Urinary tract infection (recurrent): antimicrobial prescribing

Preventing recurrent urinary tract infections

Management of antimicrobials for recurrent UTI

Management of antimicrobials for recurrent UTI

Referral and seeking specialist advice

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

Treatment for women with recurrent UTI who are not pregnant

Oestrogen

  • Consider the lowest effective dose of vaginal oestrogen*** (for example, estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate. Discuss the following with the woman to ensure shared decision-making:
    • the severity and frequency of previous symptoms
    • the risk of developing complications from recurrent UTIs
    • the possible benefits of treatment, including for other related symptoms, such as vaginal dryness
    • the possible adverse effects such as breast tenderness and vaginal bleeding (which should be reported because it may require investigation)
    • the uncertainty of endometrial safety with long-term or repeated use preferences of the woman for treatment with vaginal oestrogen
  • Review treatment within 12 months, or earlier if agreed with the woman
  • Do not offer oral oestrogens (hormone replacement therapy) specifically to reduce the risk of recurrent UTI in postmenopausal women

Antibiotic prophylaxis

  • For women with recurrent UTI who are not pregnant, consider a trial of antibiotic prophylaxis only if behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate
  • For women with recurrent UTI who are not pregnant, ensure that any current UTI has been adequately treated then consider single-dose antibiotic prophylaxis for use when exposed to an identifiable trigger (see the recommendations on choice of antibiotic prophylaxis). Take account of:
    • the severity and frequency of previous symptoms
    • the risk of developing complications
    • previous urine culture and susceptibility results
    • previous antibiotic use, which may have led to resistant bacteria
    • the woman’s preferences for antibiotic use
  • When single-dose antibiotic prophylaxis is given, give advice about:
    • how to use the antibiotic
    • possible adverse effects of antibiotics, particularly diarrhoea and nausea
    • returning for review within 6 months
    • seeking medical help if there are symptoms of an acute UTI
  • For women with recurrent UTI who are not pregnant and have had no improvement after single-dose antibiotic prophylaxis or have no identifiable triggers, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis). Take account of:
    • any further investigations (for example, ultrasound) that may be needed to identify an underlying cause
    • the severity and frequency of previous symptoms
    • the risks of long-term antibiotic use
    • the risk of developing complications
    • previous urine culture and susceptibility results
    • previous antibiotic use, which may have led to resistant bacteria
    • the woman’s preferences for antibiotic use
  • When a trial of daily antibiotic prophylaxis is given, give advice about:
    • the risk of resistance with long-term antibiotics, which means they may be less effective in the future
    • possible adverse effects of long-term antibiotics
    • returning for review within 6 months
    • seeking medical help if there are symptoms of an acute UTI

Treatment for men and pregnant women with recurrent UTI

  • For men and pregnant women with recurrent UTI, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis) if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. Take account of:
    • any further investigations (for example, ultrasound) that may be needed to identify an underlying cause
    • the severity and frequency of previous symptoms
    • the risks of long-term antibiotic use
    • the risk of developing complications
    • previous urine culture and susceptibility results
    • previous antibiotic use, which may have led to resistant bacteria
    • the person’s preferences for antibiotic use
  • When a trial of daily antibiotic prophylaxis is given, give advice as above

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

  • For children and young people under 16 years with recurrent UTI, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis) if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. Take account of:
    • underlying causes following specialist assessment and investigations
    • the uncertain evidence of benefit of antibiotic prophylaxis for reducing the risk of recurrent UTI and the rate of deterioration of renal scars
    • the severity and frequency of previous symptoms
    • the risks of long-term antibiotic use
    • the risk of developing complications
    • previous urine culture and susceptibility results
    • previous antibiotic use, which may have led to resistant bacteria
    • preferences for antibiotic use
  • When a trial of daily antibiotic prophylaxis is given, give advice as above

Reassessment

  • Review antibiotic prophylaxis for recurrent UTI at least every 6 months, with the review to include:
    • assessing the success of prophylaxis
    • discussion of continuing, stopping or changing prophylaxis (taking into account the person’s preferences for antibiotic use and the risk of antimicrobial resistance)
    • a reminder about behavioural and personal hygiene measures and self-care treatments (see the recommendations on self-care)
    • if they have an acute UTI
  • If antibiotic prophylaxis is stopped, ensure that people have rapid access to treatment

Self-care

  • Be aware that:
    • some women with recurrent UTI may wish to try D-mannose††† if they are not pregnant
    • some women with recurrent UTI may wish to try cranberry products if they are not pregnant (evidence of benefit is uncertain and there is no evidence of benefit for older women)
    • some children and young people under 16 years with recurrent UTI may wish to try cranberry products with the advice of a paediatric specialist (evidence of benefit is uncertain)
  • Advise people taking cranberry products or D-mannose about the sugar content of these products, which should be considered as part of the person’s daily sugar intake
  • Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI

Choice of antibiotic prophylaxis

  • When prescribing antibiotic prophylaxis for recurrent UTI, take account of local antimicrobial resistance data and:
    • follow the recommendations in table 1 for people aged 16 years and over
    • follow the recommendations in table 2 for children and young people under 16 years
Table 1 People aged 16 years and over
Antibiotic prophylaxis*,†Dosage

First choice

Trimethoprim§

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

Nitrofurantoin—if eGFR ≥45 ml/minute|

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

Second choice

Amoxicillin

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

Cefalexin

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

*See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.
Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI.
Doses given are by mouth using immediate release medicines, unless otherwise stated.
§ Teratogenic risk in first trimester of pregnancy (folate antagonist; BNF, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics).
| Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, August 2018).
Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.

BNF=British National Formulary; eGFR=estimated glomerular filtration rate.

Table 2 Children and young people under 16 years
Antibiotic prophylaxis**,††Dosage‡‡

Children under 3 months

Refer to paediatric specialist

Children aged 3 months and over (specialist advice only)

First choice

Trimethoprim§§

 

3 to 5 months: 2 mg/kg at night (maximum 100 mg per dose) or 12.5 mg at night

6 months to 5 years: 2 mg/kg at night (maximum 100 mg per dose) or 25 mg at night

6 to 11 years: 2 mg/kg at night (maximum 100 mg per dose) or 50 mg at night

12 to 15 years: 100 mg at night

Nitrofurantoin—if eGFR≥45 ml/minute||

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

12 to 15 years: 50 to 100 mg at night

Second choice

Cefalexin

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

Amoxicillin¶¶

 

3 to 11 months: 62.5 mg at night

1 to 4 years: 125 mg at night

5 to 15 years: 250 mg at night

** See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic and renal impairment.
†† Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI. If two or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost.
‡‡ The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child’s size in relation to the average size of children of the same age. Doses given are by mouth using immediate release medicines, unless otherwise stated.
§§ Teratogenic risk in first trimester of pregnancy (folate antagonist; BNFC, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics).
|| Avoid at term in pregnancy; may produce neonatal haemolysis (BNFC, August 2018).
¶¶ Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.

BNF=British National Formulary for children; eGFR=estimated glomerular filtration rate.

Terms used in the guideline

Recurrent urinary tract infection

  • Recurrent urinary tract infection (UTI) in adults is defined as repeated UTI with a frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months
  • Recurrent UTI is diagnosed in children and young people under 16 years if they have:
    • 2 or more episodes of UTI with acute pyelonephritis/upper UTI or
    • 1 episode of UTI with acute pyelonephritis plus 1 or more episode of UTI with cystitis/lower UTI or
    • 3 or more episodes of UTI with cystitis/lower UTI
  • See the NICE guideline on urinary tract infection in under 16s

Trigger

  • Some people (mainly women) may be able to identify one or more triggers (for example, sexual intercourse) that often brings on a UTI. These triggers may vary for different people

*** Vaginal oestrogen products are not licensed for preventing recurrent UTI, so use for this indication would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.

††† The evidence was based on a study where D-mannose was taken as 200 ml of 1% solution once daily in the evening. D-mannose is a sugar that is available to buy as powder or tablets; it is not a medicine.

© NICE 2018. Urinary tract infection (recurrent): antimicrobial prescribing. Available from: http://www.nice.org.uk/NG112. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

First included: November 2018.