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Urinary tract infections

About

What is covered

This interactive flowchart covers diagnosing, treating and managing urinary tract infections including lower (cystitis), upper (acute pyelonephritis) and recurrent UTIs.

Updates

Updates to this interactive flowchart

30 October 2018 Pyelonephritis (acute): antimicrobial prescribing (NICE guideline NG111), urinary tract infection (lower): antimicrobial prescribing (NICE guideline NG109), and urinary tract infection (recurrent): antimicrobial prescribing (NICE guideline NG112) added.
26 September 2017 Recommendations on urine testing strategies amended in line with the update of NICE guideline CG54 on urinary tract infection in under 16s.
10 February 2016 Restructured, and summarised recommendations replaced with full recommendations.
16 July 2013 Urinary tract infection in children and young people (NICE quality standard 36) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing, treating and managing urinary tract infections including lower (cystitis), upper (acute pyelonephritis) and recurrent UTIs in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing, treating and managing urinary tract infections including lower (cystitis), upper (acute pyelonephritis) and recurrent UTIs.

Updates

Updates to this interactive flowchart

30 October 2018 Pyelonephritis (acute): antimicrobial prescribing (NICE guideline NG111), urinary tract infection (lower): antimicrobial prescribing (NICE guideline NG109), and urinary tract infection (recurrent): antimicrobial prescribing (NICE guideline NG112) added.
26 September 2017 Recommendations on urine testing strategies amended in line with the update of NICE guideline CG54 on urinary tract infection in under 16s.
10 February 2016 Restructured, and summarised recommendations replaced with full recommendations.
16 July 2013 Urinary tract infection in children and young people (NICE quality standard 36) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Urinary tract infection in children and young people (2013 updated 2017) NICE quality standard 36

Quality standards

Urinary tract infection in children and young people

These quality statements are taken from the urinary tract infection in children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people under 16 and should be read in full.

Quality statements

Presentation with unexplained fever of 38°C or higher

This quality statement is taken from the urinary tract infection in children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people and should be read in full.

Quality statement

Infants, children and young people presenting with unexplained fever of 38°C or higher have a urine sample tested within 24 hours.

Rationale

It is important that a urinary tract infection is considered as a cause of feverish illness in infants, children and young people. When an infant, child or young person (under 16 years) presents to a healthcare practitioner with a temperature of 38°C or higher, and there is no obvious source of the infection, a urine sample should be tested within 24 hours to ensure prompt diagnosis and antibiotic treatment if appropriate.

Quality measures

Structure
Evidence of local arrangements to ensure that infants, children and young people (under 16 years) who present with unexplained fever of 38°C or higher have a urine sample tested within 24 hours.
Data source: Local data collection.
Process
Proportion of infants, children and young people who present with unexplained fever of 38°C or higher who have a urine sample tested within 24 hours.
Numerator – the number of people in the denominator who have a urine sample tested within 24 hours.
Denominator – the number of infants, children and young people (under 16 years) presenting with unexplained fever of 38°C or higher.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for infants, children and young people presenting with unexplained fever of 38°C or higher to have a urine sample tested within 24 hours.
Healthcare practitioners ensure that infants, children and young people presenting with unexplained fever of 38°C or higher have a urine sample tested within 24 hours.
Commissioners ensure that they commission services for infants, children and young people presenting with unexplained fever of 38°C or higher that carry out testing of urine samples within 24 hours.

What the quality statement means for patients and carers

Infants, children and young people under 16 with a temperature of 38°C or higher and no obvious infection have a urine sample tested within 24 hours of seeing a healthcare professional.

Source guidance

Urinary tract infection in under 16s: diagnosis and management (NICE clinical guideline 54), recommendations 1.1.1.1, 1.1.5.2, 1.1.5.3, 1.1.5.4 and 1.1.5.5

Definitions of terms used in this quality statement

Although all infants, children and young people with symptoms and signs suggesting urinary tract infection should have a urine sample tested for infection, this statement relates specifically to those presenting with unexplained fever of 38°C or higher.
A urinary tract infection may be the cause of fever if there is no obvious source of infection and there is no alternative diagnosis.
The NICE guideline on urinary tract infection in under 16s recommends urine-testing strategies according to 3 separate age groups. The urine-testing strategies are grouped as follows:
  • infants younger than 3 months
  • infants and children 3 months or older but younger than 3 years
  • children 3 years or older.
Assess the risk of serious illness in line with the NICE guideline on fever in under 5s to ensure appropriate urine tests and interpretation, both of which depend on the child's age and risk of serious illness.

History and examination – recording of risk factors

This quality statement is taken from the urinary tract infection in children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people and should be read in full.

Quality statement

Infants, children and young people with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.

Rationale

Presenting symptoms, findings on examination, results of urine testing and knowledge of risk factors are all important when a diagnosis of urinary tract infection is being considered. Recording of risk factors is a cumulative process as part of the history and examination of an infant, child or young person with a urinary tract infection. Recording of risk factors is also important in order to identify whether onward referral and further investigations will be needed.

Quality measures

Structure
Evidence of local arrangements to ensure that infants, children and young people (under 16 years) with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Data source: Local data collection.
Process
Proportion of infants, children and young people with a urinary tract infection who have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Numerator – the number of people in the denominator who have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Denominator – the number of infants, children and young people (under 16 years) with a urinary tract infection.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for infants, children and young people with a urinary tract infection to have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Healthcare practitioners ensure that infants, children and young people with a urinary tract infection have risk factors for urinary tract infection and serious underlying pathology recorded as part of their history and examination.
Commissioners ensure that they commission services for infants, children and young people with a urinary tract infection where risk factors for urinary tract infection and serious underlying pathology are recorded as part of their history and examination.

What the quality statement means for patients and carers

Infants, children and young people under 16 with a urinary tract infection have any factors that may put them at risk of urinary tract infection and of more serious underlying conditions recorded in their patient notes.

Source guidance

Urinary tract infection in under 16s: diagnosis and management (NICE clinical guideline 54), recommendation 1.1.7.1 (key priority for implementation)

Definitions of terms used in this quality statement

The NICE guideline on urinary tract infection in under 16s recommends that the following risk factors for a urinary tract infection (UTI) and serious underlying pathology should be recorded as part of history and examination on confirmed UTI:
  • poor urine flow
  • history suggesting previous UTI or confirmed previous UTI
  • recurrent fever of uncertain origin
  • antenatally-diagnosed renal abnormality
  • family history of vesicoureteric reflux (VUR) or renal disease
  • constipation
  • dysfunctional voiding
  • enlarged bladder
  • abdominal mass
  • evidence of spinal lesion
  • poor growth
  • high blood pressure.

Information about recognising re-infection

This quality statement is taken from the urinary tract infection in children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people and should be read in full.

Quality statement

Children and young people who have had a urinary tract infection are given information about how to recognise re-infection and to seek medical advice straight away.

Rationale

Some children and young people will experience a recurrence of urinary tract infection, and it is important that such infections are recognised and treated quickly to reduce the risk of complications.
Children and young people (and parents and carers) should be aware of the importance of seeking medical advice straight away if they think there is another urinary tract infection.

Quality measure

Structure
Evidence of local arrangements to ensure that children and young people (under 16 years) who have had a urinary tract infection are given information about how to recognise re-infection and to seek medical advice straight away.
Data source: Local data collection
Process
Proportion of children and young people who have had a urinary tract infection who receive information about how to recognise re-infection and to seek medical advice straight away.
Numerator – the number of people in the denominator who receive information about how to recognise re-infection and to seek medical advice straight away.
Denominator – the number of children and young people (under 16 years) who have had a urinary tract infection.
Data source: Local data collection.
Outcome
Patient satisfaction with information received about how to recognise re-infection and to seek medical advice straight away.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place to give children and young people who have had a urinary tract infection information about how to recognise re-infection and to seek medical advice straight away.
Healthcare practitioners give information to children and young people who have had a urinary tract infection, and/or their parents or carers, about how to recognise re-infection and to seek medical advice straight away.
Commissioners ensure that they commission services in which children and young people who have had a urinary tract infection, and/or their parents or carers, are given information about how to recognise re-infection and to seek medical advice straight away.

What the quality statement means for patients and carers

Children and young people under 16 who have had a urinary tract infection, and/or their parents or carers, are given information about how to recognise if they have another infection and to seek medical advice straight away.

Source guidance

Urinary tract infection in under 16s: diagnosis and management (NICE clinical guideline 54), recommendation 1.6.1.2

Definitions of terms used in this quality statement

The healthcare practitioner (for example, a GP or hospital paediatrician) should give children and young people who have had a confirmed urinary tract infection, and/or their parents or carers, information and advice about possible re-infection and the importance of seeking medical advice straight away if there are signs of another urinary tract infection.

Equality and diversity considerations

Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.
Children and young people with a suspected or confirmed urinary tract infection, or their parents or carers, should have access to an interpreter or advocate if needed.

Laboratory reporting – differentiation of E. coli and non-E. coli organisms

This quality statement is taken from the urinary tract infection in children and young people quality standard. The quality standard defines clinical best practice for urinary tract infection in children and young people and should be read in full.

Quality statement

Infants, children and young people with a urinary tract infection caused by coliform bacteria have results of microbiology laboratory testing differentiated by Escherichia coli (E. coli) or non-E. coli organisms.

Rationale

Most urine infections are caused by E. coli bacteria, which belong to a group of bacteria called coliforms.
If a urinary tract infection is caused by a non-E. coli coliform or any other type of bacteria, there is an increased risk of serious underlying pathology. NICE guidance recommends that infants, children and young people (under 16 years) with atypical urinary tract infection (which includes infection with non-E. coli organisms) should have ultrasound of the urinary tract during the acute infection. It is therefore important that laboratory test reports differentiate between E. coli and non-E. coli organisms to identify whether further investigations are needed.

Quality measures

Structure
Evidence of local arrangements to ensure that microbiology laboratories detecting coliform bacteria as a cause of a urinary tract infection report results differentiated by E. coli or non-E. coli organisms.
Data source: Local data collection.
Process
Proportion of infants, children and young people with a urinary tract infection caused by coliform bacteria who have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Numerator – the number of people in the denominator who have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Denominator – the number of infants, children and young people (under 16 years) with a urinary tract infection caused by coliform bacteria.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for infants, children and young people with a urinary tract infection caused by coliform bacteria to have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Healthcare practitioners ensure that infants, children and young people with a urinary tract infection caused by coliform bacteria have results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.
Commissioners ensure that they commission services for infants, children and young people with a urinary tract infection caused by coliform bacteria that report results of microbiology laboratory testing differentiated by E. coli or non-E. coli organisms.

What the quality statement means for patients and carers

Infants, children and young people under 16 with a urinary tract infection caused by coliform bacteria (a type of bacteria that usually live in the digestive system) have laboratory test results that show whether these bacteria were E. coli or not, to identify whether further investigations are needed.

Source guidance

Derived from definitions of atypical urinary tract infection as outlined in the NICE guideline on urinary tract infection in under 16s: diagnosis and management.

Definitions of terms used in this quality statement

The NICE guideline on urinary tract infection in under 16s specifies atypical causes of urinary tract infection, and includes non-E. coli organisms as an atypical cause in infants, children and young people.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Infants younger than 3 months with a possible UTI should be referred immediately to the care of a paediatric specialist. Treatment should be with parenteral antibiotics in line with NICE's recommendations on managing feverish illness in children with signs of immediately life-threatening illness.

Rationale: self-care for lower UTIs

  • Based on experience, the committee agreed that it was reasonable to advise people with lower UTI about using paracetamol for self-management of pain as this medicine has a well-established efficacy and safety profile.
  • The committee agreed, based on evidence and experience, that it was also reasonable to advise people with lower UTI about using ibuprofen for self-management of pain if this was preferred and suitable, taking account of safety concerns with NSAIDs, for example renal impairment.
  • Based on committee experience that dehydration is often cited as a cause of UTIs, the committee agreed that people should be advised about drinking enough fluids to avoid dehydration.
  • No evidence was found for using cranberry products or alkalinising agents to treat lower UTI or asymptomatic bacteriuria. There was only evidence assessing the efficacy and safety of cranberry products for preventing asymptomatic bacteriuria in healthy pregnant women.
For more information see self-care in the NICE guideline on urinary tract infection (lower): antimicrobial prescribing.

Rationale: self-care for upper UTIs

  • There was no evidence for the use of oral analgesia in acute pyelonephritis. However, paracetamol has a well-established efficacy and safety profile for managing pain. The committee agreed that it was reasonable to advise people about paracetamol for self-management of pain. A low-dose weak opioid, such as codeine, could be taken with paracetamol by adults and young people over 12 years for more severe pain.
  • Non-steroidal anti-inflammatory drugs, such as ibuprofen, are generally not recommended for people with acute pyelonephritis because of concerns about renal safety.
  • The committee discussed the need for an adequate intake of fluids to ensure a high urine output, which is believed to help resolve acute pyelonephritis through a mechanical flushing of bacteria from the kidney. No evidence was found for this and there was no evidence of what constitutes adequate hydration. However, based on committee experience that dehydration is often cited as a cause of UTIs, the committee agreed that people should be advised about drinking enough fluids to avoid dehydration.
For more information see self-care in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing.

Recurrent UTI

Recurrent UTI in adults is defined as repeated UTI with a frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months (European Association of Urology (EAU) guidelines on urological infections [2017]).
Recurrent UTI is diagnosed in children and young people under 16 years if they have:
  • 2 or more episodes of UTI with acute pyelonephritis/upper UTI or
  • 1 episode of UTI with acute pyelonephritis plus 1 or more episode of UTI with cystitis/lower UTI or
  • 3 or more episodes of UTI with cystitis/lower UTI.

Antibiotics for children and young people under 16 years with recurrent UTI

When prescribing antibiotic prophylaxis for recurrent UTI, take account of local antimicrobial resistance data and follow the recommendations in the table below for children and young people under 16 years.
Antibiotic prophylaxis1,2
Dosage3
Children under 3 months
Refer to paediatric specialist
Children aged 3 months and over (specialist advice only)
First-choice
Trimethoprim4
3 to 5 months, 2 mg/kg at night (maximum 100 mg per dose) or 12.5 mg at night
6 months to 5 years, 2 mg/kg at night (maximum 100 mg per dose) or 25 mg at night
6 to 11 years, 2 mg/kg at night (maximum 100 mg per dose) or 50 mg at night
12 to 15 years, 100 mg at night
Nitrofurantoin – if eGFR ≥45 ml/minute5
3 months to 11 years, 1 mg/kg at night
12 to 15 years, 50 to 100 mg at night
Second choice
Cefalexin
3 months to 15 years, 12.5 mg/kg at night (maximum 125 mg per dose)
Amoxicillin6
3 to 11 months, 62.5 mg at night
1 to 4 years, 125 mg at night
5 to 15 years, 250 mg at night
1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example hepatic and renal impairment.
2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI. If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost.
3 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age. Doses given are by mouth using immediate release medicines, unless otherwise stated.
4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNFC, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics).
5 Avoid at term in pregnancy; may produce neonatal haemolysis (BNFC, August 2018).
6 Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

Rationale: antibiotics for lower UTIs

  • The committee recognised the equality considerations for managing a lower UTI in transgender people, due to anatomical differences between women and men.

Non-pregnant women with lower UTI

  • Based on evidence and experience, the committee agreed that either a back-up antibiotic prescription or an immediate antibiotic prescription could be prescribed for non-pregnant women with a lower UTI. The committee discussed that sending a urine sample for culture and susceptibility testing is not usual practice in most young, non-pregnant women with a first lower UTI. Lower UTI is generally confirmed by symptoms and signs of infection together with dipstick testing of urine for some people. If urine culture has been taken, delaying the antibiotic until microbiological results are available could also be considered, depending on the severity of symptoms. Decisions around prescribing strategies should be individualised, taking account of the severity of symptoms, the risk of developing complications or having treatment failure, and preference for back-up or immediate antibiotics, or awaiting the results of urine culture.
  • The committee discussed that the evidence for back-up prescribing was only in non-pregnant women aged 18 to 70 years (mean age of 39 to 45 years) with, on average, moderate symptoms of an acute uncomplicated lower UTI, where immediate antibiotic treatment was not necessary. In this population, back-up empirical antibiotics were as effective as immediate empirical antibiotics for the severity or duration of UTI symptoms and the time to reconsultation. Back-up antibiotics (particularly a forward dated prescription) also reduced antibiotic use.
  • The committee agreed that a back-up antibiotic prescription could be used if symptoms do not start to improve within 48 hours (by which point most UTIs should be starting to improve) or if they worsen at any time.
  • Based on evidence, the committee agreed that antibiotics were effective in curing lower UTI symptoms and reducing relapse in non-pregnant women, but increased adverse events. There was no significant difference between antibiotics and placebo for the development of pyelonephritis (a complication of lower UTI). However, due to the very low incidence of pyelonephritis, it is likely the studies lacked statistical power to detect a clinically important difference.
  • Based on experience, the committee agreed that if a urine culture has been taken, and results suggest the bacteria are resistant to the antibiotic given, the woman should be contacted and the antibiotic changed if symptoms are not already improving. The committee agreed that for non-pregnant women where 3-day courses of antibiotics are given, only changing antibiotics according to susceptibility results if symptoms are not already improving is appropriate. Often, susceptibility results may not be back before short courses are nearly completed, and because of differences between the in vitro and in vivo effectiveness of antibiotics, susceptibility results may not always be accurate. For some populations, where symptoms of the UTI are already improving, an additional course of antibiotics may be unnecessary treatment.

Pregnant women and men with a lower UTI

  • The committee discussed that no evidence was identified on antibiotic treatment for pregnant women with a symptomatic lower UTI. However, evidence in pregnant women with asymptomatic bacteriuria showed that antibiotics were effective in reducing persistent bacteriuria, pyelonephritis and the delivery of a preterm baby.
  • Based on limited evidence and experience, the committee agreed that pregnant women with a lower UTI should be offered an immediate antibiotic, and urine should be sent for culture to confirm susceptibility of the bacteria and inform treatment choice.
  • Based on experience, the committee agreed that when results of urine cultures are available, if the results suggest the bacteria are resistant to the antibiotic given, pregnant woman should be contacted and the antibiotic changed regardless of whether symptoms are improving or not. The committee agreed there was a greater risk from UTIs in pregnant women and antibiotics should be changed to ensure cure.
  • The committee discussed that no evidence was identified on antibiotic treatment for men with a lower UTI, apart from 1 systematic review where about 10% of the study population were men.
  • Based on experience, the committee agreed that men with a lower UTI should be offered an immediate antibiotic, and urine should be sent for culture to confirm susceptibility of the bacteria and inform treatment choice.
  • Based on experience, the committee agreed that when results of urine cultures are available, if the results suggest the bacteria are resistant to the antibiotic given, men should be contacted and, if symptoms are not already improving, the antibiotic should be changed. The committee agreed that for men, only changing antibiotics according to susceptibility results if symptoms are not already improving is appropriate. Often, susceptibility results may not be back for some days, and because of differences between the in vitro and in vivo effectiveness of antibiotics, susceptibility results may not always be accurate. For some populations, where symptoms of the UTI are already improving, an additional course of antibiotics may be unnecessary treatment.

Children and young people with a lower UTI

  • The committee was aware that the NICE guideline on urinary tract infection in under 16s makes recommendations on diagnosing lower UTIs (including the use of dipsticks and urine culture).
  • Based on experience, the committee agreed that if a urine culture has been taken, and results suggest the bacteria are resistant to the antibiotic given, the child or young person should be contacted and, if symptoms are not already improving, the antibiotic changed. The committee agreed that for children and young people where 3-day courses of antibiotics are given, only changing antibiotics according to susceptibility results if symptoms are not already improving is appropriate. Often, susceptibility results may not be back before short courses are nearly completed, and because of differences between the in vitro and in vivo effectiveness of antibiotics, susceptibility results may not always be accurate. For some populations, where symptoms of the UTI are already improving, an additional course of antibiotics may be unnecessary treatment.
For more information see antibiotics in the NICE guideline on urinary tract infection (lower): antimicrobial prescribing.

Rationale: choice of antibiotics for upper UTIs

  • Based on evidence and experience, the committee agreed that acute pyelonephritis is a bacterial infection needing treatment with antibiotics that reach therapeutic concentrations in the kidney. Antibiotics that don't achieve adequate levels in renal tissue, such as nitrofurantoin, fosfomycin and pivmecillinam, are to be avoided.
  • A urine sample should be sent for culture to confirm susceptibility of the bacteria and inform treatment choice.
  • The committee reviewed the available evidence comparing different antibiotics in adults and children and agreed that it was limited by its setting (most studies in adults were undertaken in a hospital, and in children the setting of the studies was not reported). The studies included various different antibiotics, which may not reflect those chosen in UK practice. The committee discussed the evidence for a benefit of the intravenous third-generation cephalosporins, ceftolozane/tazobactam or ceftazidime, over an intravenous fluoroquinolone, but this was mainly limited to a benefit for composite cure (which included clinical cure, microbiological eradication and microbiological cure) and the absolute benefits were small.
  • The committee agreed, based on experience, that several oral and intravenous antibiotics should be available for people with acute pyelonephritis. This enables antibiotics to be selected based on the severity of illness, antibiotic susceptibilities from culture results when available, local resistance patterns, risk of resistant bacteria, the setting, and known patient factors (such as whether the person has a higher risk of developing complications). In line with antimicrobial stewardship, narrower-spectrum antibiotics should be used wherever possible.
  • Nationally for England, resistance of E. coli (the main causative organism of acute pyelonephritis) in laboratory-processed urine specimens to the following antibiotics is:
    • cefalexin: 9.9% (varies by area from 8.1 to 11.4%)
    • ciprofloxacin: 10.6% (varies by area from 7.8 to 13.7%)
    • co-amoxiclav: 19.8% (varies by area from 10.8 to 30.7%)
    • trimethoprim: 30.3% (varies by area from 27.1 to 33.4%)
(Public Health England. Antimicrobial resistance quarterly surveillance: March 2018)
  • The committee also discussed that prescribers should be aware of their local antimicrobial prescribing data, because resistance rates do vary by area.
  • The committee agreed that any recent previous urine culture and susceptibility results, and antibiotic prescribing, should be reviewed before choosing an antibiotic.
  • Based on experience, the committee agreed that if the results of urine culture suggest the bacteria are resistant to the antibiotic given, people with acute pyelonephritis should be contacted and the antibiotic changed regardless of whether symptoms are improving or not. The committee agreed that acute pyelonephritis is a serious infection and antibiotics should be changed to ensure cure.

Non-pregnant women and men with acute pyelonephritis

  • Based on evidence, their experience and resistance data, the committee agreed to recommend a choice of first-line oral antibiotics, at usual doses for acute pyelonephritis. These are:
    • cefalexin (a first-generation cephalosporin); based on its broad spectrum of activity and acceptable levels of resistance
    • co-amoxiclav (a penicillin with a beta-lactamase inhibitor); which is only suitable if culture results are available and bacteria are susceptible, because resistance rates are high
    • trimethoprim; which is only suitable if culture results are available and bacteria are susceptible, because resistance rates are high
    • ciprofloxacin (a fluoroquinolone); based on its broad spectrum of activity and acceptable levels of resistance (particularly for people who have had previous treatment with penicillins, or cannot tolerate or are allergic to penicillins).
  • The committee noted that use of broad-spectrum antibiotics, such as later-generation cephalosporins, fluoroquinolones or co-amoxiclav, can create a selective advantage for bacteria resistant to these second-line broad-spectrum agents, allowing such strains to proliferate and spread. And, by disrupting normal flora, broad-spectrum antibiotics can leave people susceptible to harmful bacteria such as Clostridium difficile in community settings. However, these antibiotics are appropriate for the empirical treatment of acute pyelonephritis, where coverage of more resistant strains of common bacterial pathogens is required.
  • The committee was aware of the European Medicines Agency's Pharmacovigilance Risk Assessment Committee recommendation to restrict the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons and bones and the nervous system. However, they discussed that fluoroquinolone antibiotics are a valuable option for the treatment of acute pyelonephritis, which is a severe infection. Resistant gram-negative organisms are a particular concern in acute pyelonephritis. The committee agreed that ciprofloxacin should remain a first-choice option because gram-negative organisms are likely to be sensitive to it and acute pyelonephritis can be a complex infection. The committee was keen to point out, however, that cefalexin, co-amoxiclav and trimethoprim are also first-choice options, and antibiotics should be chosen on an individual patient basis, taking fluoroquinolone safety concerns, as well as susceptibility and resistance, into account.
  • Based on evidence, experience and resistance data, the committee agreed to recommend a choice of first-line intravenous antibiotics, at usual doses, for people with acute pyelonephritis who are unable to take oral antibiotics due to vomiting, or are more severely unwell. These are:
    • co-amoxiclav (only in combination or if culture results are available and bacteria are susceptible)
    • cefuroxime (a second-generation cephalosporin) or ceftriaxone (a third-generation cephalosporin)
    • ciprofloxacin (taking safety concerns into account)
    • gentamicin or amikacin (aminoglycosides); which may be appropriate for some people with acute pyelonephritis, particularly those with severe infection or sepsis, but that efforts should be made to identify the causal bacteria and use reviewed at 48 hours. Gentamicin is the preferred aminoglycoside in the UK, but shortages of certain antibiotics may result in the use of alternatives; for example amikacin in place of gentamicin.
  • The committee agreed, based on experience, that it may be necessary to combine antibiotics in the care of people with suspected sepsis. This should be done according to local policy or on the advice of a microbiologist, taking into account local antimicrobial resistance data.

Pregnant women with acute pyelonephritis

  • Based on experience and resistance data, the committee agreed to recommend cefalexin (a first-generation cephalosporin) as the first-choice oral antibiotic for pregnant women who don't require intravenous antibiotics, and cefuroxime (a second-generation cephalosporin) as the first-choice intravenous antibiotic.
  • Ciprofloxacin and trimethoprim are not recommended because they should be avoided in pregnancy. Co-amoxiclav was not recommended because of high resistance levels nationally and the risks of treatment failure in pregnancy.
  • The committee agreed, based on experience, that local microbiologists should be consulted for advice on second-choice antibiotics, or combining antibiotics if susceptibility or sepsis is a concern.

Children and young people with acute pyelonephritis

  • The committee was aware that the NICE guideline on urinary tract infection in under 16s makes recommendations on diagnosing acute pyelonephritis and considering referral to a paediatric specialist.
  • Based on evidence, their experience and resistance data, the committee agreed to recommend cefalexin or co-amoxiclav (only if culture results are available and bacteria are susceptible) at usual doses for acute pyelonephritis, as first-choice oral antibiotics.
  • Based on evidence, experience and resistance data, the committee agreed to recommend a choice of first-line intravenous antibiotics, at usual doses, for children and young people who are unable to take oral antibiotics due to vomiting, or are more severely unwell. These are:
    co-amoxiclav (only in combination or if culture results are available and bacteria are susceptible); which can be given intravenously
    cefuroxime (a second-generation cephalosporin) or ceftriaxone (a third-generation cephalosporin); which would be suitable alternatives to co-amoxiclav
    gentamicin or amikacin (aminoglycosides); which may be appropriate for some children and young people with acute pyelonephritis, particularly those with severe infection or sepsis, but that efforts should be made to identify the causal bacteria and use reviewed at 48 hours.
  • The committee agreed, based on experience, that it may be necessary to combine antibiotics in the care of children and young people with suspected sepsis. This should be done according to local policy or on the advice of a microbiologist, taking into account local antimicrobial resistance data.
For more information see choice of antibiotic in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing.

Antibiotics for people aged 16 years and over with recurrent UTI

When prescribing antibiotic prophylaxis for recurrent UTI, take account of local antimicrobial resistance data and follow the recommendations in the table below for people aged 16 years and over.
Antibiotic prophylaxis1,2
Dosage3
First choice
Trimethoprim4
200 mg single dose when exposed to a trigger or
100 mg at night
Nitrofurantoin – if eGFR ≥45 ml/minute5
100 mg single dose when exposed to a trigger or
50 to 100 mg at night
Second choice
Amoxicillin6
500 mg single dose when exposed to a trigger or
250 mg at night
Cefalexin
500 mg single dose when exposed to a trigger or
125 mg at night
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.
2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI.
3 Doses given are by mouth using immediate release medicines, unless otherwise stated.
4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNF, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics).
5 Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, August 2018).
6 Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

Rationale: managing asymptomatic bacteriuria

  • Based on evidence and experience, the committee agreed that asymptomatic bacteriuria is not routinely screened for, or treated with antibiotics, in non-pregnant women, men, young people or children because it is not a risk factor for harm in these groups. It is routinely screened for, and treated with antibiotics, in pregnant women because it is a risk factor for harm.
  • Based on evidence, the committee agreed that antibiotics reduce persistent bacteriuria, pyelonephritis and the delivery of a pre-term baby in pregnant women with asymptomatic bacteriuria.
For more information see antibiotics in the NICE guideline on urinary tract infection (lower): antimicrobial prescribing.

Rationale: choice of antibiotic for lower UTIs

  • Based on evidence of no major differences in clinical effectiveness between classes of antibiotics, the committee agreed that the choice of antibiotic should largely be driven by minimising the risk of resistance. Resistant bacteria are a particular concern in UTIs and, where possible, any previous urine culture and susceptibility results, and antibiotic prescribing, should be checked and antibiotics chosen accordingly.
  • The committee discussed that, if an antibiotic is needed to treat an infection that is not life threatening, a narrow-spectrum antibiotic should generally be first-choice. Indiscriminate use of broad-spectrum antibiotics creates a selective advantage for bacteria resistant even to these 'last-line' broad-spectrum agents, and also kills normal commensal flora leaving people susceptible to antibiotic-resistant harmful bacteria such as Clostridium difficile. For infections that are not life threatening, broad-spectrum antibiotics need to be reserved for second-choice treatment when narrow-spectrum antibiotics are ineffective.
  • Nationally for England, resistance of E. coli (the main causative organism of lower UTIs) in laboratory-processed urine specimens to the following antibiotics is:
    • nitrofurantoin: 2.5% (varies by area from 2.0 to 3.6%)
    • trimethoprim: 30.3% (varies by area from 27.1 to 33.4%)
    • pivmecillinam: 7.5% (varies by area from 4.1 to 15.7%)
    • cefalexin: 9.9% (varies by area from 8.1 to 11.4%)
(Public Health England. Antimicrobial resistance quarterly surveillance: March 2018)
  • The committee also discussed that prescribers should be aware of their local antimicrobial prescribing data, because resistance rates do vary by area.

Non-pregnant women with a lower UTI

  • Based on evidence, experience and resistance data, the committee agreed to recommend nitrofurantoin or trimethoprim at usual doses as first-choice antibiotics.
    – Nitrofurantoin is not recommended for people with an eGFR <45 ml/minute. It may be used with caution if eGFR is 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018).
    – The committee agreed to recommend the modified-release preparation of nitrofurantoin over the immediate-release preparation because of its twice daily dosing and, in their experience, better tolerability.
    – Trimethoprim should only be prescribed if a lower risk of resistance is likely because of high resistance levels nationally. Based on experience, the committee agreed that a lower risk of resistance may be more likely if trimethoprim has not been used in the past 3 months, if previous urine culture results suggest trimethoprim susceptibility (but this was not used as treatment) and in younger people in areas where local epidemiology data suggest resistance is low. A higher risk of trimethoprim resistance may be more likely with recent use (the committee was aware of evidence that trimethoprim is significantly associated with resistant E. coli infections treated in the previous 2 to 3 months), and in older people in residential facilities.
  • Based on evidence, their experience and resistance data, the committee agreed to recommend nitrofurantoin (if not used as first-choice), pivmecillinam (a penicillin) or fosfomycin at usual doses as second-choice antibiotics for use if lower UTI symptoms do not improve on a first-choice antibiotic taken for at least 48 hours or first-choice antibiotics are not suitable. The committee acknowledged that prescribers may be less familiar with pivmecillinam or fosfomycin, but these antibiotics are often used in other European countries.
  • If there are symptoms of upper UTI (acute pyelonephritis) or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), antibiotics recommended in the NICE antimicrobial prescribing guideline on acute pyelonephritis should be prescribed.

Pregnant women with a lower UTI

  • Based on evidence, experience and resistance data, the committee agreed to recommend usual dose nitrofurantoin as the first-choice antibiotic (with the cautions outlined above):
    – Nitrofurantoin is not recommended at term in pregnancy because it may produce neonatal haemolysis (BNF, August 2018).
    – Trimethoprim was not recommended because it is contraindicated in pregnancy. Trimethoprim is a folate antagonist and there is a teratogenic risk in the first trimester (BNF, August 2018). However, the committee acknowledged that trimethoprim is sometimes used in pregnancy when given with folic acid 5 mg daily in the first trimester (NICE clinical knowledge summary on UTI (lower) – women).
  • Based on evidence, experience and resistance data, the committee agreed to recommend amoxicillin, cefalexin or other antibiotics recommended by local microbiologists (based on culture and susceptibility results) at usual doses as second-choice antibiotics for use if lower UTI symptoms do not improve on a first-choice antibiotic taken for at least 48 hours or first-choice antibiotics are not suitable.
    – Amoxicillin is recommended only if culture results are available and bacteria are susceptible because resistance rates are high.
    – If there are symptoms of upper UTI (acute pyelonephritis) or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), antibiotics recommended in the NICE antimicrobial prescribing guideline on acute pyelonephritis should be prescribed.
  • Based on evidence, experience and resistance data, the committee agreed to recommend a course of nitrofurantoin, amoxicillin or cefalexin, (with the cautions outlined above) for the treatment of asymptomatic bacteriuria in pregnant women. Choice should be based on recent culture and susceptibility results.

Men with a lower UTI

  • Based on experience and resistance data, the committee agreed to recommend trimethoprim or nitrofurantoin at usual doses as first-choice antibiotics (with the cautions outlined above).
    – Trimethoprim generally has a lower risk of resistance in men, and can reach therapeutic prostate levels. However, if acute prostatitis is suspected, quinolones are the first-choice antibiotic (see the NICE guideline on prostatitis (acute): antimicrobial prescribing).
    – Nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate.
  • Based on experience, the committee agreed that alternative diagnoses (such as acute pyelonephritis or acute prostatitis) should be considered in men whose symptoms have not responded to a first-choice antibiotic, and second-choice antibiotics should be based on recent culture and susceptibility results.

Children and young people with a lower UTI

  • Based on evidence, experience and resistance data, the committee agreed to recommend trimethoprim or nitrofurantoin at usual doses as first-choice antibiotics (with the cautions outlined above).
    – The committee was aware that nitrofurantoin suspension is currently substantially more expensive than trimethoprim suspension and, if both antibiotics are appropriate, the one with the lowest acquisition cost should be chosen.
  • Based on evidence, experience and resistance data, the committee agreed to recommend nitrofurantoin (if not used as first-choice), amoxicillin or cefalexin at usual doses as second-choice antibiotics for use if lower UTI symptoms get worse on a first-choice antibiotic taken for at least 48 hours or first-choice antibiotics are not suitable.
    – Amoxicillin is recommended only if culture results are available and bacteria are susceptible, because resistance rates are high.
    – If there are symptoms of upper UTI (acute pyelonephritis) or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), antibiotics recommended in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing should be prescribed.
For more information see choice of antibiotic in the NICE guideline on urinary tract infection (lower): antimicrobial prescribing.

Rationale: antibiotic course length for upper UTIs

  • The committee agreed that the shortest course that is likely to be effective should be prescribed to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects.
  • Based on evidence, the committee agreed that a short course of antibiotics was generally as effective as a long course of antibiotics for acute pyelonephritis, but the definition of short and long course differed depending on the clinical trial definition and the antibiotic used.
  • In line with the NICE recommendations on antimicrobial stewardship and Public Health England's Start smart – then focus, the committee agreed that the use of intravenous antibiotics should be reviewed by 48 hours (taking into account the person's response to treatment and susceptibility results from urine culture) and switched to oral treatment where possible.

Non-pregnant women and men with acute pyelonephritis

  • Based on evidence, experience and resistance data, the committee agreed that, for oral treatment, a 7-day course of ciprofloxacin was sufficient to treat acute pyelonephritis in non-pregnant women and men. However, because there was no evidence for 7-day courses of cefalexin or co-amoxiclax, a range of 7 to 10 days was recommended for these antibiotics. For trimethoprim, a 14-day course was recommended because there was no evidence for course lengths shorter than 14 days.
  • For intravenous treatment, antibiotics should be reviewed by 48 hours and stepped down to oral antibiotics where possible, for a total of 7 days.

Pregnant women with acute pyelonephritis

  • Based on evidence, experience and resistance data, the committee agreed that, for oral treatment, a 7- to 10-day course of cefalexin was required to treat acute pyelonephritis in pregnant women. For intravenous treatment, antibiotics should be reviewed by 48 hours and stepped down to oral antibiotics where possible, for a total of 7 days.

Children and young people with acute pyelonephritis

  • Based on evidence, experience and resistance data, the committee agreed that a 7- to 10-day course of oral antibiotics was required to treat acute pyelonephritis in children and young people. For intravenous treatment, antibiotics should be reviewed by 48 hours and stepped down to oral antibiotics where possible, for a total of 10 days.
For more information see antibiotic course length in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing.

Rationale: self-care for recurrent UTIs

  • Based on their experience, and the need to minimise inappropriate use of antibiotics, the committee agreed that people should be given advice about behavioural and personal hygiene measures to reduce the risk of UTI, such as:
    • drinking enough fluids to avoid dehydration
    • not delaying habitual and post-coital urination
    • wiping from front to back after defaecation
    • not douching or wearing occlusive underwear.

Probiotics (lactobacillus)

  • The committee discussed the evidence for the probiotic lactobacillus. While there was some evidence to support the use of 'effective strains', there was no information on which lactobacillus products were included in this analysis. They also noted the high drop-out rate in the study.
  • Based on evidence, the committee agreed that people should be told that there is inconclusive evidence to recommend the use of lactobacillus to prevent recurrent UTIs.

Cranberry products

  • The committee recognised that cranberry products are used widely and discussed the very low quality evidence showing some benefit for reducing the risk of UTIs, specifically in non-pregnant women, and children and young people. They were also aware that there was no evidence to suggest benefit in older women. The committee also noted the conflicting evidence for cranberry products in reducing the risk of antimicrobial resistance.
  • Taking account of the limitations of the evidence, and the need to minimise antimicrobial resistance, the committee agreed that some women who are not pregnant and some children and young people under 16 may wish to try cranberry products as a self-care treatment. However, due to safety concerns with delayed treatment, particularly in children and young people, the committee agreed that cranberry products should only be considered in this population following advice from a paediatric specialist.
  • The committee recognised that there was some evidence to suggest that cranberry juice was not significantly better than placebo in non-pregnant women, while cranberry capsules showed a significant benefit. However, due to significant limitations in the evidence the committee was not able to recommend a specific cranberry product.
  • The committee discussed the sugar content of cranberry products, and based on their experience, agreed that people should be advised to take account of their daily sugar intake if using cranberry products.

D-mannose

  • The committee was aware of the mechanism of action of D-mannose, which is also in cranberry products.
  • The committee noted evidence suggesting that D-mannose was effective in reducing the risk of recurrent UTI in non-pregnant women, and noted the low NNT of 3 (range 2 to 3) over 6 months, compared with no treatment. However, this was based on 1 small RCT. The committee agreed to make a recommendation that some women who are not pregnant may wish to try D-mannose, as a self-care treatment, noting the sugar content of this product which should be considered.
For more information see self-care in the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing.

Rationale: antibiotic route of administration for upper UTIs

  • Based on evidence, the committee agreed that, overall, oral antibiotics were as effective as other routes of administration for treating acute pyelonephritis in adults and children.
  • The committee agreed, based on evidence and experience, that oral antibiotics should be given first line when people can take oral medicines and the severity of their condition does not require intravenous antibiotics.
  • The committee agreed, based on evidence and experience, that intravenous antibiotics can be used for people who are unable to take oral antibiotics due to vomiting, or are more severely unwell, in line with Public Health England's Start Smart Then Focus.
For more information see antibiotic route of administration in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing.

Rationale: oestrogens for recurrent UTIs

  • Based on evidence of a lack of effectiveness and taking account of MHRA safety advice, the committee agreed to not recommend oral oestrogens (HRT) specifically to prevent recurrent UTI in postmenopausal women.
  • Based on evidence, the committee agreed that vaginal oestrogens were effective in reducing the risk of recurrent UTI in postmenopausal women, although this was based on small numbers of women and appears to diminish when the treatment is stopped. They noted the low NNTs for recurrent infection compared with placebo (NNT 3 [range 2 to 4] for topical cream; NNT 4 [range 3 to 9] for vaginal ring), and also when a topical cream was compared with antibiotics (NNT 2 [range 2 to 2]). However, oestrogen administered via a pessary was less effective than antibiotics.
  • Based on evidence and their experience, the committee recognised the adverse effects of vaginal oestrogens (such as breast tenderness and vaginal bleeding), which may require additional investigations. They noted the rate of adverse events appeared high in the studies (NNH 5 [range 3 to 11]) for vaginal oestrogens.
  • The committee was aware of MHRA safety advice on the use of HRT; they agreed this was important for women and prescribers to discuss the possible harms of vaginal oestrogens, but that it should not prevent the safe use of an effective treatment for recurrent UTI.
  • Vaginal oestrogens are not licensed for preventing recurrent UTI, although oestrogen deficiency is a known risk factor. The committee noted that there do not appear to be any effective, licensed, non antimicrobial alternatives for preventing recurrent UTI in postmenopausal women.
  • Based on evidence, their experience and data on antimicrobial resistance, the committee agreed that vaginal oestrogens could be considered for postmenopausal women with recurrent UTI, with review within 12 months, or earlier if agreed with the woman. The committee recognised that this was a preference-sensitive decision and the benefits and harms of vaginal oestrogens need to be discussed with the woman, taking account of other symptoms the woman may want to address, such as vaginal dryness. The committee agreed that, before vaginal oestrogen is given, women should be asked about their preferences and given advice about the possible risks and benefits, returning for review and reporting unscheduled vaginal bleeding.
  • The committee could not make any firm conclusions from the evidence or their experience about different vaginal oestrogen products. They agreed that this will need to be considered with the woman on an individual basis.
For more information see oestrogens in the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing.

Antibiotics for non-pregnant women and men aged 16 years and over

When prescribing an antibiotic for acute pyelonephritis, take account of local antimicrobial resistance data and follow the table below for non-pregnant women and men aged 16 years and over.
Antibiotic1
Dosage and course length
First-choice oral antibiotic2
Cefalexin
500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days
Co-amoxiclav (only if culture results available and susceptible)
500/125 mg three times a day for 7 to 10 days
Trimethoprim (only if culture results available and susceptible)
200 mg twice a day for 14 days
Ciprofloxacin (consider safety issues3)
500 mg twice a day for 7 days
First-choice intravenous antibiotics (if vomiting, unable to take oral antibiotics, or severely unwell). Antibiotics may be combined if susceptibility or sepsis a concern2,4
Co-amoxiclav (only in combination or if culture results available and susceptible)
1.2 g three times a day
Cefuroxime
750 mg to 1.5 g three or four times a day
Ceftriaxone
1 to 2 g once a day
Ciprofloxacin (consider safety issues3)
400 mg twice or three times a day
Gentamicin
Initially 5 to 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration5
Amikacin
Initially 15 mg/kg once a day (maximum per dose 1.5 g once a day), subsequent doses adjusted according to serum amikacin concentration (maximum 15 g per course)5
Second-choice intravenous antibiotic
Consult local microbiologist
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment and breastfeeding, and administering intravenous antibiotics.
2 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
3 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are an option in acute pyelonephritis which is a severe infection.
4 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.
5 Therapeutic drug monitoring and assessment of renal function is required (BNF, August 2018).

Rationale: antibiotic course length for lower UTIs

  • The committee agreed that the shortest course that is likely to be effective should be prescribed to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects.

Non-pregnant women with lower UTI

  • Based on evidence, the committee agreed that a 3-day course of antibiotics was as effective as a 5- to 10-day course of antibiotics in non-pregnant women with lower UTI, and resulted in significantly fewer adverse events. The committee agreed that a longer course may increase the likelihood of complete bacteriological eradication, which may be important for some women (for example, women who experience repeated lower UTIs). However, it was not possible to analyse data separately for people with repeated lower UTIs.
  • Based on evidence, the committee agreed that a 7- to 10-day course of antibiotics did not offer any clinical advantage over a 3- to 6-day course in older women with lower UTI.
  • Based on evidence, experience and resistance data, the committee agreed that a 3-day course of all the recommended antibiotics (apart from fosfomycin where a single dose is given) was sufficient to treat lower UTI in non-pregnant women of any age, with no longer duration of treatment required for older women. If women have a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), antibiotics recommended in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing should be prescribed.

Pregnant women with lower UTI

  • Based on evidence and their experience, the committee agreed that a 7-day course of all the recommended antibiotics was required to treat bacteriuria in pregnant women with either symptomatic lower UTI or asymptomatic bacteriuria.
  • A 7-day course is required to ensure complete cure because the risk of harm from a UTI is higher in pregnant women than in non-pregnant women.

Men with lower UTI

  • Based on their experience, the committee agreed that a 7-day course of all the recommended antibiotics was required to treat lower UTI in men.
  • A 7-day course is required to ensure complete cure because men are more at risk of complications from UTIs than women due to anatomical differences and possible outflow obstruction.

Children and young people with UTI

  • Based on evidence, the committee agreed that a 3- to 7-day course of antibiotics was as effective as a 7- to 14-day course of antibiotics in children and young people with lower UTI.
  • Based on evidence, experience and resistance data, the committee agreed that a 3-day course of all the recommended antibiotics was sufficient to treat lower UTI in children and young people. If children and young people have a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), antibiotics recommended in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing should be prescribed.
For more information see antibiotic course length in the NICE guideline on urinary tract infection (lower): antimicrobial prescribing.

Rationale: antibiotic prophylaxis for recurrent UTIs

People aged 16 years and over with recurrent UTI

  • Based on evidence and their experience, the committee agreed that antibiotic prophylaxis was effective in reducing the risk of recurrent UTI in non-pregnant women, although this benefit was not seen after the treatment is stopped. They noted the low NNTs for recurrent infection compared with placebo (NNT 2 [range 2 to 3]). However, they also recognised the increased risk of harms with antibiotic prophylaxis compared with placebo.
  • Based on evidence, the committee agreed that antibiotic prophylaxis was also effective in a mixed population of people with recurrent UTI, including pre- and postmenopausal women, men and children (NNT 3 [3 to 4]). However, interpretation of the evidence was more difficult due to variations in the populations studied and antibiotic choice, dosage and duration.
  • The committee discussed the evidence specifically in pregnant women, which found that antibiotic prophylaxis was effective in reducing the risk of recurrent asymptomatic bacteriuria in pregnant women (NNT 4 [range 3 to 13]). However, they recognised that the study had a number of limitations. The study was small and not powered to show any benefit in preterm births. The population was pregnant women who were admitted to hospital with acute pyelonephritis. The committee noted that nitrofurantoin is not an appropriate choice of antibiotic to show benefit in this population. They were also aware that UTI has been associated with developmental delay or cerebral palsy in the infant, and fetal death.
  • Taking account of the benefits and harms of antibiotic prophylaxis and the need to minimise antimicrobial resistance, the committee agreed that antibiotic prophylaxis could be considered in people aged 16 years and over with recurrent UTI, but only after other management options had been unsuccessful (behavioural and personal hygiene measures, managing any triggers and using non-antimicrobial treatments), if appropriate.
  • The committee recognised the importance of reviewing antibiotic prophylaxis, and considered that up to every 6 months was reasonable based on possible adverse effects of antibiotics, the risk of resistance with long-term antibiotics, the possible need for any further investigations if recurrence of UTIs continues, and to allow time to assess treatment success. People should also know to seek medical help if they experience symptoms of an acute infection despite taking prophylaxis.
  • The committee discussed the importance of the review and were aware of other conditions where a specific date is included on the prescription to prompt review within 6 months.
  • To reduce the risk of antimicrobial resistance, the committee agreed that at each review women should be reminded about self-care, and consideration should be given to either stopping, continuing or changing antibiotic prophylaxis (for example, from single-dose to daily prophylaxis). However the committee was not able to make specific recommendations about when to stop, continue or change antibiotic prophylaxis as it will depend on the circumstances of an individual person.
  • Based on evidence that suggests antibiotic prophylaxis does not continue to be effective after stopping treatment, the committee agreed that if antibiotic prophylaxis was stopped, women should be able to access treatment rapidly if they have symptoms of an acute UTI.
  • The committee recognised the limitations of the evidence on antibiotic prophylaxis in pregnant women and men, and the lack of evidence to support the use of non-antimicrobial treatments. Therefore, the committee agreed that it was appropriate to refer all pregnant women to an obstetrician if recurrent UTI is diagnosed during pregnancy. They also agreed that most men with recurrent UTI should be referred for further specialist urology investigation and management, taking an individualised approach that takes account of multimorbidity. The committee agreed that any decision to prescribe antibiotic prophylaxis in pregnant women or men should be under specialist advice.
  • The committee also recognised the higher risks associated with recurrent upper UTIs (pyelonephritis), and agreed that it was appropriate to refer these people for further specialist investigation and management.
  • The committee agreed that further consideration should be made for women with recurrent lower UTI if the underlying cause of recurrence was unknown or required further investigation. However, due to resource implications and the lower risk of complications for this population, the committee agreed that specialist advice should be sought, rather than specialist referral.
  • The committee was aware of the recommendation in the NICE guideline on suspected cancer: recognition and referral, which states that a non-urgent referral for bladder cancer should be considered for people over 60 with recurrent unexplained UTI.
  • The committee also recognised the equality considerations for managing recurrent UTI in transgender people, due to anatomical differences between women and men.

Children and young people under 16 years with recurrent UTI

  • The committee was aware that the NICE guideline on urinary tract infection in under 16s makes recommendations on referring children and young people with recurrent UTI to a paediatric specialist for assessment and investigations.
  • Based on evidence, the committee noted that antibiotic prophylaxis does not appear to be effective in reducing the risk of recurrent UTI in children. However, there was considerable uncertainty in the evidence (all very low quality).
  • Based on their experience, the committee agreed that most cases of recurrent UTI in children and young people are due to a functional or structural abnormality of the urinary tract.
  • Taking account of the uncertainty in the evidence and the need to minimise antimicrobial resistance from long-term antibiotic use, the committee agreed that antibiotic prophylaxis could be considered in children and young people under 16 years, but only under specialist advice when other management options have been unsuccessful. This would be an individualised decision following an assessment of underlying causes, taking into account the severity and frequency of previous symptoms and the risk of developing complications.
  • The committee recognised the importance of reviewing antibiotic prophylaxis, and considered that every 6 months was reasonable. They agreed that the same principles for the review in adults apply to children and young people.
For more information see antibiotic prophylaxis in the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing.

Antibiotics for pregnant women aged 12 years and over

When prescribing an antibiotic for acute pyelonephritis, take account of local antimicrobial resistance data and follow the table below for pregnant women aged 12 years and over.
Antibiotic1
Dosage and course length
First-choice oral antibiotic2
Cefalexin
500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days
First-choice intravenous antibiotic (if vomiting, unable to take oral antibiotics, or severely unwell)2,3
Cefuroxime
750 mg to 1.5 g three or four times a day
Second-choice antibiotics or combining antibiotics if susceptibility or sepsis a concern
Consult local microbiologist
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics.
2 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
3 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.

Antibiotics for non-pregnant women aged 16 years and over

When prescribing antibiotic treatment for lower UTI, take account of local antimicrobial resistance data and follow the table below for non-pregnant women aged 16 years and over.
Antibiotic1
Dosage and course length2
First-choice3
Nitrofurantoin – if eGFR ≥45 ml/minute4
100 mg modified-release twice a day for 3 days
Trimethoprim – if low risk of resistance5
200 mg twice a day for 3 days
Second-choice (no improvement in lower UTI symptoms on first-choice taken for at least 48 hours, or when first-choice not suitable)3,6
Nitrofurantoin – if eGFR ≥45 ml/minute4 and not used as first-choice
100 mg modified-release twice a day for 3 days
Pivmecillinam (a penicillin)
400 mg initial dose, then 200 mg three times a day for a total of 3 days
Fosfomycin
3 g single dose sachet
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment and breastfeeding.
2 Doses given are by mouth using immediate-release medicines, unless otherwise stated.
3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
4 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018).
5 A lower risk of resistance may be more likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where local epidemiology data suggest resistance is low. A higher risk of resistance may be more likely with recent use and in older people in residential facilities.
6 If there are symptoms of pyelonephritis or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), see antibiotic treatment in the NICE recommendations on acute pyelonephritis.

Antibiotics for children and young people under 16 years

When prescribing an antibiotic for acute pyelonephritis, take account of local antimicrobial resistance data and follow the table below for children and young people under 16 years.
Antibiotic1
Dosage and course length2
Children under 3 months
Refer to paediatric specialist and treat with intravenous antibiotics in line with the NICE recommendations on fever in under 5s.
Children aged 3 months and over
First-choice oral antibiotic3
Cefalexin
3 to 11 months, 12.5 mg/kg or 125 mg twice a day for 7 to 10 days (25 mg/kg two to four times a day [maximum 1 g per dose four times a day] for severe infections)
1 to 4 years, 12.5 mg/kg twice a day or 125 mg three times a day for 7 to 10 days (25 mg/kg two to four times a day [maximum 1 g per dose four times a day] for severe infections)
5 to 11 years, 12.5 mg/kg twice a day or 250 mg three times a day for 7 to 10 days (25 mg/kg two to four times a day [maximum 1 g per dose four times a day] for severe infections)
12 to 15 years, 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days
Co-amoxiclav (only if culture results available and susceptible)
3 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day for 7 to 10 days (dose doubled in severe infection)
1 to 5 years, 0.25 ml/kg of 125/31 suspension or 5 ml of 125/31 suspension three times a day for 7 to 10 days (dose doubled in severe infection)
6 to 11 years, 0.15 ml/kg of 250/62 suspension or 5 ml of 250/62 suspension three times a day for 7 to 10 days (dose doubled in severe infection)
12 to 15 years, 250/125 mg or 500/125 mg three times a day for 7 to 10 days
First-choice intravenous antibiotics (if vomiting, unable to take oral antibiotics or severely unwell). Antibiotics may be combined if susceptibility or sepsis a concern3,4,5
Co-amoxiclav (only in combination or if culture results available and susceptible)
3 months to 15 years, 30 mg/kg three times a day (maximum 1.2 g three times a day)
Cefuroxime
3 months to 15 years, 20 mg/kg three times a day (maximum 750 mg per dose), increased to 50 to 60 mg/kg three or four times a day (maximum 1.5 g per dose) for severe infections
Ceftriaxone
3 months to 11 years (up to 50 kg), 50 to 80 mg/kg once a day (maximum 4 g per day)
9 to 11 years (50 kg and above), 1 to 2 g once a day
12 to 15 years, 1 to 2 g once a day
Gentamicin
Initially 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration6
Amikacin
Initially 15 mg/kg once a day, subsequent doses adjusted according to serum amikacin concentration6
Second-choice intravenous antibiotic
Consult local microbiologist
1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic and renal impairment, and administering intravenous antibiotics. See the table on choice of antibiotic for pregnant women aged 12 years and over with acute pyelonephritis if a young woman is pregnant.
2 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age.
3 Check any previous urine culture and susceptibility results and antibiotic prescribing, and choose antibiotics accordingly. Where a child or young person is receiving prophylactic antibiotics, treatment should be with a different antibiotic, not a higher dose of the same antibiotic.
4 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible for a total of 10 days.
5 If intravenous treatment is not possible, consider intramuscular treatment if suitable.
6 Therapeutic drug monitoring and assessment of renal function is required (BNFC, August 2018).

Rationale: choice of antibiotic prophylaxis for recurrent UTIs

  • Based on evidence of no major differences in clinical effectiveness between classes of antibiotics, the committee agreed that the choice of antibiotic prophylaxis should largely be driven by minimising the risk of resistance. Resistant bacteria are a particular concern in UTIs and, where possible, any previous urine culture and susceptibility results, and antibiotic prescribing for UTI, should be checked and antibiotics chosen accordingly.
  • Based on their experience and resistance data, the committee agreed that a different antibiotic should be selected for antibiotic prophylaxis if an acute UTI is being treated. They also recognised that rotational use of antibiotics may be needed, based on local policies.
  • The committee discussed that, if antibiotic prophylaxis is needed to prevent an infection that is not life threatening, a narrow-spectrum antibiotic should generally be first choice. Indiscriminate use of broad-spectrum antibiotics creates a selective advantage for bacteria resistant even to these 'last-line' broad-spectrum agents, and also kills normal commensal flora leaving people susceptible to antibiotic-resistant harmful bacteria such as Clostridium difficile. Broad-spectrum antibiotics need to be reserved for second-choice treatment of non-life-threatening infections when narrow-spectrum antibiotics are ineffective.
  • Based on evidence, their experience and resistance data, the committee agreed to recommend trimethoprim or nitrofurantoin (based on culture and susceptibility results) as first choice antibiotics for prophylaxis. These antibiotics have less effect on the normal intestinal microflora in gastrointestinal tract, which is particularly imprortant when continuous antibiotic prophylaxis is used.
    • Trimethoprim should only be prescribed if a lower risk of resistance is likely, for example if trimethoprim has not been used in the past 3 months, if previous urine culture results suggest trimethoprim susceptibility (but this was not used as treatment) and in younger women in areas where local epidemiology data suggest resistance is low. There is a higher risk of trimethoprim resistance with recent use and in older people in residential facilities. Trimethoprim is contraindicated in pregnant women.
    • Nitrofurantoin is not recommended for people with an eGFR <45 ml/minute. With long-term use, there is a lower risk of resistance of nitrofurantoin compared with trimethoprim, but this needs to be balanced against the increased harms, such as pulmonary fibrosis.
    • The committee was aware that nitrofurantoin suspension is currently substantially more expensive than trimethoprim suspension and, if both antibiotics are appropriate, the one with the lowest acquisition cost should be chosen.
  • Based on evidence, their experience and resistance data, the committee agreed to recommend cefalexin or amoxicillin (based on culture and susceptibility results) as second-choice antibiotics for prophylaxis.
    • Amoxicillin and cefalexin are broad spectrum antibiotics that have a similar spectrum of activity and can be used if bacteria are susceptible.
  • Based on evidence that methenamine hippurate was less effective than antibiotic prophylaxis with nitrofurantoin, the committee was not able to make a recommendation on its use. They were also aware that methenamine hippurate is a medicine that is considered less suitable for prescribing (BNF, August 2018).
For more information see choice of antibiotic prophylaxis in the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing.

Antibiotics for pregnant women aged 12 years and over

When prescribing antibiotic treatment for lower UTI, take account of local antimicrobial resistance data and follow the table below for pregnant women aged 12 years and over.
Antibiotic1
Dosage and course length2
Treatment of lower UTI
First-choice3
Nitrofurantoin (avoid at term) – if eGFR ≥45 ml/minute4,5
100 mg modified-release twice a day for 7 days
Second-choice (no improvement in lower UTI symptoms on first choice taken for at least 48 hours or when first choice not suitable)3,6
Amoxicillin (only if culture results available and susceptible)
500 mg three times a day for 7 days
Cefalexin
500 mg twice a day for 7 days
Alternative second-choices
Consult local microbiologist, choose antibiotics based on culture and susceptibility results
Treatment of asymptomatic bacteriuria
Choose from nitrofurantoin4,5, amoxicillin or cefalexin based on recent culture and susceptibility results
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.
2 Doses given are by mouth using immediate-release medicines, unless otherwise stated.
3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
4 Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, August 2018).
5 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018).
6 If there are symptoms of pyelonephritis or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), see antibiotic treatment in the NICE recommendations on acute pyelonephritis.
Be aware that acute pyelonephritis is an infection of one or both kidneys usually caused by bacteria travelling up from the bladder.

Rationale: antibiotic dosing and course length for recurrent UTIs

  • Based on evidence, the committee was aware that a range of doses and course lengths were used for daily antibiotic prophylaxis. The committee agreed that usual BNF doses for daily prophylaxis should be used. The duration of treatment needs to be determined on an individual basis with a review of treatment success within 6 months, to include discussion of a trial of stopping antibiotic prophylaxis as appropriate.
  • The committee discussed the evidence for using single-dose antibiotic prophylaxis (including post-coital single-dose antibiotics) in non-pregnant women. The committee agreed that the single dose used when exposed to an identifiable trigger would be the same as a single treatment dose for a UTI.
  • Based on evidence, their experience and antimicrobial resistance data, the committee agreed that single-dose prophylaxis was as effective as continuous prophylaxis, with fewer adverse effects in non-pregnant women with an identifiable trigger, and should be considered as the first option for antibiotic prophylaxis in this group of women. Prophylaxis needs to be tailored to an individual woman's personal triggers, and advice given about how to use the antibiotic. Antibiotics for single-dose prophylaxis would be kept at home to avoid unnecessary GP and pharmacy visits.
  • No evidence from systematic reviews and RCTs was identified for using a course of antibiotics to keep at home for treating an acute UTI in people with recurrent UTIs (also known as stand-by antibiotics). The use of stand-by antibiotics could potentially lead to inappropriate antibiotic overuse in the absence of medical supervision, which would not reflect the principles of antimicrobial stewardship. Therefore, while the committee recognised that they may have a role in some specialist cases, they were not able to make a recommendation on their use.
For more information see antibiotic dosing and course length in the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing.
Reassess if symptoms worsen at any time or do not start to improve within 48 hours of taking the antibiotic, taking account of:
  • other possible diagnoses
  • any symptoms or signs suggesting a more serious illness or condition, such as sepsis
  • previous antibiotic use, which may have led to resistant bacteria.

Self-care

Advise people with acute pyelonephritis about using paracetamol for pain, with the possible addition of a low-dose weak opioid such as codeine for people over 12 years.
Advise people with acute pyelonephritis about drinking enough fluids to avoid dehydration.

Advice when an antibiotic prescription is given

When an antibiotic is given, as well as the general advice on self-care, give advice about:
  • possible adverse effects of the antibiotic, particularly diarrhoea and nausea
  • nausea with vomiting also being a possible indication of worsening pyelonephritis
  • seeking medical help if:
    • symptoms worsen at any time or
    • symptoms do not start to improve within 48 hours of taking the antibiotic or
    • the person becomes systemically very unwell.

Antibiotics for children and young people under 16 years

When prescribing antibiotic treatment for lower UTI, take account of local antimicrobial resistance data and follow the table below for children and young people under 16 years.
Antibiotic1
Dosage and course length2
Children under 3 months
Refer to paediatric specialist and treat with intravenous antibiotics in line with the NICE recommendations on fever in under 5s.
Children aged 3 months and over
First-choice3,4
Trimethoprim – if low risk of resistance5
3 to 5 months, 4 mg/kg (maximum 200 mg per dose) or 25 mg twice a day for 3 days
6 months to 5 years, 4 mg/kg (maximum 200 mg per dose) or 50 mg twice a day for 3 days
6 to 11 years, 4 mg/kg (maximum 200 mg per dose) or 100 mg twice a day for 3 days
12 to 15 years, 200 mg twice a day for 3 days
Nitrofurantoin – if eGFR ≥45 ml/minute6
3 months to 11 years, 750 micrograms/kg four times a day for 3 days
12 to 15 years, 50 mg four times a day or 100 mg modified-release twice a day for 3 days
Second-choice (no improvement in lower UTI symptoms on first choice taken for at least 48 hours or when first choice not suitable)3,4,7
Nitrofurantoin – if eGFR ≥45 ml/minute6 and not used as first choice
3 months to 11 years, 750 micrograms/kg four times a day for 3 days
12 to 15 years, 50 mg four times a day or 100 mg modified-release twice a day for 3 days
Amoxicillin (only if culture results available and susceptible)
1 to 11 months, 125 mg three times a day for 3 days
1 to 4 years, 250 mg three times a day for 3 days
5 to 15 years, 500 mg three times a day for 3 days
Cefalexin
3 to 11 months, 12.5 mg/kg or 125 mg twice a day for 3 days
1 to 4 years, 12.5 mg/kg twice a day or 125 mg three times a day for 3 days
5 to 11 years, 12.5 mg/kg twice a day or 250 mg three times a day for 3 days
12 to 15 years, 500 mg twice a day for 3 days
1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic and renal impairment. See the table on choice of antibiotic for pregnant women aged 12 years and over if the young woman is pregnant.
2 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age. Doses given are by mouth using immediate-release medicines, unless otherwise stated.
3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly. Where a child or young person is receiving prophylactic antibiotics, treatment should be with a different antibiotic, not a higher dose of the same antibiotic.
4 If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost. Some children may also be able to take a tablet or part-tablet, rather than a liquid formulation, if the dose is appropriate.
5 A lower risk of resistance may be more likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where local epidemiology data suggest resistance is low. A higher risk of resistance may be more likely with recent use and in older people in residential facilities.
6 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018).
7 If there are symptoms of pyelonephritis or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), see the recommendations on antibiotic treatment in the NICE guidance on acute pyelonephritis.
Be aware that recurrent UTI:
  • includes lower UTI and upper UTI (acute pyelonephritis)
  • may be due to relapse (with the same strain of organism) or reinfection (with a different strain or species of organism)
  • is particularly common in women.
Give advice to people with recurrent UTI about behavioural and personal hygiene measures and self-care treatments that may help to reduce the risk of UTI.
Be aware that:
  • some women with recurrent UTI may wish to try D-mannoseThe evidence was based on a study where D-mannose was taken as 200 ml of 1% solution once daily in the evening. D-mannose is a sugar that is available to buy as powder or tablets; it is not a medicine. if they are not pregnant
  • some women with recurrent UTI may wish to try cranberry products if they are not pregnant (evidence of benefit is uncertain and there is no evidence of benefit for older women)
  • some children and young people under 16 years with recurrent UTI may wish to try cranberry products with the advice of a paediatric specialist (evidence of benefit is uncertain).
Advise people taking cranberry products or D-mannose about the sugar content of these products, which should be considered as part of the person's daily sugar intake.
Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI.
Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.
When results of urine cultures are available:
  • review the choice of antibiotic and
  • change the antibiotic according to susceptibility results if the bacteria are resistant, using a narrow-spectrum antibiotic wherever possible.
When a trial of daily antibiotic prophylaxis is given, give advice about:
  • the risk of resistance with long-term antibiotics, which means they may be less effective in the future
  • possible adverse effects of long-term antibiotics
  • returning for review within 6 months
  • seeking medical help if there are symptoms of an acute UTI.
Review antibiotic prophylaxis for recurrent UTI at least every 6 months, with the review to include:
  • assessing the success of prophylaxis
  • discussion of continuing, stopping or changing prophylaxis (taking into account the person's preferences for antibiotic use and the risk of antimicrobial resistance)
  • a reminder about behavioural and personal hygiene measures and self-care treatments.
If antibiotic prophylaxis is stopped, ensure that people have rapid access to treatment if they have an acute UTI.
Be aware that lower UTI is an infection of the bladder usually caused by bacteria from the gastrointestinal tract entering the urethra and travelling up to the bladder.

Antibiotics for men aged 16 years and over

When prescribing antibiotic treatment for lower UTI, take account of local antimicrobial resistance data and follow the table below for men aged 16 years and over.
Antibiotic1
Dosage and course length2
First-choice3
Trimethoprim
200 mg twice a day for 7 days
Nitrofurantoin – if eGFR ≥45 ml/minute4,5
100 mg modified-release twice a day for 7 days
Second-choice (no improvement in UTI symptoms on first choice taken for at least 48 hours or when first choice not suitable)3
Consider alternative diagnoses and follow recommendations in the NICE recommendations on acute pyelonephritis or acute prostatitis, basing antibiotic choice on recent culture and susceptibility results.
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.
2 Doses given are by mouth using immediate-release medicines, unless otherwise stated.
3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
4 Nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate.
5 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018).
Reassess if symptoms worsen rapidly or significantly at any time, or do not start to improve within 48 hours of taking the antibiotic, taking account of:
  • other possible diagnoses
  • any symptoms or signs suggesting a more serious illness or condition, such as pyelonephritis
  • previous antibiotic use, which may have led to resistant bacteria.
Send a urine sample for culture and susceptibility testing if this has not already been done and review treatment when results are available.
Give advice about managing symptoms with self-care to all people with lower UTI.

Self-care

Advise people with lower UTI about using paracetamol for pain, or if preferred and suitable ibuprofen.
Advise people with lower UTI about drinking enough fluids to avoid dehydration.
Be aware that no evidence was found on cranberry products or urine alkalinising agents to treat lower UTI.

Advice when an antibiotic prescription is given

When a back-up antibiotic prescription is given, as well as the general advice on self-care, give advice about:
  • an antibiotic not being needed immediately
  • using the back-up prescription if symptoms do not start to improve within 48 hours or if they worsen at any time
  • possible adverse effects of antibiotics, particularly diarrhoea and nausea
  • seeking medical help if antibiotics are taken and:
    • symptoms worsen rapidly or significantly at any time, or
    • symptoms do not start to improve within 48 hours of taking the antibiotic, or
    • the person becomes systemically very unwell.
When an immediate antibiotic prescription is given, as well as the general advice on self-care, give advice about:
  • possible adverse effects of the antibiotic, particularly diarrhoea and nausea
  • seeking medical help if symptoms worsen rapidly or significantly at any time, do not start to improve within 48 hours of taking the antibiotic, or the person becomes systemically very unwell.

Glossary

Includes seriously ill (for more information refer to NICE's recommendations on fever in under 5s), poor urine flow, abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment with suitable antibiotics within 48 hours, infection with non-E. coli organisms.
2 or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or 1 episode of UTI with acute pyelonephritis/upper urinary tract infection plus 1 or more episode of UTI with cystitis/lower urinary tract infection, or 3 or more episodes of UTI with cystitis/lower urinary tract infection.
prescription given in a way to delay the use of an antibiotic, and with advice to only use it if symptoms worsen or don't improve within a specified time; the prescription may be given during the consultation (which may be a post-dated prescription) or left at an agreed location for collection at a later date
bacteria in the urine with or without urinary tract infection
British natural formulary
British natural formulary for children
dimercaptosuccinic acid
estimated glomerular filtration rate
hormone replacement therapy
micturating cystourethrogram
non-steroidal anti-inflammatory drug
white cells in the urine
suprapubic aspiration
some people (mainly women) may be able to identify 1 or more triggers (for example, sexual intercourse) that often brings on a UTI; these triggers may vary for different people
urinary tract infection
vesicoureteric reflux

Paths in this pathway

Pathway created: August 2012 Last updated: October 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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