protection Agency and the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2006; HPA, 2008a; HPA, 2008b].

Boric acid has been identified in the medical literature as being a cause of false-negative culture results [Sanderson, 1998].

Differential diagnosis

What else might it be?

Conditions which present similarly to lower urinary tract infection (UTI) in men include:

Pyelonephritis — suspect pyelonephritis when there is loin pain or fever (or both). See the CKS topic on Pyelonephritis - acute.

Although treatment decisions are made on the basis of clinical features, localizing the site of UTI is difficult; it is not possible to distinguish with certainty between upper and lower UTI solely on the basis of symptoms and signs.

Urethritis — suspect urethritis when there is dysuria (pain or discomfort on urination).

Urethritis can be caused by Chlamydia trachomatis (pyuria without bacteriuria), Neisseria gonorrhoeae (urethral discharge), other sexually transmitted diseases, or herpes simplex virus.

If other findings (such as urethral discharge) suggest urethritis or the man is at high risk (for example a history of multiple partners), or if symptoms persist despite treatment of a presumed UTI, rule out urethritis.

Urethritis is ruled out with a urethral Gram stain or a first-voided urine specimen wet mount to look for urethral leucocytosis. A urethral Gram stain demonstrating leucocytes and predominant Gram-negative rods suggests Escherichia coli urethritis, which may precede or accompany a UTI [European Association of Urology, 2009]. For more information, see the CKS topic on Urethritis - male.

Acute prostatitis — suspect acute prostatitis if the man presents with a feverish illness of sudden onset, irritative urinary voiding symptoms (dysuria, frequency, urgency), pain (perineal or suprapubic pain, pain on ejaculation, or pain during bowel movements), and exquisitely tender prostate on rectal examination. For more information, see the CKS topic on Prostatitis - acute.

Drug-induced cystitis — suspect this if the man has been treated with cyclophosphamide, allopurinol, danazol, or tiaprofenic acid (and possibly other nonsteroidal anti-inflammatory drugs).

Epididymitis — suspect this when there is scrotal pain, and the epididymis is oedematous and tender.

Basis for recommendation

Basis for recommendation

These recommendations are based on what CKS considers to be good clinical practice.

The recommendation regarding distinguishing between upper and lower urinary tract infection is based on guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2006].

Management

Management

Scenario: Lower UTI in men : covers the management of lower urinary tract infection in men.

Scenario: UTI in men with an indwelling catheter : covers the management of lower urinary tract infection in men with an indwelling urinary catheter.

Scenario: Lower UTI in men

Scenario: Lower urinary tract infection in men

192months3060monthsBoth

Treatment

How should I manage lower urinary tract infection in a man without an indwelling urinary catheter?

Follow local guidelines, when these are available.

If symptoms are severe (for example severe nausea and vomiting, confusion, tachypnoea, tachycardia, or hypotension), admit the person to hospital; intravenous antibiotics may be required.

If there is fever or loin pain (or both), manage as upper urinary tract infection (UTI) — see the CKS topic on Pyelonephritis - acute.

Otherwise, treat for lower UTI:

Obtain a urine sample for culture and microscopy before starting antibiotic treatment.

Relieve symptoms with paracetamol or ibuprofen.

Start empirical treatment with trimethoprim or nitrofurantoin:

Trimethoprim 200 mg twice daily, for 7 days. Trimethoprim should not be used for empirical treatment if the man has a history of recurrent infections or has taken trimethoprim within the past 12 months.

Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days. The standard formulation is suitable for most people. Consider prescribing the modified-release formulation if nausea has previously been troublesome with the standard formulation, or if adherence with taking medication four times daily is likely to be poor.

Follow up after 48 hours (or according to the clinical situation) to check response to treatment and the urine culture results.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidelines from the Scottish Intercollegiate Guidelines Network (SIGN), the Health Protection Agency (HPA), and the European Urological Association (EUA) [SIGN, 2006; HPA and Association of Medical Microbiologists, 2008; European Association of Urology, 2009]. Because urinary tract infection (UTI) in men is rare, there are no controlled trials. These guidelines are therefore based on expert opinion or extrapolation from studies in women with UTI.

Obtaining a urine sample before starting treatment

Obtaining a urine sample for culture and sensitivity before starting treatment is recommended:

To confirm UTI — urine dipstick tests are not sufficiently accurate. This recommendation is pragmatic, and is extrapolated from the evidence on the use of urine dipstick tests to diagnose lower UTI in women. Recent UK national and European guidelines do not discuss the use of urine dipstick tests for men with suspected UTI [SIGN, 2006; HPA and Association of Medical Microbiologists, 2008; European Association of Urology, 2009]. A recent systematic review and meta-analysis of urine dipstick tests to exclude UTI found that only one of 23 studies was done in men, and reported results combined from all studies without regard to gender [St John et al, 2006].

To guide the choice of antibiotic — resistance to first-line antibiotics is not uncommon, and infections with multi-resistant Escherichia coli with extended-spectrum beta-lactamase enzymes (ESBL) are increasing [HPA and Association of Medical Microbiologists, 2008].

Empirical treatment with trimethoprim or nitrofurantoin

There is no evidence from clinical trials of antibiotics for lower UTI in men. Therefore, recommendations are based on evidence extrapolated from treatment of lower UTI in women (which is reviewed in the CKS topic on Urinary tract infection (lower) - women) and on expert opinion.

Choice of antibiotic

Trimethoprim and nitrofurantoin are active against most uropathogens, and are recommended as first-line options by the Health Protection Agency (HPA) and Association of Medical Microbiologists for use in men with lower UTI and without fever and flank pain [HPA, 2009].

Several guidelines recommend that nitrofurantoin should not be used to treat UTI in men. This is on the grounds that it can be difficult to exclude the possibility of prostatitis, and that nitrofurantoin is not present in therapeutic concentrations in prostatic secretions [SIGN, 2006; European Association of Urology, 2009]. However, these recommendations refer to UTI with fever or other signs of acute prostatitis, and neither guideline expressed concern that acute prostatitis would be likely in men with symptoms of lower UTI and without fever and other symptoms of prostatitis.

For initial empirical treatment, the HPA and Association of Medical Microbiologists recommend not using broad-spectrum antibiotics (such as co-amoxiclav, quinolones, and cephalosporins) when narrow-spectrum antibiotics remain effective. This is because broad-spectrum antibiotics increase the risk of Clostridium difficile, meticillin resistant Staphylococcus aureus (MRSA), and the development of antibiotic resistance [HPA and Association of Medical Microbiologists, 2008].

Trimethoprim is not recommended if the man has used it in the past 12 months because use of trimethoprim up to 1 year previously is associated with increased risk of infection with a resistant organism. The evidence is reviewed in the CKS topic on Urinary tract infection (lower) - women.

Trimethoprim is not recommended for empirical treatment of recurrent UTI in men because of the (theoretical) increased risk that this is due to a resistant organism.

Duration of treatment

In contrast to the situation in women, there is no evidence that short courses are as effective as longer courses of antibiotics to treat lower UTI in men. Because men are more likely than women to have an occult complicating factor, at least 7 days of antibiotic treatment is recommended [SIGN, 2006; European Association of Urology, 2009].

Follow up

How should I follow up a man with lower urinary tract infection?

Review after 48 hours (or according to the clinical situation) to check response to treatment and the culture results.

If urine culture shows that the organism is resistant to the current antibiotic, change to an antibiotic that the organism is sensitive to.

If symptoms have resolved by the time the culture result is available, consider continuing with the current antibiotic, and doing a 'test of cure' urine culture after completing treatment. If symptoms then recur, treat with an antibiotic shown to cover the infecting organism.

Consider if there are any risk factors that need to be excluded or managed.

Consider referral for specialist urological assessment when the man has recovered from the acute infection.

Basis for recommendation

Basis for recommendation

These recommendations are pragmatic, as there is no evidence from clinical trials or published expert opinion.

Continuing the initial antibiotic is recommended when urine culture reveals a resistant uropathogen and the man's symptoms have resolved, because either the infection is resolving on its own or the organism is susceptible despite the laboratory assessment of resistance.

Referral

When should I refer a man with lower urinary tract infection?

Admit the man to hospital if symptoms are severe (for example severe nausea and vomiting, confusion, tachypnoea, tachycardia, or hypotension) — intravenous antibiotics may be required.

Referral for urological assessment is not routinely required for men who have had a urinary tract infection (UTI).

Refer for urological assessment men who:

Have failed to respond to appropriate antibiotic treatment.

May have an underlying cause for the UTI (such as urinary obstruction, which is more likely in older men, especially if they have hesitancy, straining, or weak urinary stream).

Have frequent episodes of UTI (for example two or more episodes in a 3-month period).

Have a history of pyelonephritis, calculi, or previous genitourinary tract surgery.

Are younger than 50 years of age and have persistent microscopic haematuria with otherwise normal renal function tests (urinary protein and serum creatinine).

Refer for renal assessment if the man has persistent microscopic haematuria with proteinuria or raised serum creatinine.

Refer urgently if cancer is suspected. Refer the man to a team specializing in the management of urological cancer if:

He is of any age, with macroscopic haematuria and urine culture fails to confirm a UTI or the haematuria does not resolve with treatment of the UTI. 

He is 40 years of age or older, and presents with recurrent or persistent UTI associated with haematuria.

He is 50 years of age or older, and is found to have unexplained microscopic haematuria.

An abdominal mass is identified (clinically or on imaging) that is thought to arise from the urinary tract.

Additional information

Additional information

Urological assessment aims to identify and manage possible underlying causes, such as:

Prostatitis.

Prostatic enlargement due to cancer or benign prostatic hypertrophy.

Calculi.

Bladder cancer.

Basis for recommendation

Basis for recommendation

The referral guidelines for suspected cancer are those published by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Primary Care, 2005].

The other recommendations are pragmatic. National and European guidelines agree that the value of urological evaluation in men who have had a single uncomplicated urinary tract infection (UTI) has not been determined sufficiently well to make recommendations on referral [SIGN, 2006; European Association of Urology, 2009].

However, the recommendations on referral do take account of weak evidence from a systematic review of urological investigations in men with lower UTI that urological abnormalities are most likely to be found in men who are more than 45 years of age, who do not respond well to antibiotics, or who have recurrent UTIs [Fernandez, 2004].

Recurrent UTI

How should I manage recurrent urinary tract infection?

Culture the urine (whatever the results of urine dipstick tests).

Treat each episode as for acute lower urinary tract infection (UTI).

If the man is sexually active, rule out chlamydial infection — see the CKS topic on Urethritis - male.

Refer for urological assessment if there are two or more episodes of UTI in 3 months.

Basis for recommendation

Basis for recommendation

In the absence of relevant clinical trials, authoritative guidelines, and published expert opinion, these recommendations are pragmatic.

Managing each episode as for acute lower urinary tract infection (UTI) is recommended because there is no evidence that an alternative approach would be preferable.

Excluding chlamydial infection in sexually active men is recommended because this is fairly common, and is easy to miss unless it is specifically looked for.

The details of the recommendations on referral are pragmatic, but are in line with national and European guidelines [SIGN, 2006; European Association of Urology, 2009].

The use of antibiotics to prevent UTIs from recurring has not been mentioned in the recommendations because:

It is not discussed in guidelines.

It has not been studied in controlled trials.

Men with problematic recurrent UTIs should be referred to a urologist.

Scenario: UTI in men with an indwelling catheter

Scenario: Urinary tract infection in men with an indwelling catheter

192months3060monthsBoth

Treatment

How should I manage lower urinary tract infection in a man with an indwelling catheter?

Follow local guidelines, when these are available.

Do not treat asymptomatic bacteriuria.

Considerable clinical judgement is required to diagnose urinary tract infection (UTI) in men with an indwelling urinary catheter.

If symptoms are severe (for example severe nausea and vomiting, confusion, tachypnoea, tachycardia, hypotension, reduced urine output), admit the person to hospital; intravenous antibiotics may be required.

Check that the catheter is correctly positioned and is not blocked. If the catheter has been in place for more than a week, consider changing it before starting antibiotic treatment.

If there is fever or loin pain (or both), manage as upper UTI. See the CKS topic on Pyelonephritis - acute.

Otherwise, treat for lower UTI:

Relieve symptoms with paracetamol or ibuprofen.

Before starting antibiotic treatment, obtain a urine sample for culture and microscopy.

Treat with an antibiotic for 7 days.

If symptoms are mild, consider withholding antibiotics until the result of urine culture is available to guide choice of antibiotic.

If treatment cannot wait for the culture results, start empirical treatment with trimethoprim or nitrofurantoin.

Trimethoprim 200 mg twice daily, for 7 days. Trimethoprim should not be used for empirical treatment if the man has a history of recurrent infections or has taken trimethoprim within the past 12 months.

Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days. The standard formulation is suitable for most people. Consider prescribing the modified-release formulation if nausea has previously been troublesome with the standard formulation, or if adherence with taking medication four times daily is likely to be poor.

Follow up after 48 hours (or according to the clinical situation) to check response to treatment and the urine culture results.

Basis for recommendation

Basis for recommendation

Using clinical judgement to decide when to use antibiotics

Careful clinical judgement is recommended when deciding to use an antibiotic in people with an indwelling urinary catheter. This is because all people with a long-term indwelling urinary catheter will have bacteriuria at some stage, there is no good evidence that antibiotics are beneficial for asymptomatic bacteriuria, and repeated treatment of asymptomatic bacteriuria increases the risk of colonization by drug-resistant bacteria [SIGN, 2006; European Association of Urology, 2009].

Admitting to hospital

The recommendation to admit the person to hospital if systemic symptoms and signs are present is based on expert opinion [SIGN, 2006].

Reviewing catheter care

The recommendation to review the care of the catheter is based on expert opinion [NICE, 2003; European Association of Urology, 2009].

The recommendation to consider changing the catheter before starting antibiotic treatment for urinary tract infection (UTI) is based on one small trial and expert opinion [SIGN, 2006; European Association of Urology, 2009]. See the evidence in the CKS topic on Urinary tract infection (lower) - women.

Using urine culture to guide the choice of antibiotic

The recommendation to use the culture results to guide treatment and, if practical, to withhold treatment until the culture results are available, is based on expert opinion. It is intended to reduce the risks of complications and treatment failure, which are generally increased in people with an indwelling urinary catheter [SIGN, 2006].

The recommendation to change to a more appropriate antibiotic if the antibiotic was started empirically and a resistant organism is isolated on urine culture is based on expert opinion. It is intended to reduce the risks of complications and treatment failure [SIGN, 2006; European Association of Urology, 2009].

Relieving symptoms

CKS found no trials of analgesics for relieving the symptoms of UTI. The recommendation to use paracetamol or ibuprofen to treat the symptoms of UTI is based on their use in other painful infections and the experience of experts [SIGN, 2006].

Choosing an antibiotic

As there is no direct evidence from clinical trials of different antibiotics in men with an indwelling urinary catheter, the recommendation to prescribe trimethoprim or nitrofurantoin for empirical treatment of UTI is based on the recommendations in the Treatment section of Managing lower UTI in men.

Treating for 7 days

Antibiotic treatment for 7 days is recommended because there is only one small trial of treatment duration. Although this found that shorter courses are equally effective for UTI in people with an indwelling urinary catheter, further studies are required to support a recommendation for a shorter course. See the evidence in the CKS topic on Urinary tract infection (lower) - women.

Follow up

How should I follow up a catheterized man with lower urinary tract infection?

Review after 48 hours, or according to the clinical situation, to ensure the man is responding to treatment, and to check the results of the urine culture.

If urine culture shows that the organism is resistant to the current antibiotic, and:

If symptoms have not resolved, change to an antibiotic that the organism is sensitive to.

If symptoms have resolved, consider continuing with the current antibiotic.

If symptoms recur, start treatment with an antibiotic shown in the laboratory report to cover the infecting organism.

If the man fails to respond to two courses of antibiotic shown by urine culture to be appropriate treatment, and compliance has been good, consider referring for assessment and investigation.

Basis for recommendation

Basis for recommendation

These recommendations are pragmatic. CKS found no published expert opinion.

When the uropathogen is resistant to the empirically chosen antibiotic and the man has responded:

The recommendation to consider continuing treatment until the end of the antibiotic course is based on the comments of CKS expert reviewers. If symptoms have resolved, there is likely to be little added benefit from changing the antibiotic. This is because either the infection is resolving on its own, or the laboratory assessment of resistance does not reflect the true susceptibility of the uropathogen.

Referral

When should I refer a catheterized man with lower urinary tract infection?

Consider referring for assessment and investigation if the man fails to respond to two courses of antibiotic shown by urine culture to be appropriate treatment, and treatment adherence has been verified.

If cancer is suspected, refer urgently. Refer the man to a team specializing in the management of urological cancer if:

He is of any age, with macroscopic haematuria and urine culture fails to confirm a urinary tract infection (UTI) or the haematuria does not resolve with treatment of a UTI. 

He is 40 years of age or older, and presents with recurrent or persistent UTI associated with haematuria.

He is 50 years of age or older, and has unexplained microscopic haematuria — exclude causes such as the urinary catheter and infection.

An abdominal mass is identified (clinically or on imaging) that is thought to arise from the urinary tract.

If there is persistent microscopic haematuria, and this is not thought to be caused by a urinary catheter:

Refer for urological assessment those men younger than 50 years of age who do not have proteinuria or raised serum creatinine.

Refer for renal assessment those men with proteinuria or raised serum creatinine.

Basis for recommendation

Basis for recommendation

Referral for failure to respond to appropriate antibiotics

The recommendation to consider referring men who have failed to respond to an appropriate antibiotic (shown by urine culture) is pragmatic, as CKS found no direct evidence from clinical trials or recommendations in national guidelines.

Urgent referral for urological cancer

The recommendation to refer men with suspected urological cancer is based on criteria in guidelines from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2005].

Prevention

How can I prevent urinary tract infections in men with indwelling catheters?

Ensure an indwelling urinary catheter is appropriate.

Use an indwelling catheter only after alternative methods of management have been considered.

Regularly review the clinical need for catheterization and remove the catheter as soon as possible.

Use intermittent catheterization in preference to an indwelling catheter if this is clinically appropriate and is a practical option for the person.

Prevent the introduction of infection.

Healthcare personnel should be trained and assessed in their competence to perform urethral catheterization using aseptic procedures.

Urine samples should be obtained from a sampling port using an aseptic technique.

Catheters should be changed only when clinically necessary (for example to prevent blockage), or according to the manufacturer's recommendations.

When changing catheters, antibiotic prophylaxis should only be used for people with a history of catheter-associated urinary tract infection following catheter change.

Do not use:

Bladder instillations or washouts.

Prophylactic antibiotics when changing catheters in men with a heart valve lesion, septal defect, patent ductus, or prosthetic valve.

Topical antiseptics or antibiotics applied to the catheter, urethra, or meatus — daily washing of the meatus with soap and water is sufficient.

Basis for recommendation

Basis for recommendation

These recommendations are based on guidelines from the National Institute for Health and Care Excellence (NICE) [NICE, 2003].

Minimizing the use of indwelling urinary catheters

The recommendations on training and practical ways to minimize the use of indwelling urinary catheters reflect guidelines from NICE [NICE, 2003].

NICE based their recommendation to use intermittent catheterization rather than an indwelling urinary catheter on a systematic review which included 22 studies, and 10 further studies.

Not using bladder instillations or washouts

Bladder instillations and washouts are discouraged because the NICE systematic review found good evidence that they do not prevent urinary tract infections, and there is concern that they may have local toxic effects [NICE, 2003].

Not using prophylactic antibiotics or antiseptics

The recommendation not to use prophylactic antibiotics when changing catheters is based on findings from two studies in the NICE systematic review that reported that not using antibiotic prophylaxis did not increase the risk of urinary tract infection [NICE, 2003].

The recommendation not to use prophylactic antibiotics when changing catheters in men with a heart valve lesion, septal defect, patent ductus, or prosthetic valve is based on the NICE clinical guideline on prophylaxis for infective endocarditis, which found this not to be cost-effective [NICE, 2008a]. The advice in this guideline has superseded the advice in the NICE Infection control guideline [NICE, 2003]. However, some experts still recommend antibiotic cover.

The recommendation not to use topical antiseptics or antibiotics applied to the catheter, urethra, or meatus is based on findings from six clinical studies that compared meatal cleansing with a variety of antiseptic/antimicrobial agents or soap and water; use of antiseptics and antimicrobial agents did not reduce the rate of bacteriuria [NICE, 2003].

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Trimethoprim

Trimethoprim

Contraindications

Avoid using trimethoprim in men with blood dyscrasias.

Basis for recommendation

Because of its potential anti-folate effect, there have been reports that trimethoprim causes blood disorder. Consequently, trimethoprim is contraindicated in people with dyscrasias [Actavis, 2007; BNF 57, 2009].

Precautions

Trimethoprim should be prescribed with caution in the following conditions:

Severe renal impairment

As the drug is predominantly excreted by the kidney, dose adjustment may be required.

[Actavis, 2007; BNF 57, 2009]

Adverse effects

Trimethoprim is generally well tolerated.

Nausea, vomiting, pruritus, and skin rashes have occasionally been reported. These are generally mild and reversible when trimethoprim is withdrawn.

Severe adverse drug reactions with trimethoprim are rare.

[Aronson, 2006; Actavis, 2007]

Drug interactions

What drug interactions should I be aware of with trimethoprim?

The following drug interactions have been reported with trimethoprim, when it is combined:

With phenytoin

There is a small risk of phenytoin toxicity (particularly if the serum phenytoin levels are at the top end of the range) as trimethoprim can decrease the clearance of phenytoin [Baxter, 2008]. Signs of phenytoin toxicity include blurred vision, nystagmus, ataxia, or drowsiness.

With ciclosporin

Increased nephrotoxicity has been reported. However, this interaction has not been firmly established.

[Baxter, 2008; BNF 57, 2009]

Nitrofurantoin

Nitrofurantoin

Contraindications

Avoid prescribing nitrofurantoin for people with:

Creatinine clearance less than 60 mL per minute, or elevated serum creatinine [Goldshield Pharmaceuticals, 2007].

Confirmed deficiency of glucose-6-phosphate dehydrogenase — as it may cause haemolysis.

This is found in 10% of black people and a variable percentage of ethnic groups of Mediterranean, near Eastern, and Asian origin. It is rare in white people.

Discontinue nitrofurantoin if there is any sign of haemolysis (which ceases when the drug is withdrawn).

Peripheral neuropathy

Nitrofurantoin should be used with caution in people with anaemia, diabetes mellitus, electrolyte imbalance, debilitating conditions, or vitamin B (particularly folate) deficiency since these conditions may enhance the occurrence of peripheral neuropathy.

The manufacturer of nitrofurantoin advises stopping the drug at the first signs of neural involvement (paraesthesiae).

If the person develops unexplained pulmonary, hepatotoxic, haematological, or neurologic syndromes, discontinue treatment with nitrofurantoin.

[Goldshield Pharmaceuticals, 2002a; Goldshield Pharmaceuticals, 2002b; Goldshield Pharmaceuticals, 2007]

Adverse effects

Adverse effects associated with nitrofurantoin

Pulmonary: nitrofurantoin-associated pulmonary reactions are reported in less than 1% of people treated with nitrofurantoin. Common manifestations are dry cough, chest pain, dyspnoea, and hypoxemia. Skin rash, arthralgia, and elevated liver enzymes are occasionally present. Chest imaging shows patchy infiltrates and fibrosis. Treatment includes stopping the medication and prescribing a course of corticosteroids [Vahid and Wildemore, 2006].

Gastrointestinal: nausea and anorexia have been reported. Vomiting, abdominal pain, and diarrhoea are less common gastrointestinal reactions.

Peripheral neuropathy (including optical neuritis), with symptoms of sensory as well as motor involvement, has been reported infrequently.

Stop treatment at the first sign of neurological involvement.

Drug interactions

The use of alkalinizing agents (such as potassium citrate) should be avoided in people taking nitrofurantoin. The antibacterial activity of nitrofurantoin is reduced when the pH of the urine is increased [SIGN, 2006].

Although the manufacturer of nitrofurantoin advises against concomitant administration of magnesium trisilicate with nitrofurantoin (due to reduced absorption), the clinical significance is uncertain as only one very small study in six people has reported this effect [Baxter, 2008].

Evidence

Evidence

Supporting evidence

Because lower urinary tract infection (UTI) is uncommon in men, it has been little studied. CKS found no relevant clinical trials to provide evidence on issues such as the use of urine dipstick tests, treatment of symptoms, and the management of UTI in the presence of an indwelling urinary catheter.

The evidence on antibiotic resistance is reviewed in the section on Antibiotic resistance in the CKS topic on Urinary tract infection (lower) - women.

Choice of antibiotic - lower UTI

Evidence on choice of antibiotic to treat lower UTI in men

CKS found no relevant controlled clinical trials of antibiotics to treat lower urinary tract infection (UTI) in men.

Duration of treatment - lower UTI

Evidence on duration of treatment of lower UTI in men

CKS found no relevant controlled clinical trials of the duration of antibiotic treatment for lower urinary tract infection (UTI) in men.

Antibiotic treatment - indwelling urinary catheter and lower UTI

Evidence on antibiotic treatment for men with an indwelling urinary catheter and lower UTI

CKS found no relevant clinical trials carried out in men.

Urological investigations

Evidence on the value of urological investigations in men with lower UTI

Weak evidence from a systematic review of urological investigations in men with lower urinary tract infection (UTI) shows that urological abnormalities are most likely to be found in those older than 45 years of age, or who do not respond well to antibiotics, or who have recurrent UTIs.

A systematic review (literature search: up to July 2004) found seven observational studies of urological investigations in men post-UTI [Fernandez, 2004].

Data from two studies suggest that healthy men younger than 45 years of age who have a UTI for the first time and who respond well to antibiotic treatment are unlikely to have an underlying urological abnormality.

Data from five studies suggest that men who are older, do not respond well to antibiotics, or who have recurrent UTIs are likely to have underlying urological abnormalities that would be discovered by urological investigations.

The most common urological abnormalities are benign prostatic hypertrophy, renal cortical scarring, urinary tract stones, bladder diverticulae, urethral strictures, and prostate cancer.

This body of evidence provides weak support for any conclusions because of methodological weaknesses in the studies.

All the studies reported urological investigations for small numbers of selected participants.

Only one study compared the prevalence of urological disorders in men with and without UTI; the study was based in Cameroon and may not accurately reflect the situation in developed countries.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of Urinary tract infections in men, with additional searches in the following areas:

UTIs with an indwelling urinary catheter

Pathogen resistance

Benefits of urological investigations of men with a UTI

Nitrofurantoin penetration of the prostate (search dates: January 1966 – September 2009)

PSA levels in men with a UTI (search dates: January 1966 – September 2009)

The search excluded articles on women and children.

Search dates

Medline and Embase: January 2003 – September 2009 (except where otherwise stated)

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

exp Urinary Tract Infections/, exp Cystitis/, cystitis.tw, uti.tw, (urinary adj tract adj infection$).tw, exp Bacteriuria/, bacteriuria.tw, exp Hematuria/, (microscopic adj haematuria).tw

exp Anti-Bacterial Agents/, exp Ciprofloxacin/, ciprofloxacin.tw, exp Nitrofurantoin/, nitrofurantoin.tw, exp Trimethoprim/, exp Trimethoprim-Sulfamethoxazole Combination/, Trimethoprim.tw, exp Cephalexin/, cephalexin.tw, exp Norfloxacin/, norfloxacin.tw

exp Drug Resistance, Microbial/, exp Drug Resistance, Bacterial/

exp Prostate/, exp Prostate-Specific Antigen/, psa level$.tw

exp Catheterization/, exp Catheters, Indwelling

exp "Laboratory Techniques and Procedures"/

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSH subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Topic specific literature search sources

European Association of Urology

Health Protection Agency

SIGN

NICE

Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

National Guidelines Clearinghouse

New Zealand Guidelines Group

British Columbia Medical Association

Canadian Medical Association

Institute for Clinical Systems Improvement

Guidelines International Network

National Library of Guidelines

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Royal College of Nursing

Singapore Ministry of Health

Health Protection Agency

National Resource for Infection Control

CREST

World Health Organization

NHS Scotland National Patient Pathways

Agency for Healthcare Research and Quality

TRIP database

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

MeReC

NPCi

DynaMed

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

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