Prescribing for lower urinary tract infections
This guideline sets out an antimicrobial prescribing strategy for lower urinary tract infection (also called cystitis) in children, young people and adults who do not have a catheter. It aims to optimise antibiotic use and reduce antibiotic resistance. It covers the difference in treatment strategies for women who are pregnant and those who are not, as well as reassessment and referral and choice of antibiotic.
The most common cause of uncomplicated lower UTI (cystitis) is bacteria from the gastrointestinal tract (E. coli in 70 – 95% of cases) entering the urethra and travelling up to the bladder.
All patients presenting with UTI should be offered advice on self-care – advise patients to take paracetamol or, if preferred and suitable, ibuprofen for pain, and to drink sufficient fluid to avoid dehydration. While popular home remedies for UTI include cranberry juice and alkalinising agents, no evidence was found for their effectiveness.
When considering antibiotics, take account of the severity of symptoms, the risk of complications, previous urine culture and susceptibility results, and previous antibiotic use that may have led to resistant bacteria. It is also important to consider local antimicrobial resistance data.
If urine is sent for culture and susceptibility and an antibiotic is given:
- Review antibiotic choice when results are available, and
- Change antibiotic for pregnant women if bacteria resistant
- Change antibiotic for children and young people, men and non-pregnant women if bacteria resistant and symptoms are not improving
- Use a narrow spectrum antibiotic when possible
With all antibiotic prescriptions, advise:
- Possible side effects of antibiotics, including diarrhoea and nausea
- To seek further medical advice if symptoms worsen at any time, do not improve within 48 hours of taking the antibiotic of if the person becomes very unwell.
With a back-up antibiotic prescription, also advise:
- That the antibiotic is not needed immediately
- To use the prescription if there is no improvement within 48 hours or if symptoms get worse at any time
NON-PREGNANT WOMEN
Acute, uncomplicated lower UTI in non-pregnant women can be self-limiting and for some women delaying antibiotic treatment with a back-up prescription to see if symptoms will resolve without antibiotic treatment may be an option. Recommended choice of antibiotics is shown in Table 1, below.
PREGNANT WOMEN, MEN
- Send midstream urine for culture and susceptibility
- Offer immediate antibiotic (See Tables 2 & 3)
Pregnant women should be screened for asymptomatic bacteriuria – significant levels of bacteria in the urine in the absence of UTI symptoms – and treated because it is a risk factor for pyelonephritis and premature delivery.
CHILDREN
- Send urine for culture and susceptibility or dipstick in line with NICE guideline on urinary tract infection for under 16s
- Offer immediate antibiotic (See Table 4)
- Assess and manage fever in under 5s in line with NICE guideline on fever in under 5s
REASSESSMENT AND REFERRAL
Reassess at any time if symptoms worsen rapidly or significantly, or do not improve within 48 hours of taking antibiotic. Send a urine sample for culture and sensitivity if you have not already done so. Take account of:
- Other possible diagnoses
- Symptoms or signs suggesting a more serious illness of condition
- Previous antibiotic use, which may have led to resistance
Refer to hospital any patient aged 16 or over who has any symptoms or signs suggesting a more serious illness or condition, such as sepsis. Children and young people should be referred in line with the NICE guideline on urinary tract infection in under 16s.
Children under 3 months should be referred to a paediatric specialist and treated with intravenous antibiotics.
CHOICE OF ANTIBIOTIC
Consult the BNF for appropriate use and dosing in specific populations, e.g. hepatic or renal impairment, breastfeeding. A lower risk of resistance may be more likely if the antibiotic has not been used in the past 3 months, previous urine culture suggests susceptibility or where local epidemiology data suggest resistance is low. The risk of resistance is higher with recent use and in older people in residential care.
Recommendations for specific groups are given in the tables below.
Table 1. Antibiotics for non-pregnant women aged 16 and over
Antibiotic | Dosage and course length |
First choice | |
Nitrofurantoin – if eGFR ≥45ml/minute | 100mg modified release twice a day for 3 days |
Trimethoprim – if low risk of resistance | 200mg twice a day for 3 days |
Second choice (no improvement in symptoms on first-choice taken for at least 48 hours, or first choice not suitable) | |
Nitrofurantoin – if eGFR ≥45ml/minute and not used as first choice | 100mg modified release twice a day for 3 days |
Pivmecillinam (a penicillin) | 400mg initial dose, then 200mg three times a day for a total of 3 days |
Fosfomycin | 3g single dose sachet |
Table 2. Antibiotics for pregnant women aged 12 and over
Antibiotic | Dosage and course length |
Treatment of lower UTI | |
First choice | |
Nitrofurantoin – if eGFR ≥45ml/minute | 100mg modified release twice a day for 7 days |
Second choice (no improvement in symptoms on first-choice taken for at least 48 hours, or first choice not suitable) | |
Amoxiciliin (only if culture results available and susceptible) | 500mg 3 times a day for 7 days |
Cefalexin | 500mg twice a day for 7 days |
Alternative second choices | Consult local microbiologist |
Treatment of asymptomatic bacteriuria | |
Choose from nitrofurantoin, amoxicillin or cephalexin based on recent culture and susceptibility results |
Table 3. Antibiotics for men aged 16 years and over
Antibiotic | Dosage and course length |
First choice | |
Trimethoprim | 200mg twice a day for 7 days |
Nitrofurantoin* – if eGFR ≥45ml/minute | 100mg modified release twice a day for 7 days |
Second choice (no improvement in symptoms on first-choice taken for at least 48 hours, or first choice not suitable) | |
Consider alternative diagnoses and follow recommendations in NICE guidelines on antimicrobial prescribing |
*Nitrofurantoin is not recommended for men with suspected prostate involvement as it is unlikely to reach therapeutic levels in the prostate
Table 4. Antibiotics for children and young people under 16 years
Antibiotic | Dosage and course length |
Children aged 3 months and over | |
First choice | |
Trimethropim – if low risk of resistance | 3 – 5 months, 4mg/kg (max 200mg per dose) or 25mg twice a day for 3 days 6 months to 5 years, 4mg/kg (max 200mg per dose) or 50mg twice a day for 3 days 6 – 11 years, 4mg/kg (max 200mg per dose) or 100mg twice a day for 3 days. 12 – 15 years, 200mg twice a day for 3 days. |
Nitrofurantoin – if eGFR ≥45ml/minute | 3 months – 11 years, 750mcg/kg 4 times a day for 3 days 12 – 15 years, 50mg 4 times a day or 100mg modified release twice a day for 3 days |
Second choice | |
Nitrofurantoin – if eGFR ≥45ml/minute and not used as first choice | 3 months – 11 years, 750mcg/kg 4 times a day for 3 days 12 – 15 years, 50mg 4 times a day or 100mg modified release twice a day for 3 days |
Amoxicillin (only if culture results available and susceptible) | 1 – 11 months, 125mg 3 times a day for 3 days 1 – 4 years, 250mg 3 times a day for 3 days 5 – 15 years, 500mg 3 times a day for 3 days |
Cefalexin | 3 – 11 months, 12.5mg/kg or 125mg twice a day for 3 days 1 – 4 years, 12.5 mg/kg twice a day or 125mg 3 times a day for 3 days 5 – 11 years, 12.5mg/kg twice a day or 250mg 3 times a day for 3 days 12 – 15 years, 500mg twice a day for 3 days |
NICE NG109. Urinary tract infection (lower): antimicrobial prescribing, October 2018
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