Recommendations

Guidance

1.1 Managing lower urinary tract infection
1.2 Managing asymptomatic bacteriuria
1.3 Self-care
1.4 Choice of antibiotic

Recommendations

1.1 Managing lower urinary tract infection

1.1.1

Be aware that lower urinary tract infection (UTI) is an infection of the bladder usually caused by bacteria from the gastrointestinal tract entering the urethra and travelling up to the bladder.

1.1.2

Give advice about managing symptoms with self-care (see the recommendations on self-care) to all people with lower UTI.

Treatment for women with lower UTI who are not pregnant

1.1.3

Consider a back-up antibiotic prescription (to use if symptoms do not start to improve within 48 hours or worsen at any time) or an immediate antibiotic prescription (see the recommendations on choice of antibiotic) for women with lower UTI who are not pregnant. Take account of:

the severity of symptoms
the risk of developing complications, which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract or immunosuppression
the evidence for back-up antibiotic prescriptions, which was only in non-pregnant women with lower UTI where immediate antibiotic treatment was not considered necessary
previous urine culture and susceptibility results
previous antibiotic use, which may have led to resistant bacteria
preferences of the woman for antibiotic use.

1.1.4

If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given:

review the choice of antibiotic when microbiological results are available, and
change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving, using a narrow-spectrum antibiotic wherever possible.

Treatment for pregnant women and men with lower UTI

1.1.5

Offer an immediate antibiotic prescription (see the recommendations on choice of antibiotic) to pregnant women and men with lower UTI. Take account of:

previous urine culture and susceptibility results
previous antibiotic use, which may have led to resistant bacteria.

1.1.6

Obtain a midstream urine sample from pregnant women and men before antibiotics are taken, and send for culture and susceptibility testing.

1.1.7

For pregnant women with lower UTI:

review the choice of antibiotic when microbiological results are available, and
change the antibiotic according to susceptibility results if the bacteria are resistant, using a narrow-spectrum antibiotic wherever possible.

1.1.8

For men with lower UTI:

review the choice of antibiotic when microbiological results are available, and
change the antibiotic according to susceptibility results if the bacteria are resistant and symptoms are not already improving, using a narrow-spectrum antibiotic wherever possible.

Treatment for children and young people under 16 years with lower UTI

1.1.9

Obtain a urine sample from children and young people with lower UTI before antibiotics are taken, and dipstick test or send for culture and susceptibility testing in line with the NICE guideline on urinary tract infection in under 16s.

1.1.10

Assess and manage children under 5 with lower UTI who present with fever as outlined in the NICE guideline on fever in under 5s.

1.1.11

Offer an immediate antibiotic prescription (see the recommendations on choice of antibiotic) for children and young people under 16 years with lower UTI. Take account of:

previous urine culture and susceptibility results
previous antibiotic use, which may have led to resistant bacteria.

1.1.12

If a urine sample has been sent for culture and sensitivity testing when an antibiotic prescription has been given:

review the choice of antibiotic when microbiological results are available, and
change the antibiotic according to susceptibility results if the bacteria are resistant and symptoms are not already improving, using a narrow-spectrum antibiotic wherever possible.

Advice for all people with lower UTI when an antibiotic prescription is given

1.1.13

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.

1.1.14

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.

Reassessment

1.1.15

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 (see recommendations 1.1.4, 1.1.7, 1.1.8 and 1.1.12).

Referral

1.1.16

Refer people aged 16 years and over with lower UTI to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis).

1.1.17

Refer children or young people with lower UTI to hospital in line with the NICE guideline on urinary tract infection in under 16s.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on antibiotics.

Full details of the evidence and the committee's discussion are in the evidence review.

1.2 Managing asymptomatic bacteriuria

1.2.1

Be aware that asymptomatic bacteriuria:

is significant levels of bacteria (greater than 10⁵ colony forming units/ml) in the urine with no symptoms of UTI
is not routinely screened for, or treated, in women who are not pregnant, men, young people and children
is treated with antibiotics in pregnant women because it is a risk factor for pyelonephritis and premature delivery (see the recommendations on choice of antibiotic).

1.2.2

Offer an immediate antibiotic prescription to pregnant women with asymptomatic bacteriuria, taking account of:

recent urine culture and susceptibility results
previous antibiotic use, which may have led to resistant bacteria.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on antibiotics.

Full details of the evidence and the committee's discussion are in the evidence review.

1.3 Self-care

1.3.1

Advise people with lower UTI about using paracetamol for pain, or if preferred and suitable ibuprofen.

1.3.2

Advise people with lower UTI about drinking enough fluids to avoid dehydration.

1.3.3

Be aware that no evidence was found on cranberry products or urine alkalinising agents to treat lower UTI.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on self-care.

Full details of the evidence and the committee's discussion are in the evidence review.

1.4 Choice of antibiotic

1.4.1

When prescribing antibiotic treatment for lower UTI, take account of local antimicrobial resistance data and follow:

table 1 for non-pregnant women aged 16 years and over
table 2 for pregnant women aged 12 years and over
table 3 for men aged 16 years and over
table 4 for children and young people under 16 years.

**Table 1 Antibiotics for non-pregnant women aged 16 years and over**
Treatment	Antibiotic, dosage and course length
First choices If there are symptoms of pyelonephritis (such as fever) or a complicated urinary tract infection (UTI), see the NICE guideline on acute pyelonephritis for antibiotic choices.	Nitrofurantoin (if estimated glomerular filtration rate [eGFR] is 45 ml/minute or more): 100 mg modified-release twice a day (or, if unavailable, 50 mg four times a day) for 3 days Trimethoprim (if there is a low risk of resistance): 200 mg twice a day for 3 days
Second choices (if no improvement in lower UTI symptoms on first choice taken for at least 48 hours, or when first choice is not suitable) If there are symptoms of pyelonephritis (such as fever) or a complicated UTI, see the NICE guideline on acute pyelonephritis for antibiotic choices.	Nitrofurantoin (if eGFR is 45 ml/minute or more, and it was not used as first-choice): 100 mg modified-release twice a day (or, if unavailable, 50 mg four times 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

See the BNF for appropriate use and dosing in specific populations, for example, in hepatic or renal impairment, and breastfeeding.

Check any previous urine culture and susceptibility results, and antibiotic prescribing, and choose antibiotics accordingly.

Nitrofurantoin may be used with caution if eGFR is 30 ml/minute to 44 ml/minute to treat uncomplicated lower UTIs caused by suspected or proven multidrug-resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018).

A lower risk of resistance may be more likely if trimethoprim has not been 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.

**Table 2 Antibiotics for pregnant women aged 12 years and over**
Treatment	Antibiotic, dosage and course length
First choice If there are symptoms of pyelonephritis (such as fever) or a complicated urinary tract infection (UTI), see the NICE guideline on acute pyelonephritis for antibiotic choices.	Nitrofurantoin (if estimated glomerular filtration rate [eGFR] is 45 ml/minute or more): 100 mg modified-release twice a day (or, if unavailable, 50 mg four times a day) for 7 days Avoid at term because it may produce neonatal haemolysis (BNF, August 2018)
Second choices (if no improvement in lower UTI symptoms on first choice taken for at least 48 hours, or when first choice is not suitable) If there are symptoms of pyelonephritis (such as fever) or a complicated UTI, see the NICE guideline on acute pyelonephritis for antibiotic choices.	Amoxicillin (only if culture results are 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, and choose antibiotics based on culture and susceptibility results
Treatment of asymptomatic bacteriuria	Choose from nitrofurantoin, amoxicillin or cefalexin based on recent culture and susceptibility results

See the BNF for appropriate use and dosing in specific populations, for example, in hepatic or renal impairment.

Check any previous urine culture and susceptibility results, and antibiotic prescribing, and choose antibiotics accordingly.

**Table 3 Antibiotics for men aged 16 years and over**
Treatment	Antibiotic, dosage and course length
First choices If there are symptoms of pyelonephritis (such as fever) or a complicated urinary tract infection (UTI), see the NICE guideline on acute pyelonephritis for antibiotic choices.	Trimethoprim: 200 mg twice a day for 7 days Nitrofurantoin (if estimated glomerular filtration rate [eGFR] is 45 ml/minute or more): 100 mg modified-release twice a day (or, if unavailable, 50 mg four times a day) for 7 days Nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate.
Second choices (if no improvement in lower UTI symptoms on first choice taken for at least 48 hours, or when first choice is not suitable) If there are symptoms of pyelonephritis (such as fever) or a complicated UTI, see the NICE guideline on acute pyelonephritis for antibiotic choices.	Consider alternative diagnoses and follow recommendations in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing or the NICE guideline on prostatitis (acute): antimicrobial prescribing, basing antibiotic choice on recent culture and susceptibility results.

See the BNF for appropriate use and dosing in specific populations, for example, in hepatic or renal impairment.

Check any previous urine culture and susceptibility results, and antibiotic prescribing, and choose antibiotics accordingly.

**Table 4 Antibiotics for children and young people under 16 years**
Treatment	Antibiotic, dosage and course length
Children under 3 months	Refer to a paediatric specialist and treat with intravenous antibiotics in line with the NICE guideline on fever in under 5s
First choices for children aged 3 months and over If there are symptoms of pyelonephritis (such as fever) or a complicated UTI, see the NICE guideline on acute pyelonephritis for antibiotic choices. 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.	Trimethoprim (if there is a low risk of resistance): 3 months 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 years to 11 years, 4 mg/kg (maximum 200 mg per dose) or 100 mg twice a day for 3 days 12 years to 15 years, 200 mg twice a day for 3 days Nitrofurantoin (if estimated glomerular filtration rate (eGFR) is 45 ml/minute or more): 3 months to 11 years, 750 micrograms/kg four times a day for 3 days 12 years to 15 years, 50 mg four times a day or 100 mg modified-release twice a day for 3 days
Second choices for children aged 3 months and over (if no improvement in lower UTI symptoms on first choice taken for at least 48 hours, or when first choice is not suitable) If there are symptoms of pyelonephritis (such as fever) or a complicated UTI, see the NICE guideline on acute pyelonephritis for antibiotic choices. 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.	Nitrofurantoin (if eGFR is 45 ml/minute or more and it was not used as first-choice): 3 months to 11 years, 750 micrograms/kg four times a day for 3 days 12 years 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 month to 11 months, 125 mg three times a day for 3 days 1 year to 4 years, 250 mg three times a day for 3 days 5 years to 15 years, 500 mg three times a day for 3 days Cefalexin: 3 months to 11 months, 12.5 mg/kg or 125 mg twice a day for 3 days 1 year to 4 years, 12.5 mg/kg twice a day or 125 mg three times a day for 3 days 5 years to 11 years, 12.5 mg/kg twice a day or 250 mg three times a day for 3 days 12 years to 15 years, 500 mg twice a day for 3 days

See the BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, in hepatic or renal impairment. See table 2 if a young woman is pregnant.

The age bands apply to children of average size and, in practice, the prescriber will use the age bands 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.

Check any previous urine culture and susceptibility results, and antibiotic prescribing. and choose antibiotics accordingly. When a child or young person is having prophylactic antibiotics, treatment should be with a different antibiotic, not a higher dose of the same antibiotic.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on choice of antibiotic and antibiotic course length.

Full details of the evidence and the committee's discussion are in the evidence review.