Urinary tract infections in women

Back

Plus –

supportive care and safety-netting

Treatment recommended for ALL patients in selected patient group

Give all patients information on self-care and safety-netting advice, including advice to:[4][3][69]

Drink enough fluids so they do not feel thirsty (aim to drink 6 to 8 glasses per day, including water or decaffeinated, sugar-free drinks)
Take paracetamol or ibuprofen (if appropriate) at regular intervals for pain relief.
- Public Health England recommends the TARGET UTI patient leaflet. TARGET: antibiotic toolkit Opens in new window

Practical tip

The UK’s NICE found no evidence to support the use of cranberry products or urine alkalinising agents to treat lower UTI.[3]

Recommend that patients should contact healthcare services if they have any of the following:[4]

Shivering, chills, and muscle pain
Feeling confused or very drowsy
Not passing urine all day
Vomiting
Blood in the urine
Temperature above 38ºC or below 36ºC
Kidney pain in the back or under the ribs
Worsening UTI symptoms
UTI symptoms are not starting to improve within 48 hours of taking antibiotics.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Back

Consider –

pathogen-targeted antibiotics

Additional treatment recommended for SOME patients in selected patient group

When results of any urine culture and sensitivity testing are available:[3]

Review the choice of antibiotic based on the microbiological results
Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not improving, selecting a narrow-spectrum antibiotic where possible.

Reassess the patient if symptoms worsen rapidly or significantly at any time or do not start to improve within 48 hours of taking an antibiotic.[3]

Take account of:[3]
- Other possible diagnoses
- Any symptoms or signs suggesting a more serious illness or condition (e.g., 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.[3]

In the community, refer patients with lower UTI to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[3]

no more than 1 key diagnostic sign/symptom and/or other urinary symptoms (dipstick negative)

1st line – reassurance

Back

1st line –

reassurance

Do not give immediate or back-up antibiotics to women with no or only 1 key diagnostic sign or symptom (dysuria, new nocturia, cloudy-looking urine) and a dipstick test negative for nitrites, leukocytes, and red blood cells, even if they have other severe urinary symptoms (urgency, frequency, visible haematuria, and suprapubic tenderness).[4]

Reassure that a UTI is less likely.
Consider other diagnoses.
Do not send a urine culture.

Give all patients safety-netting advice.

Recommend that patients should contact healthcare services if they have any of the following:[4]

Shivering, chills, and muscle pain
Feeling confused or very drowsy
Not passing urine all day
Vomiting
Blood in the urine
Temperature above 38ºC or below 36ºC
Kidney pain in the back or under the ribs
Worsening UTI symptoms
UTI symptoms are not starting to improve within 48 hours of taking antibiotics.

Practical tip

Think ‘ Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[37][38][39] See Sepsis in adults.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[37][38][40][47] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[41]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[41]
Send urine for culture before giving antibiotics if there are signs or symptoms of sepsis in a patient with suspected UTI.[4]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[39]
- Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
- At risk of neutropenic sepsis.

Immediately (after taking a urine sample for culture) start an antibiotic for upper UTI, taking into account local antimicrobial resistance and following local and national guidelines[4][62]
Refer if signs or symptoms of serious illness (e.g., sepsis)[4]
See Acute pyelonephritis.

Do not treat non-pregnant women who have asymptomatic bacteriuria.[4][2]

Asymptomatic bacteriuria is where culture or microscopy in a urine sample shows the presence of bacteria, without the patient experiencing any symptoms of lower or upper urinary tract infection.[54]
Asymptomatic bacteriuria is not a disease and there is no reduction in morbidity or mortality by treating it.[4]
Growth of bacteria in the urine of an asymptomatic patient is very common and is due to colonisation.[1]
Asymptomatic bacteriuria occurs in:[1]
- 1% to 5% of pre-menopausal women
- 4% to 19% of otherwise healthy elderly women
- 2% to 10% of pregnant women
- 15% to 50% of institutionalised elderly patients.

no catheter in situ: age ≥65 years

severe signs/symptoms and/or high risk of complications

Back

1st line –

immediate empirical antibiotics

Give immediate antibiotics, ideally after sending urine for culture, for women aged ≥65 years with severe symptoms and a likely UTI:[4]

New onset dysuria alone OR
2 or more other severe signs/symptoms of UTI:
- Temperature 1.5ºC above normal in last 12 hours
- New frequency or urgency
- New incontinence
- New or worsening delirium or debility
- New suprapubic pain
- Visible haematuria.

Consider the likelihood of a complicated UTI.

Complicated UTIs include infections in patients with functional or structural impairments that reduce the efficacy of antimicrobial therapy, e.g., abnormalities of the genitourinary tract, the presence of urological obstruction, an underlying condition that interferes with host defence, or recent urological intervention.[1][3][37][2]

Practical tip

Think ‘ Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[37][38][39] See Sepsis in adults.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[37][38][40][47] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[41]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[41]
Send urine for culture before giving antibiotics if there are signs or symptoms of sepsis in a patient with suspected UTI.[4]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[39]
- Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
- At risk of neutropenic sepsis.

Immediately (after taking a urine sample for culture) start an antibiotic for upper UTI, taking into account local antimicrobial resistance and following local and national guidelines[4][62]
Refer if signs or symptoms of serious illness (e.g., sepsis)[4]
See Acute pyelonephritis.

Consider local antimicrobial resistance data.[3] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[3]

For first-choice antibiotic, prescribe:[3]

Nitrofurantoin if eGFR ≥45 mL/minute
- Nitrofurantoin may be used with caution if eGFR is 30 to 44 mL/minute to treat uncomplicated UTI caused by suspected or proven multidrug resistant bacteria, and only if potential benefit outweighs risk.[3]
- Nitrofurantoin is effective against Escherichia coli, the most common causative pathogen in uncomplicated UTIs (70%-95% of patients) with only 0.9% resistance.[65]
Trimethoprim if low risk of resistance
- Risk of resistance is lower if not used in the previous 3 months, if previous urine culture suggests susceptibility (but trimethoprim was not prescribed), and in younger people where local data suggest resistance is low.[3] Higher risk of resistance is more likely with recent use and in older patients in residential facilities.[3]

Nitrofurantoin (if eGFR ≥45 mL/minute and not used as a first choice)
Pivmecillinam
Fosfomycin.

In the community, consider changing antibiotics, or hospital admission, in any patient with worsening signs or symptoms.[4]

Reassess the patient if symptoms worsen rapidly or significantly at any time or do not start to improve within 48 hours of taking an antibiotic.[3]

Take account of:[3]
- Other possible diagnoses
- Any symptoms or signs suggesting a more serious illness or condition (e.g., 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.[3]

Primary options

nitrofurantoin: 100 mg orally (modified-release) twice daily; 50 mg orally (immediate-release) four times daily

trimethoprim: 200 mg orally twice daily

Secondary options

pivmecillinam: 400 mg orally as a single dose, followed by 200 mg three times daily

fosfomycin: 3 g orally as a single dose

Back

Plus –

supportive care and safety-netting

Treatment recommended for ALL patients in selected patient group

Give all patients information on self-care and safety-netting advice, including advice to:[4][3][69]

Drink enough fluids so they do not feel thirsty (aim to drink 6 to 8 glasses per day, including water or decaffeinated, sugar-free drinks)
Take paracetamol or ibuprofen (if appropriate) at regular intervals for pain relief.
- Public Health England recommends the TARGET UTI patient leaflet. TARGET: antibiotic toolkit Opens in new window

Consider delirium management if needed.

Practical tip

The UK’s NICE found no evidence to support the use of cranberry products or urine alkalinising agents to treat lower UTI.[3]

Recommend that patients should contact healthcare services if they have any of the following:[4]

Shivering, chills, and muscle pain
Feeling confused or very drowsy
Not passing urine all day
Vomiting
Blood in the urine
Temperature above 38ºC or below 36ºC
Kidney pain in the back or under the ribs
Worsening UTI symptoms
UTI symptoms are not starting to improve within 48 hours of taking antibiotics.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

1st line – prescription for back-up antibiotics

Back

Consider –

pathogen-targeted antibiotics

Additional treatment recommended for SOME patients in selected patient group

When results of any urine culture and sensitivity testing are available:[3]

Review the choice of antibiotic based on the microbiological results
Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not improving, selecting a narrow-spectrum antibiotic where possible.

Reassess the patient if symptoms worsen rapidly or significantly at any time or do not start to improve within 48 hours of taking an antibiotic.[3]

Take account of:[3]
- Other possible diagnoses
- Any symptoms or signs suggesting a more serious illness or condition (e.g., 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.[3]

In the community, refer patients with lower UTI to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[3]

mild signs/symptoms and low risk of complications

Back

1st line –

prescription for back-up antibiotics

Watch and wait and give a back-up prescription for antibiotics, ideally after sending urine for culture, for women aged ≥65 years with mild symptoms and a likely UTI:[4]

New onset dysuria alone OR
2 or more other severe signs/symptoms of UTI:
- Temperature 1.5ºC above normal in last 12 hours
- New frequency or urgency
- New incontinence
- New or worsening delirium or debility
- New suprapubic pain
- Visible haematuria.

In the community, refer patients with lower UTI to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[3]

Practical tip

Think ‘ Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[37][38][39] See Sepsis in adults.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[37][38][40][47] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[41]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[41]
Send urine for culture before giving antibiotics if there are signs or symptoms of sepsis in a patient with suspected UTI.[4]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[39]
- Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
- At risk of neutropenic sepsis.

Immediately (after taking a urine sample for culture) start an antibiotic for upper UTI, taking into account local antimicrobial resistance and following local and national guidelines[4][62]
Refer if signs or symptoms of serious illness (e.g., sepsis)[4]
See Acute pyelonephritis.

Consider the likelihood of a complicated UTI.

Complicated UTIs include infections in patients with functional or structural impairments that reduce the efficacy of antimicrobial therapy, e.g., abnormalities of the genitourinary tract, the presence of urological obstruction, an underlying condition that interferes with host defence, or recent urological intervention.[1][3][37][2]

Consider local antimicrobial resistance data.[3] Follow your local protocol or take advice from microbiology. However, NICE recommends the following.[3]

For first-choice antibiotic, prescribe:[3]

Nitrofurantoin if eGFR ≥45 mL/minute
- Nitrofurantoin may be used with caution if eGFR is 30 to 44 mL/minute to treat uncomplicated UTI caused by suspected or proven multidrug resistant bacteria, and only if potential benefit outweighs risk.[3]
- Nitrofurantoin is effective against Escherichia coli, the most common causative pathogen in uncomplicated UTIs (70%-95% of patients) with only 0.9% resistance.[65]
Trimethoprim if low risk of resistance
- Risk of resistance is lower if not used in the previous 3 months or if previous urine culture suggests susceptibility (but trimethoprim was not prescribed). Higher risk of resistance is more likely with recent use and in older patients in residential facilities.[3]

Nitrofurantoin (if eGFR ≥45 mL/minute and not used as a first choice)
Pivmecillinam
Fosfomycin.

Reassess the patient if symptoms worsen rapidly or significantly at any time or do not start to improve within 48 hours of taking an antibiotic.[3]

Take account of:[3]
- Other possible diagnoses
- Any symptoms or signs suggesting a more serious illness or condition (e.g., 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.[3]

Watch and wait and investigate other causes in women ≥65 years in whom UTI is less likely:[4]

No new onset dysuria OR fewer than 2 of the following symptoms:
- Temperature 1.5ºC above normal in last 12 hours
- New frequency or urgency
- New incontinence
- New or worsening delirium or debility
- New suprapubic pain
- Visible haematuria.
No apparent causes of delirium (using the PINCH ME criteria - pain, other infection, poor nutrition, constipation, poor hydration, other medications, environment change).
Fewer than 2 localised signs/symptoms of infection (respiratory, skin/ soft tissue, or gastrointestinal).

Primary options

nitrofurantoin: 100 mg orally (modified-release) twice daily; 50 mg orally (immediate-release) four times daily

trimethoprim: 200 mg orally twice daily

Secondary options

pivmecillinam: 400 mg orally as a single dose, followed by 200 mg three times daily

fosfomycin: 3 g orally as a single dose

Back

Plus –

supportive care and safety-netting

Treatment recommended for ALL patients in selected patient group

Give all patients information on self-care and safety-netting advice, including advice to:[4][3][69]

Drink enough fluids so they do not feel thirsty (aim to drink 6 to 8 glasses per day, including water or decaffeinated, sugar-free drinks)
Take paracetamol or ibuprofen (if appropriate) at regular intervals for pain relief.
- Public Health England recommends the TARGET UTI patient leaflet. TARGET: antibiotic toolkit Opens in new window

Practical tip

The UK’s NICE found no evidence to support the use of cranberry products or urine alkalinising agents to treat lower UTI.[3]

Consider delirium management if needed.

Recommend that patients should contact healthcare services if they have any of the following:[4]

Shivering, chills, and muscle pain
Feeling confused or very drowsy
Not passing urine all day
Vomiting
Blood in the urine
Temperature above 38ºC or below 36ºC
Kidney pain in the back or under the ribs
Worsening UTI symptoms
UTI symptoms are not starting to improve within 48 hours of taking antibiotics.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Back

Consider –

pathogen-targeted antibiotics

Additional treatment recommended for SOME patients in selected patient group

When results of any urine culture and sensitivity testing are available:[3]

Review the choice of antibiotic based on the microbiological results
Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not improving, selecting a narrow-spectrum antibiotic where possible.

Reassess the patient if symptoms worsen rapidly or significantly at any time or do not start to improve within 48 hours of taking an antibiotic.[3]

Take account of:[3]
- Other possible diagnoses
- Any symptoms or signs suggesting a more serious illness or condition (e.g., 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.[3]

In the community, refer patients with lower UTI to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[3]

no catheter in situ: pregnant

Back

1st line –

immediate empirical antibiotics

Prescribe an immediate antibiotic, after sending urine for culture, for all pregnant women with symptoms of a UTI.

Take into account previous urine culture and susceptibility results.
Consider previous antibiotic use, which may have caused resistance.[3]

Prescribe an immediate antibiotic for all pregnant women with asymptomatic bacteriuria (>10 ⁵ CFU/mL).[3]

Take into account previous urine culture and susceptibility results.
Consider previous antibiotic use, which may have caused resistance.[3]

In the community, refer patients to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[3]

Practical tip

Think ‘ Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[37][38][39] See Sepsis in adults.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[37][38][40][47] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[41]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[41]
Send urine for culture before giving antibiotics if there are signs or symptoms of sepsis in a patient with suspected UTI.[4]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[39]
- Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
- At risk of neutropenic sepsis.

Immediately (after taking a urine sample for culture) start an antibiotic for upper UTI, taking into account local antimicrobial resistance and following local and national guidelines[4][62]
Refer if signs or symptoms of serious illness (e.g., sepsis)[4]
See Acute pyelonephritis.

Consider local antimicrobial resistance data.[3] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[3]

For first-choice antibiotic, prescribe:[3]

Nitrofurantoin if eGFR ≥45 mL/minute
- Avoid nitrofurantoin if the pregnancy is at term; may cause neonatal haemolysis.
- Nitrofurantoin may be used with caution if eGFR is 30 to 44 mL/minute to treat uncomplicated UTI caused by suspected or proven multidrug resistant bacteria, and only if potential benefit outweighs risk.[3]

Amoxicillin (only if culture results are available and sensitivities show susceptibility)
Cefalexin
Alternative second choices after consulting microbiology, which should be based on culture and sensitivity results.

For women with asymptomatic bacteriuria prescribe nitrofurantoin (if eGFR ≥45 mL/minute; avoid at term), amoxicillin, or cefalexin based on recent culture and susceptibility results.[3]

Prescribe the shortest course that is likely to be effective to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects.[3] NICE recommends a 7-day course of all the recommended antibiotics to treat bacteriuria in pregnant women with either symptomatic lower UTI or asymptomatic bacteriuria.[3]

Reassess the patient if symptoms worsen rapidly or significantly at any time or do not start to improve within 48 hours of taking an antibiotic.[3]

Take account of:[3]
- Other possible diagnoses
- Any symptoms or signs suggesting a more serious illness or condition (e.g., 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.[3]

Primary options

nitrofurantoin: 100 mg orally (modified-release) twice daily; 50 mg orally (immediate-release) four times daily

Secondary options

amoxicillin: 500 mg orally three times daily

cefalexin: 500 mg orally twice daily

Back

Plus –

supportive care and safety-netting

Treatment recommended for ALL patients in selected patient group

Give all patients information on self-care and safety-netting advice, including advice to:[4][3][69]

Drink enough fluids so they do not feel thirsty (aim to drink 6 to 8 glasses per day, including water or decaffeinated, sugar-free drinks)
Take paracetamol at regular intervals for pain relief.
- Public Health England recommends the TARGET UTI patient leaflet. TARGET: antibiotic toolkit Opens in new window

Practical tip

The UK’s NICE found no evidence to support the use of cranberry products or urine alkalinising agents to treat lower UTI.[3]

Recommend that patients should contact healthcare services if they have any of the following:[4]

Shivering, chills, and muscle pain
Feeling confused or very drowsy
Not passing urine all day
Vomiting
Blood in the urine
Temperature above 38ºC or below 36ºC
Kidney pain in the back or under the ribs
Worsening UTI symptoms
UTI symptoms are not starting to improve within 48 hours of taking antibiotics.

Consider the risk of preterm delivery in pregnant women as this is associated with UTI in pregnancy.[42]

Call the on-call obstetric team for advice if there are any signs of preterm labour such as abdominal pain, vaginal bleeding, or premature rupture of the membranes.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

catheter in situ

non-pregnant: symptomatic without upper UTI signs/symptoms

Plus – check catheter for blockage ± change or remove catheter

Back

1st line –

immediate empirical antibiotics

Send a urine sample for culture and susceptibility testing, noting a suspected catheter-associated infection, before prescribing any antibiotic.[57]

Drain a few mLs of residual urine from the catheter tubing before using the sampling port, then collect a fresh sample from the catheter sampling port using aseptic technique.[4][57]
If the catheter has been changed, obtain the sample from the new catheter.[57]

Prescribe an antibiotic to women with symptomatic catheter-associated UTI, taking account of:[57]

Severity of symptoms
Risk of developing complications (higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression)
Previous urine culture and susceptibility results
Previous antibiotic use (may have led to resistant bacteria).

Refer patients with catheter-associated UTI in the community to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[57]

Practical tip

Think ‘ Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[37][38][39] See Sepsis in adults.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[37][38][40][47] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[41]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[41]
Send urine for culture before giving antibiotics if there are signs or symptoms of sepsis in a patient with suspected UTI.[4]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[39]
- Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
- At risk of neutropenic sepsis.

Immediately (after taking a urine sample for culture) start an antibiotic for upper UTI, taking into account local antimicrobial resistance and following local and national guidelines[4][62]
If the patient has had a urinary catheter for more than 7 days, consider changing (or if possible removing) it as soon as possible, but do not delay antibiotics[4]
- Seek senior urological input before changing a suprapubic catheter
Refer if signs or symptoms of serious illness (e.g., sepsis)[4]
See Acute pyelonephritis.

Consider seeking specialist advice, or in the community referring to hospital, for people with catheter associated UTI if they:[57]

Are significantly dehydrated or unable to take oral fluids and medicines
Have a higher risk of developing complications (e.g., people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease [such as diabetes or immunosuppression])
Have recurrent catheter-associated UTI
Have bacteria that are resistant to oral antibiotics.

Do not prescribe antibiotics for asymptomatic bacteriuria in patients with a catheter.[57]

Consider local antimicrobial resistance data.[57] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[57]

For first-choice antibiotic, prescribe:[57]

Nitrofurantoin if eGFR ≥45 mL/minute
- Nitrofurantoin is licensed only for uncomplicated UTIs and is not suitable for patients with upper UTI symptoms or a blocked catheter.[57]
- Nitrofurantoin may be used with caution if eGFR is 30 to 44 mL/minute to treat uncomplicated UTI caused by suspected or proven multidrug resistant bacteria, and only if potential benefit outweighs risk.
Trimethoprim if low risk of resistance[57]
- Risk of resistance is lower if not used in the previous 3 months or if previous urine culture suggests susceptibility (but trimethoprim was not prescribed). Higher risk of resistance is more likely with recent use and in older patients in residential facilities.[57]
Amoxicillin if culture results are available and causative organism is susceptible.[57]

For second-choice antibiotic (when first-choice not suitable).[57]

Pivmecillinam
- Pivmecillinam is licensed only for uncomplicated UTIs and is not suitable for patients with upper UTI symptoms or a blocked catheter.[57]

Practical tip

Catheter-associated UTIs are often associated with resistant bacteria.[57]

UTI is the most common healthcare-acquired infection, accounting for 19% of all healthcare-associated infections, with around half of these infections due to an indwelling urinary catheter.[57]

Prescribe at least a 7-day course of antibiotics to ensure complete cure.[57]

Patients with a catheter are more at risk of complications from UTI than those without a catheter.[57]

Reassess patients with catheter-associated UTI if symptoms worsen at any time, or do not start to improve within 48 hours of taking an antibiotic, taking account of any symptoms or signs suggesting a more serious illness or condition, such as sepsis.[57]

In longer term management, assess the ongoing need for the catheter. Consider alternatives or a trial without a catheter, if possible.[2]

Primary options

nitrofurantoin: 100 mg orally (modified-release) twice daily; 50 mg orally (immediate-release) four times daily

trimethoprim: 200 mg orally twice daily

amoxicillin: 500 mg orally three times daily

Secondary options

pivmecillinam: 400 mg orally as a single dose, followed by 200 mg three times daily

Plus – supportive care

Back

Consider –

pathogen-targeted antibiotics

Additional treatment recommended for SOME patients in selected patient group

When results of any urine culture and sensitivity testing are available:[57]

Review the choice of antibiotic based on the microbiological results
Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not improving, selecting a narrow-spectrum antibiotic where possible.

Prescribe at least a 7-day course of antibiotics to ensure complete cure.[57]

Patients with a catheter are more at risk of complications from UTI than those without a catheter.[57]

In longer term management, assess the ongoing need for the catheter. Consider alternatives or a trial without a catheter, if possible.[2]

non-pregnant: symptomatic with upper UTI signs/symptoms

Plus – check catheter for blockage ± change or remove catheter

Back

1st line –

immediate empirical antibiotics

Send a urine sample for culture and susceptibility testing, noting a suspected catheter-associated infection, before prescribing any antibiotic.[57]

Drain a few mLs of residual urine from the catheter tubing before using the sampling port, then collect a fresh sample from the catheter sampling port using an aseptic technique.[4][57]
If the catheter has been changed, obtain the sample from the new catheter.[57]

Prescribe an antibiotic to women with symptomatic catheter-associated UTI, taking account of:[57]

Severity of symptoms
Risk of developing complications (higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression)
Previous urine culture and susceptibility results
Previous antibiotic use (may have led to resistant bacteria).

In the community, refer patients with catheter-associated UTI to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[57]

Practical tip

Think ‘ Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[37][38][39] See Sepsis in adults.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[37][38][40][47] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[41]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[41]
Send urine for culture before giving antibiotics if there are signs or symptoms of sepsis in a patient with suspected UTI.[4]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[39]
- Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
- At risk of neutropenic sepsis.

Immediately (after taking a urine sample for culture) start an antibiotic for upper UTI, taking into account local antimicrobial resistance and following local and national guidelines[4][62]
If the patient has had a urinary catheter for more than 7 days, consider changing (or if possible removing) it as soon as possible, but do not delay antibiotics[4]
- Seek senior urological input before changing a suprapubic catheter
Refer if signs or symptoms of serious illness (e.g., sepsis)[4]
See Acute pyelonephritis.

Consider seeking specialist advice, or in the community referring to hospital, for people with catheter associated UTI if they:[57]

Are significantly dehydrated or unable to take oral fluids and medicines
Have a higher risk of developing complications (e.g., people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease [such as diabetes or immunosuppression])
Have recurrent catheter-associated UTI
Have bacteria that are resistant to oral antibiotics.

Do not prescribe antibiotics for asymptomatic bacteriuria in patients with a catheter.[57]

Consider local antimicrobial resistance data.[57] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[57]

For first-choice oral antibiotic, prescribe:[57]

Cefalexin
Amoxicillin/clavulanate (if culture results are available and the causative agent is susceptible)
Trimethoprim (if culture results are available and the causative agent is susceptible)
Ciprofloxacin.

For first-choice intravenous antibiotic, in patients who are vomiting, are unable to take oral antibiotics, or are severely unwell, prescribe (antibiotics may be combined if susceptibility or sepsis is a concern):[57]

Amoxicillin/clavulanate (only in combination unless culture results confirm susceptibility)
Cefuroxime
Ceftriaxone
Ciprofloxacin
Gentamicin
Amikacin

Consider referring or admitting the patient to hospital if intravenous antibiotics are required.

Consider safety issues with fluoroquinolones such as ciprofloxacin.

In November 2018, the European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.

As a consequence of this review, the EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, they recommend that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided.[67] The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations.[68]
Consult with a microbiologist about whether a fluoroquinolone is an appropriate option for your patient.

Therapeutic drug monitoring and assessment of renal function is required with gentamicin and amikacin.

Consult microbiology if a second-choice antibiotic is required, or when combining antibiotics if susceptibility or sepsis is a concern.[57]

Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.[57]

Practical tip

Catheter-associated UTIs are often associated with resistant bacteria.[57]

UTI is the most common healthcare-acquired infection, accounting for 19% of all healthcare-associated infections, with around half of these infections due to an indwelling urinary catheter.[57]

Prescribe at least a 7-day course of antibiotics to ensure complete cure.[57]

Patients with a catheter are more at risk of complications from UTI than those without a catheter.[57]

In longer term management, assess the ongoing need for the catheter. Consider alternatives or a trial without a catheter, if possible.[2]

Primary options

cefalexin: 500 mg orally two to three times daily, may increase up to 1000-1500 mg three or four times daily for severe infections

amoxicillin/clavulanate: 500/125 mg orally three times daily

trimethoprim: 200 mg orally twice daily

ciprofloxacin: 500 mg orally twice daily

Secondary options

amoxicillin/clavulanate: 1.2 g intravenously every 8 hours

cefuroxime: 750-1500 mg intravenously every 6-8 hours

ceftriaxone: 1-2 g intravenously every 24 hours

ciprofloxacin: 400 mg intravenously every 8-12 hours

gentamicin: 5-7 mg/kg intravenously every 24 hours

amikacin: 15 mg/kg intravenously every 24 hours, maximum 1.5 g/day and 15 g/treatment course

Plus – supportive care

Plus – pathogen-targeted antibiotics

Back

Plus –

pathogen-targeted antibiotics

Treatment recommended for ALL patients in selected patient group

When results of any urine culture and sensitivity testing are available:[57]

Review the choice of antibiotic based on the microbiological results
Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not improving, selecting a narrow-spectrum antibiotic where possible.

Prescribe at least a 7-day course of antibiotics to ensure complete cure.[57]

Patients with a catheter are more at risk of complications from UTI than those without a catheter.[57]

In longer term management, assess the ongoing need for the catheter. Consider alternatives or a trial without a catheter, if possible.[2]

pregnant

Plus – check catheter for blockage ± change or remove catheter

Back

1st line –

immediate empirical antibiotics

Send a urine sample for culture and susceptibility testing, noting a suspected catheter-associated infection, before prescribing any antibiotic.[57]

Drain a few mLs of residual urine from the catheter tubing before using the sampling port, then collect a fresh sample from the catheter sampling port using aseptic technique.[4][57]
If the catheter has been changed, obtain the sample from the new catheter.[57]

Prescribe an antibiotic to women with symptomatic catheter-associated UTI, taking account of:[57]

Severity of symptoms
Risk of developing complications (higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression)
Previous urine culture and susceptibility results
Previous antibiotic use (may have led to resistant bacteria).

In the community, refer patients with catheter-associated UTI to hospital if they have any signs or symptoms suggesting a more serious illness or condition, such as sepsis.[57]

Practical tip

Think ‘ Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[37][38][39] See Sepsis in adults.

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[37][38][40][47] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[41]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[41]
Send urine for culture before giving antibiotics if there are signs or symptoms of sepsis in a patient with suspected UTI.[4]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[39]
- Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
- At risk of neutropenic sepsis.

Immediately (after taking a urine sample for culture) start an antibiotic for upper UTI, taking into account local antimicrobial resistance and following local and national guidelines[4][62]
If the patient has had a urinary catheter for more than 7 days, consider changing (or if possible removing) it as soon as possible, but do not delay antibiotics[4]
- Seek senior urological input before changing a suprapubic catheter
Refer if signs or symptoms of serious illness (e.g., sepsis)[4]
See Acute pyelonephritis.

Consider seeking specialist advice, or in the community referring to hospital, for people with catheter associated UTI if they:[57]

Are significantly dehydrated or unable to take oral fluids and medicines
Are pregnant
Have a higher risk of developing complications (e.g., people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease [such as diabetes or immunosuppression])
Have recurrent catheter-associated UTI
Have bacteria that are resistant to oral antibiotics.

Consider local antimicrobial resistance data.[57] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[57]

For first-choice oral antibiotic, prescribe cefalexin.[57]

Consider referring or admitting the patient to hospital for intravenous antibiotics.

For first-choice intravenous antibiotic, in patients who are vomiting, are unable to take oral antibiotics, or are severely unwell, prescribe cefuroxime.[57]

Consult microbiology if a second-choice antibiotic is required, or when combining antibiotics if susceptibility or sepsis is a concern.[57]

Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.[57]

Practical tip

Catheter-associated UTIs are often associated with resistant bacteria.[57]

UTI is the most common healthcare-acquired infection, accounting for 19% of all healthcare-associated infections, with around half of these infections due to an indwelling urinary catheter.[57]

Prescribe at least a 7-day course of antibiotics to ensure complete cure.[57]

Patients with a catheter are more at risk of complications from UTI than those without a catheter.[57]

In longer term management, assess the ongoing need for the catheter. Consider alternatives or a trial without a catheter, if possible.[2]

Primary options

cefalexin: 500 mg orally two to three times daily, may increase up to 1000-1500 mg three or four times daily for severe infections

Secondary options

cefuroxime: 750-1500 mg intravenously every 6-8 hours

Plus – supportive care