Recommendations
Urgent
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 for assessment; urgently consult a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis.[37][39][40][41]
Refer to local guidelines for the recommended approach at your institution for assessment and management of the patient with suspected sepsis.
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.
For patients with new signs and symptoms of pyelonephritis:
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.
Key Recommendations
Give immediate antibiotics to all pregnant women with likely UTI.
Take into account urine culture/susceptibility results and previous use of antibiotics which may have led to resistant bacteria.[3][57]
Give immediate antibiotics to non-pregnant women with likely UTI based on severity of symptoms.[4][3][57]
Take into account the risk of complications, urine culture/susceptibility results, previous use of antibiotics which may have led to resistant bacteria, and patient preference when considering whether to give immediate antibiotics.[3][57]
Consider giving a back-up prescription instead of immediate antibiotics to non-pregnant women with a likely UTI and mild symptoms.[4]
Advise the patient to use the back-up prescription if symptoms do not start to improve within 48 hours or if they worsen at any time.[57]
Advise women about supportive self-care and when to seek further help.[4][3][2]
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.
For patients with new signs and symptoms of pyelonephritis (kidney pain/tenderness in the back or under the ribs, new or different myalgia or flu-like symptoms, nausea or vomiting, rigors, or a temperature over 37.9ºC (or ≤36ºC in women aged over 65 years):
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.
Initial management
Give immediate antibiotics for women with severe symptoms who have:
2 or 3 of the key diagnostic signs and symptoms for UTI (dysuria, new nocturia, cloudy-looking urine) OR
1 key diagnostic sign or symptom AND
A urine dipstick positive for nitrite OR
A urine dipstick positive for leukocytes and negative for nitrite OR
A urine dipstick positive for both leukocytes and red blood cells.[4]
No key diagnostic signs or symptoms but other severe urinary symptoms AND
A urine dipstick positive for nitrite OR
A urine dipstick positive for leukocytes and negative for nitrites OR
A urine dipstick positive for both leukocytes and red blood cells.
Watch and wait and provide a back-up prescription for antibiotics for women with mild symptoms who have:
2 or 3 of the key diagnostic signs and symptoms for UTI (dysuria, new nocturia, cloudy-looking urine) OR
1 key diagnostic sign or symptom AND
A urine dipstick positive for nitrite OR
A urine dipstick positive for leukocytes and negative for nitrite OR
A urine dipstick positive for both leukocytes and red blood cells.[4]
No key diagnostic signs or symptoms but other mild urinary symptoms AND
A urine dipstick positive for nitrite OR
A urine dipstick positive for leukocytes and negative for nitrites OR
A urine dipstick positive for both leukocytes and red blood cells.
As well as symptom severity, base your decision for giving immediate or back-up antibiotics on:[3]
Risk of complications
Previous urine culture and susceptibility results
Previous antibiotic use, which may have led to resistant bacteria
Patient preference.
More info: Non-steroidal anti-inflammatory drugs (NSAIDs) as an alternative first-line treatment
The Scottish Intercollegiate Guidelines Network (SIGN) guideline on management of suspected bacterial lower urinary tract infection in adult women recommends considering NSAIDs as a first-line treatment in women aged under 65 with mild symptoms.[2]
This offers an alternative to antibiotics in order to reduce antibiotic prescribing.
Consider and discuss with the patient the risks and benefits if considering this approach.
Limit the duration to 3 days and ask the patient to make contact if the symptoms do not resolve or worsen in this time. [2]
Advise patients to use the back-up antibiotics if the symptoms do not start to improve within 48 hours or if they worsen at any time.[3]
Evidence: Back-up versus immediate antibiotic prescriptions
Back-up prescriptions for women with acute uncomplicated UTI seem to be as effective as immediate prescriptions (measured by severity of symptoms, duration of symptoms, and time to reconsultation) and reduce the number of women using antibiotics.
The evidence for back-up antibiotics in the treatment of lower UTIs was reviewed by the UK National Institute for Health and Care Excellence (NICE) for its guideline on antimicrobial prescribing for lower UTI.[3] It found one open-label randomised controlled trial of 309 non-pregnant women (age 18-70 years, mean 39-45 years) with suspected lower UTI.[63]
Most women had moderate symptoms at baseline and 82% to 87% had a history of at least one previous episode of cystitis.
The trial had five arms:
Immediate antibiotics (control group)
Back-up antibiotics
Three different targeted antibiotic groups (based on midstream urine culture, dipstick results, or symptom score).
Immediate antibiotics consisted of a 3-day course of trimethoprim (cefaclor or cefalexin in women allergic to trimethoprim).
In the group receiving back-up antibiotics, women were advised to drink plenty, and offered a prescription if symptoms did not improve after 48 hours. Urine culture was only mandatory in the midstream urine group and two-thirds of women in this group had a confirmed UTI. Women in the other groups could have urine culture depending on the treating doctor’s decision: the proportion tested was 23% in the immediate group versus 15% in the back-up group; however, the number of confirmed UTIs was not reported.
There was no significant difference between back-up prescription and immediate antibiotic prescribing in:
Mean frequency symptom severity reported 2 to 4 days after seeing the healthcare professional (mean difference -0.04, 95% CI -0.47 to +0.40; low-quality evidence assessed using GRADE)
Duration of moderately bad symptom days (3.96 days with back-up vs. 3.54 days with immediate; incidence ratio 1.12, 95% CI 0.85 to 1.47; GRADE very low)
Time to reconsultation (HR 0.60, 95% CI 0.35 to 1.05; GRADE very low).
In additional analyses by NICE, women prescribed immediate antibiotics were significantly more likely to use antibiotics (41/53 with back-up vs. 58/60 with immediate; RR 1.25, 95% CI 1.07 to 1.46; GRADE very low) and they were also significantly less likely to wait 48 hours before taking antibiotics compared with women prescribed back-up antibiotics (28/53 with back-up vs. 5/60 with immediate; RR 0.16, 95% CI 0.07 to 0.38; GRADE low).
Women in all groups delayed starting their antibiotics for 24 hours (mean 2.21 days in back-up group versus 1.19 days in the immediate group; GRADE very low). Delaying by more than 48 hours was associated with a longer duration of moderately bad symptoms. However this was only significant in the midstream urine group (back-up vs. immediate: incidence ratio 1.22, 95% CI 0.88 to 1.68; GRADE very low).
Evidence: Antibiotic effectiveness in uncomplicated lower UTI
Antibiotics are more effective than placebo at treating uncomplicated lower UTI in women as assessed by symptom resolution after treatment, microbiological success at the end of treatment, and reduced re-infection/relapse rates. Although adverse events may occur more frequently with antibiotics, they seem to be well tolerated.
An evidence review by the UK National Institute for Health and Care Excellence (NICE) for its guideline on antimicrobial prescribing for lower UTI found one systematic review comparing antibiotics with placebo.[3][64]
The systematic review included five randomised controlled trials (RCTs) with a total of 1407 non-pregnant women (age 15-84 years), most with mild to moderate symptoms of lower UTI (uncomplicated cystitis) and all confirmed by dipstick and/or laboratory culture.
The antibiotics included: pivmecillinam, nitrofurantoin, cefixime, trimethoprim/sulfamethoxazole, ofloxacin, and amoxicillin.
Two of the studies included arms looking at different doses of the antibiotic. The duration of antibiotics varied between studies from a single dose (two studies) to 7 days (two studies); the remaining study examined a 3-day course. Follow-up ranged from 3 days from starting treatment to 3 months after the end of treatment.
The review found:
Antibiotics significantly increased complete symptom resolution after treatment compared with placebo (4 RCTs, n=1062; 61.8% vs. 25.7%; additional analysis by NICE: RR 2.26 [95% CI 1.79 to 2.86]; NNT 3 [95% CI 3 to 4]; high-quality evidence as assessed by GRADE).
Antibiotics also significantly increased microbiological success (defined as negative urine culture) at the end of treatment (3 RCTs, n=967; 90% vs. 33.3%; additional analysis by NICE: RR 2.49 [95% CI 1.64 to 3.78]; NNT 2 [95% CI 2 to 2]; GRADE moderate). However, this was no longer significant after the end of treatment (RR 1.79, 95% CI 0.99 to 3.22; GRADE low).
Compared with placebo, antibiotics significantly reduced microbiological reinfection or relapse after the end of treatment (5 RCTs, n=742; 15.8% vs. 41.6%; additional analysis by NICE: RR 0.42, 95% CI 0.28 to 0.64; GRADE moderate).
There was no significant difference in the incidence of pyelonephritis between groups (2 RCTs, n=742; 0.21% vs. 0.75%; additional analysis by NICE: RR 0.42, 95% CI 0.05 to 3.37; GRADE low). However, it is likely the studies were underpowered to detect any clinically important difference for this outcome.
Adverse events were more frequent with antibiotics than placebo (4 RCTs, n=1068; 19.2% vs. 12.9%; additional analysis by NICE: RR 1.49, 95% CI 1.06 to 2.08; GRADE moderate). However, there was no significant difference in withdrawals due to adverse events (GRADE low).
There was no significant difference in the emergence of resistance (5 RCTs, n=962; absolute figures not reported; OR 0.33, 95% CI 0.40 to 2.70; GRADE low).
Do not give immediate or back-up antibiotics to women with no key diagnostic signs or symptoms and a dipstick test negative for nitrites, leukocytes, and red blood cells even if they have other severe urinary symptoms.[4]
Reassure that a UTI is less likely.
Consider other diagnoses.
Do not send a urine culture.
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.
Choice of antibiotic
Consider local antimicrobial resistance data.[3] Follow your local protocol or take advice from microbiology. However in the UK, the National Institute for Health and Care Excellence (NICE) recommends the following.[3]
Empirical antibiotics
For first-choice antibiotic, prescribe:[3]
Nitrofurantoin if estimated glomerular filtration rate (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]
For second-choice antibiotic, where patients have shown no improvement in lower UTI symptoms after taking a first-choice antibiotic for at least 48 hours or if the first choice is not suitable, prescribe:[3]
Nitrofurantoin (if eGFR ≥45 mL/minute and not used as a first choice)
Pivmecillinam
Fosfomycin.
Pathogen-targeted antibiotics
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.
Duration of treatment
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 3-day course of all the recommended antibiotics (apart from fosfomycin where a single dose is given).[3]
The NICE antimicrobial prescribing guideline committee agreed, based on evidence, that a 3-day course of antibiotics was as effective as a 5- to 10-day course of antibiotics in non-pregnant women with lower UTI, and resulted in significantly fewer adverse events.[3]
It agreed, based on evidence, that a longer course may increase the likelihood of complete bacteriological eradication, which may be important for some women (e.g., women who have recurrent lower UTIs).[3]
Ongoing management
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]
When to refer
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]
Initial management
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.
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.
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).
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 delirium management if needed.[4]
Consider starting or changing antibiotics, or hospital admission if in the community, in any patient with worsening signs or symptoms.[4]
Choice of antibiotic
Consider local antimicrobial resistance data.[3] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[3]
Empirical antibiotics
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.
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 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.
For second-choice antibiotic, where patients have shown no improvement in lower UTI symptoms after taking a first-choice antibiotic for at least 48 hours, or if the first choice is not suitable, prescribe:
Nitrofurantoin (if eGFR ≥45 mL/minute and not used as a first choice)
Pivmecillinam
Fosfomycin.
Pathogen-targeted antibiotics
When results of 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.
Duration of treatment
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 3-day course of all the recommended antibiotics (apart from fosfomycin where a single dose is given).[3]
The NICE antimicrobial prescribing guideline committee agreed, based on evidence, that a 3-day course of antibiotics was as effective as a 5- to 10-day course of antibiotics in non-pregnant women with lower UTI, and resulted in significantly fewer adverse events.[3]
It agreed, based on evidence, that a 7- to 10-day course of antibiotics did not offer any clinical advantage over a 3- to 6-day course in older women with lower UTI.[3]
It agreed, based on evidence, that a longer course may increase the likelihood of complete bacteriological eradication, which may be important for some women (e.g., women who have recurrent lower UTIs).[3]
Ongoing management
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]
When to refer
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]
Initial management
Prescribe an immediate antibiotic, after sending urine for culture, for all pregnant women with symptoms of a UTI.[4][3]
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]
Choice of antibiotic
Consider local antimicrobial resistance data.[3] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[3]
Empirical antibiotics
For first-choice antibiotic in women with symptoms of a UTI, 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.
For second-choice antibiotic, where patients have shown no improvement in lower UTI symptoms after taking a first-choice antibiotic for at least 48 hours, or if the first choice is not suitable, prescribe:[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]
Pathogen-targeted antibiotics
Review the antibiotic when the urine culture results are available and change the antibiotic if the sensitivities indicate resistance.[3]
Use a narrow spectrum antibiotic if possible.
Duration of treatment
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]
NICE states that a 7-day course is required (compared with a 3-day course in non-pregnant women) to ensure complete cure because the risk of harm from a UTI is higher in pregnant women than in non-pregnant women.[3]
Ongoing management
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]
When to refer
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]
Initial management
Check for catheter blockage in women with a catheter where UTI is likely.[4]
A UTI is likely if there is new onset dysuria alone or 2 or more other 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).[4]
Consider removing or, if this cannot be done, changing the catheter as soon as possible if a woman with likely UTI has had a catheter for more than 7 days. Do not allow catheter removal to delay antibiotic treatment.[4][57]
Seek senior urological input before changing or removing a suprapubic catheter.
After insertion of a suprapubic catheter, the tract takes up to 4 weeks to establish or ‘mature’.[66]
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).
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]
Do not prescribe antibiotics for asymptomatic bacteriuria in patients with a catheter.[57]
Choice of antibiotic: catheter-associated UTI and no upper UTI symptoms
Consider local antimicrobial resistance data.[57] Follow your local protocol or take advice from microbiology. However, in the UK NICE recommends the following.[57]
Empirical antibiotics
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]
Pathogen-targeted antibiotics
When results of 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.
Choice of antibiotic: catheter-associated UTI with upper UTI symptoms
Empirical antibiotics
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 (see More info panel below). Therapeutic drug monitoring and assessment of renal function is required with gentamicin and amikacin.
More info: EMA and MHRA restrictions on the use of fluoroquinolone antibiotics
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.
Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.[57]
Consult microbiology if a second-choice antibiotic is required, or when combining antibiotics if susceptibility or sepsis is a concern.[57]
Pathogen-targeted antibiotics
When results of 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.
Choice of antibiotic: pregnant women with catheter-associated UTI
For first-choice oral antibiotic prescribe cefalexin.[57]
Consider referring or admitting the patient to hospital if intravenous antibiotics are required.
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]
Ongoing management
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]
When to seek specialist advice or refer
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]
Consider seeking specialist advice, or if 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., with 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.
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] In addition, one randomised controlled trial in the NICE evidence review found that cranberry juice was not effective in preventing episodes of asymptomatic bacteriuria or UTI in healthy pregnant women.[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.
Patients with a catheter
Advise patients with catheter-associated UTI to:[57]
Take paracetamol for managing pain associated with a UTI
Drink enough fluids to avoid dehydration
Seek medical help if:[57]
Symptoms worsen at any time
Symptoms do not start to improve within 48 hours of taking an antibiotic
The patient becomes systemically very unwell.
Ask patients to check that the catheter is draining.
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