Guidance

Recommendations

Recommendations

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.

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.

Referral and seeking specialist advice

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

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

Treatment for women with recurrent UTI who are not pregnant

Oestrogen
1.1.5

Consider the lowest effective dose of vaginal oestrogen (for example, estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate. Discuss the following with the woman 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

  • the possible adverse effects such as breast tenderness and vaginal bleeding (which should be reported because it may require investigation)

  • the uncertainty of endometrial safety with long-term or repeated use

  • preferences of the woman for treatment with vaginal oestrogen.

    Review treatment within 12 months, or earlier if agreed with the woman. In October 2018, this was an off-label use of vaginal oestrogen products. See NICE's information on prescribing medicines.

1.1.6

Do not offer oral oestrogens (hormone replacement therapy) specifically to reduce the risk of recurrent UTI in postmenopausal women.

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

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

Antibiotic prophylaxis
1.1.7

For women with recurrent UTI who are not pregnant, consider a trial of antibiotic prophylaxis only if behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate.

1.1.8

For women with recurrent UTI who are not pregnant, ensure that any current UTI has been adequately treated then consider single-dose antibiotic prophylaxis for use when exposed to an identifiable trigger (see the recommendations on choice of antibiotic 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 woman's preferences for antibiotic use.

1.1.9

When single-dose antibiotic prophylaxis is given, 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.

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

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

1.1.10

For women with recurrent UTI who are not pregnant and have had no improvement after single‑dose antibiotic prophylaxis or have no identifiable triggers, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis). Take account of:

  • any further investigations (for example, ultrasound) that may be needed to identify an underlying cause

  • 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

  • the woman's preferences for antibiotic use.

1.1.11

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.

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

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

Treatment for men and pregnant women with recurrent UTI

1.1.12

For men and pregnant women with recurrent UTI, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis) if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. Take account of:

  • any further investigations (for example, ultrasound) that may be needed to identify an underlying cause

  • 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

  • the person's preferences for antibiotic use.

1.1.13

When a trial of daily antibiotic prophylaxis is given, give advice as in recommendation 1.1.11.

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

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

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

1.1.14

For children and young people under 16 years with recurrent UTI, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis) if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. Take account of:

  • underlying causes following specialist assessment and investigations

  • the uncertain evidence of benefit of antibiotic prophylaxis for reducing the risk of recurrent UTI and the rate of deterioration of renal scars

  • 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

  • preferences for antibiotic use.

1.1.15

When a trial of daily antibiotic prophylaxis is given, give advice as in recommendation 1.1.11.

Reassessment

1.1.16

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 (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.

1.2 Self-care

1.2.1

Be aware that:

  • Some women with recurrent UTI may wish to try D‑mannose if they are not pregnant (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.

  • 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).

1.2.2

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.

1.2.3

Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent 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 committee's discussion are available in the evidence review.

1.3 Choice of antibiotic prophylaxis

Table 1 People aged 16 years and over
Treatment Antibiotic prophylaxis and dosage

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 (trimethoprim summary of product characteristics)

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)

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, hepatic impairment, renal impairment, pregnancy and 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 Antibiotic prophylaxis and dosage

Choice for children under 3 months

Refer to paediatric specialist

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 (trimethoprim summary of product characteristics)

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)

Second-choice oral antibiotics for children aged 3 months and over

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, hepatic and 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 these recommendations, see the evidence and committee discussion on choice of antibiotic prophylaxis and antibiotic dosing and course length.

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