Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about 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.

Healthcare professionals should follow our general guidelines for people delivering care:

1.1 Preventing recurrent urinary tract infections

1.1.2

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, and trans men and non-binary people with a female urinary system. [2018]

1.1.3

Give advice to people with recurrent UTI about behavioural and personal hygiene measures and self-care treatments (see the recommendations on self-care) that may help to reduce the risk of UTI. [2018]

Referral and seeking specialist advice for recurrent UTI

1.1.4

Refer or seek specialist advice on further investigation and management for:

  • men, and trans women and non-binary people with a male genitourinary system, aged 16 and over

  • people with recurrent upper UTI

  • people with recurrent lower UTI when the underlying cause is unknown

  • pregnant women, and pregnant trans men and non-binary people

  • children and young people aged under 16 years, in line with NICE's guideline on urinary tract infection in under 16s

  • people with suspected cancer, in line with NICE's guideline on suspected cancer: recognition and referral

  • anyone who has had gender reassignment surgery that involved structural alteration of the urethra. [2018, amended 2024]

For a short explanation of why the committee made the 2018 recommendations, see the evidence and committee discussion on antibiotic prophylaxis.

Full details of the evidence and committee's discussion are available in evidence review A: antimicrobial prescribing for recurrent UTIs.

1.2 Treatments for preventing recurrent UTI

Oestrogen

In December 2024, this was an off-label use of vaginal oestrogen products. See NICE's information on prescribing medicines.

See also the recommendations on genitourinary symptoms associated with menopause in NICE's guideline on menopause. This section of the menopause guideline, which includes advice on the use of vaginal oestrogen for people with a personal history of breast cancer, should be read in conjunction with the recommendations in this guideline.

These recommendations are for women, and trans men and non-binary people with a female urinary system, who are experiencing perimenopause or menopause, or who have already experienced menopause.

1.2.1

Consider vaginal oestrogen for recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate. [2018, amended 2024]

1.2.2

When discussing vaginal oestrogen for preventing recurrent UTI, cover the following to ensure shared decision making:

  • the severity and frequency of previous symptoms

  • the risk of developing complications from recurrent UTIs

  • the possible benefits of treatment, including for other related symptoms such as vaginal dryness

  • that serious side effects are very rare

  • that vaginal oestrogen is absorbed locally – a minimal amount is absorbed into the bloodstream, but this is unlikely to have a significant effect throughout the body

  • the person's preferred treatment option for vaginal oestrogen (for example, a cream, gel, tablet, pessary or ring). [2018, amended 2024]

1.2.3

Review treatment with vaginal oestrogen within 12 months, or earlier if agreed with the person. [2018]

For a short explanation of why the committee made the 2018 recommendations, see the evidence and committee discussion on oestrogens.

Full details of the evidence and committee's discussion are available in evidence review A: antimicrobial prescribing for recurrent UTIs.

Single-dose antibiotic prophylaxis

These recommendations are for women, and trans men and non-binary people with a female urinary system, who are not pregnant.

1.2.5

Consider a trial of single-dose antibiotic prophylaxis (a one-off dose of an antibiotic) for recurrent UTI only if behavioural and personal hygiene measures, and vaginal oestrogen, are not effective or not appropriate. [2018]

1.2.6

Ensure that any current UTI has been adequately treated, then consider single-dose antibiotic prophylaxis for recurrent UTI for use when there has been exposure to an identifiable trigger (see the recommendations on choice of antibiotic or antiseptic prophylaxis). Take account of:

  • the severity and frequency of previous symptoms

  • the risk of developing complications

  • previous urine culture and susceptibility results

  • previous antibiotic use, which may have led to resistant bacteria

  • the person's preferences for antibiotic use. [2018]

1.2.7

When single-dose antibiotic prophylaxis is offered, give advice about:

  • how to use the antibiotic

  • possible adverse effects of antibiotics, particularly diarrhoea and nausea

  • returning for review within 6 months

  • seeking medical help if there are symptoms of an acute UTI. [2018]

For a short explanation of why the committee made the 2018 recommendations, see the evidence and committee discussions on antibiotic prophylaxis and antibiotic dosing and course length.

Full details of the evidence and committee's discussion are available in evidence review A: antimicrobial prescribing for recurrent UTIs.

Methenamine hippurate

1.2.8

Consider methenamine hippurate as an alternative to daily antibiotic prophylaxis for recurrent UTI in women, and trans men and non-binary people with a female urinary system, if:

1.2.9

Seek specialist advice if considering methenamine hippurate as an alternative to daily antibiotic prophylaxis for recurrent UTI:

  • during pregnancy

  • in people with recurrent upper UTI or complicated lower UTI

  • in men, and trans women and non-binary people with a male genitourinary system

  • in children and young people. [2024]

    In December 2024, the use of methenamine hippurate as prophylaxis for recurrent upper UTI or complicated lower UTI, and for recurrent UTI in children aged under 6, was off label. See NICE's information on prescribing medicines.

1.2.10

If discussing methenamine hippurate as a preventative treatment, explain that:

  • over-the-counter sachets that make urine more alkaline (such as sachets used to relieve UTI symptoms that contain potassium citrate or sodium citrate) should not be used while taking methenamine hippurate because these can make the medicine less effective

  • medical help should be sought for acute UTI symptoms. [2024]

1.2.11

Review treatment with methenamine hippurate within 6 months, and then every 12 months, or earlier if agreed with the person. [2024]

For a short explanation of why the committee made the 2024 recommendations, see the evidence and committee discussion on methenamine hippurate.

Full details of the evidence and committee's discussion are available in evidence review B: effectiveness of methenamine hippurate in the prevention of recurrent UTIs.

Daily antibiotic prophylaxis

General principles for prescribing

These recommendations are for children, young people and adults with recurrent UTI.

1.2.12

When considering a trial of daily antibiotic prophylaxis, take account of:

  • the severity and frequency of previous symptoms

  • the risks of long-term antibiotic use

  • the risk of developing complications

  • previous urine culture and susceptibility results

  • previous antibiotic use, which may have led to resistant bacteria. [2018]

1.2.13

When offering a trial of daily antibiotic prophylaxis, 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. [2018]

For women, and trans men and non-binary people with a female urinary system, who are not pregnant
1.2.14

If there has been no improvement after vaginal oestrogen, single-dose antibiotic prophylaxis or methenamine hippurate (if any of these have been appropriate and are applicable), ensure that any current UTI has been adequately treated, then consider a trial of daily antibiotic prophylaxis for recurrent UTI. Take account of the following:

For advice to give when offering daily antibiotic prophylaxis, see the section on general principles for prescribing.

During pregnancy, or for men, and trans women and non-binary people with a male genitourinary system
1.2.15

Ensure that any current UTI has been adequately treated, then consider a trial of daily antibiotic prophylaxis for recurrent UTI if behavioural and personal hygiene measures alone, or methenamine hippurate (if used in line with recommendation 1.2.9), are not effective or not appropriate, with specialist advice. Take account of the following:

For advice to give when offering daily antibiotic prophylaxis, see the section on general principles for prescribing.

For children and young people under 16 years
1.2.16

Ensure that any current UTI has been adequately treated, then consider a trial of daily antibiotic prophylaxis for recurrent UTI if behavioural and personal hygiene measures alone, or methenamine hippurate (if used in line with recommendation 1.2.9), are not effective or not appropriate, with specialist advice. Take account of the following:

For advice to give when offering daily antibiotic prophylaxis, see the section on general principles for prescribing.

Reassessing the use of daily antibiotic prophylaxis in all people
1.2.17

Review daily 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 (see the recommendations on self-care).

    If antibiotic prophylaxis is stopped, ensure that people have rapid access to treatment if they have an acute UTI. [2018]

For a short explanation of why the committee made the 2018 recommendations, see the evidence and committee discussion on antibiotic prophylaxis.

Full details of the evidence and committee's discussion are available in evidence review A: antimicrobial prescribing for recurrent UTIs.

1.3 Self-care

1.3.1

Be aware that some women, and trans men and non-binary people with a female urinary system, who have recurrent UTI and are not pregnant may wish to try:

  • D‑mannose (the evidence for D‑mannose was based on a study in which it 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

  • cranberry products (evidence of benefit is uncertain and there is no evidence of benefit for older women, or older trans men or non-binary people with a female urinary system). [2018]

1.3.2

Be aware that 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). [2018]

1.3.3

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. [2018]

1.3.4

Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI. [2018]

For a short explanation of why the committee made the 2018 recommendations, see the evidence and committee discussion on self-care.

Full details of the evidence and committee's discussion are available in evidence review A: antimicrobial prescribing for recurrent UTIs.

1.4 Choice of antibiotic or antiseptic prophylaxis

1.4.1

When prescribing antibiotic prophylaxis for recurrent UTI, take account of local antimicrobial resistance (AMR) data from the UK Health Security Agency and:

  • follow the recommendations in table 1 for people aged 16 years and over

  • follow the recommendations in table 2 for children and young people under 16 years.

    Also see tables 1 and 2 for information about methenamine hippurate, if thinking about this treatment as an alternative to daily antibiotics. [2018, amended 2024]

Table 1 People aged 16 years and over
Treatment Prophylaxis and dosage

Antiseptic prophylaxis

Methenamine hippurate:

1 g twice a day

In December 2024, use of methenamine hippurate for prophylaxis of recurrent upper UTI or complicated lower UTI was off label; see NICE's information on prescribing medicines

First-choice oral antibiotics

Trimethoprim:

200 mg as a single dose when exposed to a trigger, or 100 mg at night

There is a teratogenic risk in first trimester of pregnancy (folate antagonist; BNF information on trimpethoprim). The companies advise that it is contraindicated in pregnancy

See also the summary of product characteristics for trimethoprim

Nitrofurantoin (if estimated glomerular filtration rate is 45 ml/minute or more):

100 mg as a single dose when exposed to a trigger, or 50 mg to 100 mg at night

Avoid at term in pregnancy; may produce neonatal haemolysis (BNF information on nitrofurantoin)

In December 2024, use of nitrofurantoin for recurrent upper UTI or complicated lower UTI was off label; see NICE's information on prescribing medicines

Second-choice oral antibiotics

Amoxicillin (off-label use):

500 mg as a single dose when exposed to a trigger, or 250 mg at night

Cefalexin:

500 mg as a single dose when exposed to a trigger, or 125 mg at night

See the BNF for appropriate use and dosing in specific populations, for example, in people who have hepatic or renal impairment, or during pregnancy or breastfeeding.

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.

For off-label use, see NICE's information on prescribing medicines.

Table 2 Children and young people under 16 years
Treatment Prophylaxis and dosage

Choice for children under 3 months

Refer to paediatric specialist

Antiseptic prophylaxis for children aged 6 and over (specialist advice only)

Methenamine hippurate:

6 years to 12 years, 500 mg twice a day

12 years to 15 years, 1 g twice a day

In December 2024, use of methenamine hippurate for prophylaxis of recurrent upper UTI or complicated lower UTI, and for recurrent UTI in children aged under 6, was off label. See NICE's information on prescribing medicines

First-choice oral antibiotics for children aged 3 months and over (specialist advice only)

Trimethoprim:

3 months 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 years to 11 years, 2 mg/kg at night (maximum 100 mg per dose) or 50 mg at night

12 years to 15 years, 100 mg at night

There is a teratogenic risk in first trimester of pregnancy (folate antagonist; BNFC information on trimpethoprim). The companies advise that it is contraindicated in pregnancy

See also the summary of product characteristics for trimethoprim

Nitrofurantoin (if estimated glomerular filtration rate is 45 ml/minute or more):

3 months to 11 years, 1 mg/kg at night

12 years to 15 years, 50 mg to 100 mg at night

Avoid at term in pregnancy; may produce neonatal haemolysis (BNFC information on nitrofurantoin)

In December 2024, use of nitrofurantoin for recurrent upper UTI or complicated lower UTI was off label; see NICE's information on prescribing medicines

Second-choice oral antibiotics for children aged 3 months and over (specialist advice only)

Cefalexin:

3 months to 15 years, 12.5 mg/kg at night (maximum 125 mg per dose)

Amoxicillin (off-label use):

3 months to 11 months, 62.5 mg at night

1 year to 4 years, 125 mg at night

5 years to 15 years, 250 mg at night

See the BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, in children or young people with hepatic or renal impairment.

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.

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.

For off-label use, see NICE's information on prescribing medicines.

For a short explanation of why the committee made the 2018 recommendations, see the evidence and committee discussions on choice of antibiotic or antiseptic prophylaxis and antibiotic dosing and course length.

Full details of the evidence and committee's discussion are available in:

Terms used in the guideline

Complicated lower UTI

Lower UTI is where 1 or more factors predispose a person to persistent or recurrent infection, or may make treatment ineffective. These factors can include abnormalities of the urinary tract, a virulent organism that is causing infection, a weakened immune system (for example, caused by diabetes mellitus) or impaired renal function.

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.

See NICE's guideline on urinary tract infection in under 16s.

Systemic hormone replacement therapy (HRT)

HRT that is absorbed into the bloodstream and can have an effect throughout the body.

Trigger

Some people (mainly women, and trans men and non-binary people with a female urinary system) 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.