UTI (lower): antimicrobial prescribing

? With all antibiotic prescriptions, advise:

Background
• possible adverse effects of antibiotics
include diarrhoea and nausea • Lower UTI (cystitis) is a bladder
Consider a back-up antibiotic infection usually caused by bacteria
• seeking medical help if symptoms
prescription or immediate antibiotic, travelling up to the urethra from the
worsen at any time, do not improve
Non-pregnant noting that the evidence for back-up gastrointestinal tract
within 48 hours of taking the antibiotic,
woman antibiotics was from women not
or the person becomes very unwell
needing immediate treatment
With a back-up antibiotic prescription,
Self-care
also advise:
• Advise paracetamol for pain or, if
• antibiotic is not needed immediately preferred and suitable, ibuprofen
• use prescription if no improvement in • Advise drinking enough fluid
48 hours or symptoms worsen at any time to avoid dehydration
Lower urinary tract infection (UTI)

If urine sent for culture and susceptibility, • No evidence found for cranberry
and antibiotic given: products or urine alkalinising
agents to treat lower UTI
• review antibiotic choice when results
available, and
Reassess at any time if symptoms worsen Antibiotics
• change antibiotic for pregnant women if
Give advice about rapidly or significantly or do not improve
bacteria resistant
managing symptoms in 48 hours of taking antibiotics, sending a
• When considering antibiotics, take
with self-care • change antibiotic for children and young urine sample for culture and susceptibility
account of severity of symptoms,
people, men and non-pregnant women if if not already done. Take account of: risk of complications, previous urine
bacteria resistant and symptoms culture and susceptibility results,
• other possible diagnoses
not improving previous antibiotic use which may
• any symptoms or signs suggesting a
Use a narrow spectrum antibiotic have led to resistant bacteria and
more serious illness or condition local antimicrobial resistance data
when possible
• previous antibiotic use, which
may have led to resistance
Asymptomatic bacteriuria

• Asymptomatic bacteriuria is
significant levels of bacteria in
• Send midstream urine for urine with no UTI symptoms
Pregnant woman, or culture and susceptibility for • Screened for and treated in pregnant
Man, or pregnant women and men Refer to hospital if a person aged women because risk factor for
• Send urine for culture and 16 or over has any symptoms or pyelonephritis and premature delivery
Child or young person susceptibility or dipstick in line signs suggesting a more serious
illness or condition (for example, • Not screened for or treated in
under 16 years with the NICE guideline on urinary non-pregnant women, men,
tract infection for under 16s sepsis)
children or young people
• Offer immediate antibiotic
Refer children and young people October 2018
• Assess and manage fever in to hospital in line with the NICE
under 5s in line with the NICE guideline on urinary tract infection
guideline on fever in under 5s in under 16s NICE uses ‘offer’ when there is more
certainty of benefit and ‘consider’ when
evidence of benefit is less clear.
UTI (lower): antimicrobial prescribing
Choice of antibiotic: non-pregnant women aged 16 years and over Choice of antibiotic: children and young people under 16 years
Antibiotic1 Dosage and course length2 Antibiotic1 Dosage and course length2

First choice3 Refer children under 3 months to paediatric specialist and treat with intravenous antibiotics in line
with the NICE guideline on fever in under 5s
Nitrofurantoin - 100 mg modified-release twice a day for 3 days
if eGFR ≥45 ml/minute4 Children aged 3 months and over - First choice3, 4
Trimethoprim – if low risk of 3 to 5 months, 4 mg/kg (maximum 200 mg per dose) or 25 mg twice
Trimethoprim - if low risk of 200 mg twice a day for 3 days resistance5 a day for 3 days; 6 months to 5 years, 4 mg/kg (maximum 200 mg
resistance5 per dose) or 50 mg twice a day for 3 days; 6 to 11 years, 4 mg/kg
(maximum 200 mg per dose) or 100 mg twice a day for 3 days;
Second choice (no improvement in lower UTI symptoms on first choice taken for at least 12 to 15 years, 200 mg twice a day for 3 days
48 hours, or when first choice not suitable)3, 6 Nitrofurantoin - 3 months to 11 years, 750 micrograms/kg four times a day for 3 days
Nitrofurantoin – if eGFR 100 mg modified-release twice a day for 3 days if eGFR ≥45 ml/minute6 12 to 15 years, 50 mg four times a day or 100 mg modified-release
≥45 ml/minute4 and not first twice a day for 3 days
choice Children aged 3 months and over - Second choice (worsening lower UTI symptoms on first choice
Pivmecillinam (a penicillin) 400 mg initial dose, then 200 mg three times a day for a taken for at least 48 hours or when first choice not suitable)3,4,7
total of 3 days Nitrofurantoin – if eGFR 3 months to 11 years, 750 micrograms/kg four times a day for 3 days
≥45 ml/minute6 and not first 12 to 15 years, 50 mg four times a day or 100 mg modified-release
Fosfomycin 3 g single dose sachet
choice twice a day for 3 days
1
See BNF for use and dosing in specific populations, for example, hepatic impairment, renal Amoxicillin (only if culture 1 to 11 months, 125 mg three times a day for 3 days;
impairment and breast-feeding. results available and 1 to 4 years, 250 mg three times a day for 3 days;
2
Doses given are by mouth using immediate-release medicines, unless otherwise stated. susceptible) 5 to 15 years, 500 mg three times a day for 3 days
3
Check any previous urine culture and susceptibility results and antibiotic prescribing and
choose antibiotics accordingly. Cefalexin 3 to 11 months, 12.5 mg/kg or 125 mg twice a day for 3 days; 1 to 4
4
May be used with caution if eGFR 30-44 ml/minute to treat uncomplicated lower UTI years, 12.5 mg/kg twice a day or 125 mg three times a day for 3 days;
caused by suspected or proven multidrug resistant bacteria and only if potential benefit 5 to 11 years, 12.5 mg/kg twice a day or 250 mg three times a day for
outweighs risk (BNF, August 2018). 3 days; 12 to 15 years, 500 mg twice a day for 3 days
5
A lower risk of resistance may be more likely if not used in the past 3 months, previous 1
See BNF for children (BNFC) for use and dosing in specific populations.
urine culture suggests susceptibility (but this was not used), and in younger people in areas 2
Age bands apply to children of average size; in practice the prescriber will use these with other
where local epidemiology data suggest resistance is low. A higher risk of resistance may be factors. Doses given are by mouth using immediate release medicines, unless otherwise stated.
more likely with recent use and in older people in residential facilities. 3
Check previous urine culture and susceptibility results and antibiotic prescribing. If receiving
6
If there are symptoms of pyelonephritis or the person has a complicated UTI (associated prophylactic antibiotics, treatment should be with a different antibiotic.
with a structural or functional abnormality, or underlying disease, which increases the risk 4
If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost. Some
of a more serious outcome or treatment failure), see the recommendations on choice of children may also be able to take a tablet or part-tablet, rather than a liquid formulation if the dose is
antibiotic in the NICE antimicrobial prescribing guideline on acute pyelonephritis. appropriate.
Abbreviations: eGFR, estimated glomerular filtration rate.
5
A lower risk of resistance may be more likely if not used in the past 3 months, previous urine culture
suggests susceptibility (but this was not used), and in younger people in areas where data suggest
resistance is low. Risk of resistance may be higher with recent use and in older people in care homes.
6
May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by
suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNFC,
August 2018).
7
If there are symptoms of pyelonephritis or the person has a complicated UTI, see the recommendations
on choice of antibiotic in the NICE antimicrobial prescribing guideline on acute pyelonephritis.
Abbreviations: eGFR, estimated glomerular filtration rate.
UTI (lower): antimicrobial prescribing
Choice of antibiotic: pregnant women aged 12 years and over Choice of antibiotic: men aged 16 years and over
Antibiotic1 Dosage and course length2 Antibiotic1 Dosage and course length2

First choice for treating lower UTI3 First choice3

Nitrofurantoin (avoid at term) 100 mg modified-release twice a day for 7 days Trimethoprim 200 mg twice a day for 7 days
- if eGFR ≥45 ml/minute4, 5
Nitrofurantoin - 100 mg modified-release twice a day for 7 days
Second choice for treating lower UTI (no improvement in lower UTI symptoms on first
if eGFR ≥45 ml/minute4, 5
choice taken for at least 48 hours or when first choice not suitable)3, 6
Amoxicillin (only if culture 500 mg three times a day for 7 days Second choice (no improvement in UTI symptoms on first choice taken for at least 48 hours or
results available and when first choice not suitable)3
susceptible)
Consider alternative diagnoses and follow recommendations in the NICE antimicrobial prescribing
Cefalexin 500 mg twice a day for 7 days guidelines on acute pyelonephritis or acute prostatitis, basing antibiotic choice on recent culture
and susceptibility results.
Alternative second choices Consult local microbiologist, choose antibiotics based on 1
See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment
culture and susceptibility results and renal impairment.
Treating asymptomatic bacteriuria
2
Doses given are by mouth using immediate-release medicines, unless otherwise stated.
3
Check any previous urine culture and susceptibility results and antibiotic prescribing and choose
Choose from nitrofurantoin4, 5, amoxicillin or cefalexin based on recent culture and antibiotics accordingly.
susceptibility results 4
Nitrofurantoin is not recommended for men with suspected prostate involvement because it is
1
See BNF for appropriate use and dosing in specific populations, for example, hepatic unlikely to reach therapeutic levels in the prostate.
impairment and renal impairment.
5
May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by
2
Doses given are by mouth using immediate-release medicines, unless otherwise stated. suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF,
3
Check any previous urine culture and susceptibility results and antibiotic prescribing and August 2018).
choose antibiotics accordingly. Abbreviations: eGFR, estimated glomerular filtration rate.
4
Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, June 2018).
5
May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI
caused by suspected or proven multidrug resistant bacteria and only if potential benefit
outweighs risk (BNF, August 2018).
6
If there are symptoms of pyelonephritis or the person has a complicated UTI (associated
with a structural or functional abnormality, or underlying disease, which increases the risk
of a more serious outcome or treatment failure), see the recommendations on choice of
antibiotic in the NICE antimicrobial prescribing guideline on acute pyelonephritis.
Abbreviations: eGFR, estimated glomerular filtration rate.

When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service.
It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and
carers or guardian.
© NICE 2018. All rights reserved. Subject to Notice of rights.