Urinary tract infections

Asymptomatic bacteriuria is:

• not routinely screened for, or treated, in non-pregnant women, men, children and young people
• routinely screened for, and treated with antibiotics, in pregnant women because it is a risk factor for pyelonephritis and premature delivery

Screen for asymptomatic bacteriuria on first antenatal visit by sending urine for culture. If asymptomatic bacteriuria is found send a second urine sample for culture.

If the second urine culture confirms asymptomatic bacteriuria (growth of same organism), then offer an immediate antibiotic prescription to pregnant women with asymptomatic bacteriuria, checking any previous urine culture, susceptibility results, and antibiotic prescribing. Please see Pregnant women ≥12 years with UTI (lower) slider below for antibiotic recommendations.

Consider a 3-day prescription (delayed for 2 days) for patients presenting with symptoms which do not start to improve within the next 2 days or worsen at any time, or an immediate antibiotic prescription for women with lower UTI who are not pregnant, taking into account the considerations described above.

If urine sent for culture and susceptibility, and antibiotic given:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Nitrofurantoin

• 100mg modified release twice daily for 3 days

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection or suspected upper urinary tract infections
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice option taken for at least 2 days or when first choice option not suitable:

Pivmecillinam

• 400mg initial dose, then 200mg three times day for a total of 3 days
• This is an extended-spectrum penicillin antibiotic

OR

Fosfomycin

• Prescribe as Monuril® brand
• 3g as a single dose sachet dissolved into a glass of water
• Take on an empty stomach, preferably before bedtime and after emptying the bladder

If worsening of symptoms on second choice treatment options, taken for at least 2 days, consult local microbiologist.

Refer to Urinary Tract Infections in females Clinical Referral Guidelines:

• West Devon
• South Devon

See 5.1.1 Penicillins and 5.1.13 Urinary-tract infections

Best Use of Medicines in Pregnancy (BUMPS); provided by the UK Teratology Information Service (UKTIS), contains useful information on prescribing in pregnancy.

Offer immediate antibiotic prescription to pregnant women with lower UTI, taking into account the considerations described above.

Send midstream urine for culture and susceptibility before antibiotics are taken and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant

Nitrofurantoin

• 100mg modified release twice daily for 7 days
• Avoid at term in pregnancy; may produce neonatal haemolysis

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection or suspected upper urinary tract infections
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice taken for at least 2 days or when first choice not suitable:

Amoxicillin

• 500mg three times a day for 7 days
• Use only if culture results available and susceptible

OR

Cefalexin

• 500mg twice daily for 7 days
• Use with caution in non-severe penicillin allergy

If worsening of symptoms on second choice treatment options, taken for at least 2 days, consult local microbiologist.

Refer to Urinary Tract Infections in females Clinical Referral Guidelines:

• West Devon
• South Devon

See 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.13 Urinary-tract infections

Offer immediate antibiotic prescription to men with lower UTI, taking into account the considerations described above.

Send midstream urine for culture and susceptibility before antibiotics are taken and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Nitrofurantoin

• 100mg modified release twice daily for 7 days
• Nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection or suspected upper urinary tract infections
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice taken for at least 2 days or when first choice not suitable:

Consider alternative diagnoses, such as urethritis / STI, pyelonephritis (acute) or prostatitis in men presenting with cystitis symptoms that are recurrent or are accompanied by pelvic or perineal pain, or fever, or the presence of obstructive symptoms such as dribbling and hesitancy.

Please see pyelonephritis (acute) or prostatitis (acute) sliders below for further helpful information.

Where the diagnosis remains lower UTI, local microbiologists suggest considering Pivmecillinam and Fosfomycin as reasonable second line empirical options for those patients.

Pivmecillinam

• 400mg initial dose, then 200mg three times day for a total of 3 days
• This is an extended-spectrum penicillin antibiotic

OR

Fosfomycin

• Prescribe as Monuril® brand
• 3g as a single dose sachet initially, dissolved into a glass of water, then repeated after 3 days (unlicensed)
• Take on an empty stomach, preferably before bedtime and after emptying the bladder

Refer to Urinary Tract Infections in males Clinical Referral Guidelines:

• West Devon
• South Devon

See 5.1.1 Penicillins and 5.1.13 Urinary-tract infections

Do not perform urine dipsticks

Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults will have bacteria present in the bladder/urine without an infection.

This asymptomatic bacteriuria is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm.

Check for signs/ symptoms of sepsis or pyelonephritis, and consider alternative diagnoses and causes of delirium, according to the Public Health England (PHE) quick reference diagnostic toolkit for patients over 65 years.

Please see pyelonephritis (acute) or prostatitis (acute) sliders below for further helpful information.

If signs/ symptoms suggest UTI, always send urine culture if feasible, as greater resistance in older adults.

Consider a 3-day antibiotic prescription (delayed for 2 days) in women with mild symptoms without catheters and low risk of complications or an immediate antibiotic prescription for patients with lower UTI, taking into account the considerations described above.

When urine culture results are available:

• review antibiotic choice and
• change antibiotic if bacteria resistant and symptoms not improving

For antibiotic choice please see the appropriate sliders above; Non-pregnant women ≥16 years with UTI (lower) or Men ≥16 years with UTI (lower)

Please see Catheter-associated urinary tract infections (CA-UTI) slider below for formulary guidance if patient has an indwelling urinary catheter.

If worsening signs or symptoms, consider admission or start/change antibiotic

Assess and manage children <5 years of age with a lower UTI and fever as per NICE Guideline NG143: Fever in under 5s: assessment and initial management (November 2019).

Children under 3 months of age

Infants and children under 3 months with a possible UTI should be referred to a paediatric specialist.

Children over 3 months of age

Offer an immediate antibiotic prescription for children and young people under 16 years with lower UTI, taking into account the considerations described above.

Obtain a urine sample from children and young people 3 months or older with suspected lower UTI before antibiotics are taken, and dipstick test or send for culture and susceptibility testing, in line with NICE CG54 Urinary tract infection in under 16s: diagnosis and management (August 2007 [updated October 2018]).

When results are available:

• review antibiotic choice and
• change antibiotic if bacteria resistant and symptoms not improving

Trimethoprim

• Children and young people aged 3 months and over (doses given twice daily for 3 days):
  • 3 to 5 months: 4 mg/kg (maximum 200mg per dose) or 25mg
  • 6 months to 5 years: 4 mg/kg (maximum 200mg per dose) or 50mg
  • 6 to 11 years: 4 mg/kg (maximum 200mg per dose) or 100mg
  • 12 to 15 years: 200mg

Notes

• Nitrofurantoin is advocated if trimethoprim has been used in the past 3 months, previous urine culture suggests not susceptible, or if patient is not responding

OR

Nitrofurantoin

• Children and young people aged 3 months and over:
  • 3 months to 11 years: 750micrograms/kg four times a day for 3 days
  • 12 to 15 years: 50mg four times a day or 100mg modified release twice a day for 3 days

Notes

• Nitrofurantoin suspension is significantly more expensive than tablets and capsules, and should be avoided unless other options are not appropriate
• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin
• Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection or suspected upper urinary tract infections
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If no improvement in lower UTI symptoms on first choice first-line option taken for at least 2 days, try alternative first-line option before considering second-line options below:

Cefalexin

• Children and young people aged 3 months and over:
  • 3 to 11 months: 12.5mg/kg or 125mg twice a day for 3 days
  • 1 to 4 years: 12.5mg/kg twice a day or 125mg three times a day for 3 days
  • 5 to 11 years: 12.5mg/kg twice a day or 250mg three times a day for 3 days
  • 12 to 15 years: 500mg twice a day for 3 days

If worsening of symptoms on second choice treatment options, taken for at least 2 days, consult local microbiologist.

Refer to Urinary tract infection (UTI) - suspected referral guideline

See 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim, and 5.1.13 Urinary-tract infections

If GFR <45mL/min

Pivmecillinam

• Consider pivmecillinam if eGFR less than 45mL/min
• 400mg single dose on day one then 200mg every 8 hours for 3 days in women, 7 days in men
• This is an extended-spectrum penicillin antibiotic

If high risk of resistance

Fosfomycin

• Consider fosfomycin if high risk of resistance to first line options
• Female: 3g sachet as a single dose
  
• Male: 3g sachet initial dose and repeat after 3 days; unlicensed but in line with PHE guidance
  
• Doses should be taken preferably before bedtime and after emptying the bladder

For formulary catheter guidance and products, please see Chapter 18. Continence

CA-UTI is defined as the presence of symptoms or signs compatible with an UTI in people with a catheter with no other identified source of infection, plus significant levels of bacteria in a catheter or a midstream urine specimen when the catheter has been removed within the previous 48 hours.

The longer a catheter is in place, the more likely bacteria will be found in the urine; after 1 month, nearly all people have bacteriuria.

Antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter, please see Asymptomatic bacteriuria slider above for information.

Self-care advice:

• Consider self-care options as listed in the UTI section introduction (above)

Consider removing or, if this cannot be done, changing the catheter as soon as possible in people with a CA-UTI if it has been in place for more than 7 days. Do not allow catheter removal or change to delay antibiotic treatment.

Obtain a urine sample before antibiotics are taken. Take the sample from the catheter, via a sampling port if provided, using an aseptic technique.

• If the catheter has been changed, obtain the sample from the new catheter.
• If the catheter has been removed, obtain a midstream specimen of urine

Send urine for culture and susceptibility, noting a suspected catheter-associated infection and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Do not routinely offer antibiotic prophylaxis to prevent CA-UTI in people with a short-term or a long-term (indwelling or intermittent) catheter.

Consider referring or seeking specialist advice for people if they:

• are significantly dehydrated or unable to take oral fluids and medicines or
• are pregnant or
• have a higher risk of developing complications (for example, people with known or suspected structural or functional abnormality of the genitourinary tract, or underlying disease [such as diabetes or immunosuppression]) or
• have recurrent CA-UTIs or
• have bacteria that are resistant to oral antibiotics

Seek specialist advice if the patient cannot take oral antibiotics to explore options for giving intravenous antibiotics at home or in the community, rather than in hospital, where this is appropriate e.g. via outpatient or home parenteral antibiotic therapy service where available

Refer to Catheter Acquired Urinary Tract Infection (CAUTI) Clinical Referral Guidelines:

• Southern Locality
• Western Locality

Antibiotics for non-pregnant women and men aged 16 years and over

Offer an antibiotic to people with CA-UTI; taking into account the considerations described in the introductory text to UTI, above, when prescribing antibiotics.

• The risk of developing complications is higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression

1st line if no upper UTI symptoms

If the catheter has been removed and is not reinserted

Nitrofurantoin

• 100mg modified release twice daily for 7 days

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 45 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection or suspected upper urinary tract infections
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If the catheter has been changed or remains in situ

Trimethoprim

• 200mg twice a day for 7 days

Notes

• A lower risk of resistance is likely if trimethoprim not used in the past 3 months, previous urine culture suggests susceptibility (but trimethoprim was not used)
• A higher risk of resistance is likely with recent use and in older people in care homes.

2nd line if no upper UTI symptoms

Consider 2nd line options when 1st line options are not suitable

Pivmecillinam

• 400mg initial dose, then 200mg three times day for a total of 7 days
• This is an extended-spectrum penicillin antibiotic

Alternative if no upper UTI symptoms (use only if culture results available and susceptible):

Amoxicillin

• 500mg three times a day for 7 days

1st line if upper UTI symptoms

Cefalexin

• 1g three times a day for 7 to 10 days

Ciprofloxacin

• 500mg twice a day for 7 days
• See MHRA Drug Safety Updates below

University Hospitals Plymouth NHS Trust laboratory tests and reports levofloxacin: where susceptibility is identified with levofloxacin, ciprofloxacin may be prescribed.

Levofloxacin

• 500mg once daily for 7 days
• See MHRA Drug Safety Updates below

For Ciprofloxacin and Levofloxacin:

• MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
• MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects

Alternative if upper UTI symptoms (use only if culture results available and susceptible):

Co-amoxiclav

• 500/125mg three times a day for 7 to 10 days

Trimethoprim

• 200mg twice daily for 14 days

See section: 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim, and 5.1.12 Quinolones

Antibiotics for pregnant women aged 12 years and over

Consider referring or seeking specialist advice for pregnant women aged 12 years and over

If no upper UTI symptoms

Cefalexin

• 500mg twice daily for 7 to 10 days
• If severe infection, use dose for upper UTI symptoms below

If upper UTI symptoms

Cefalexin

• 1g three times a day for 7 to 10 days

Consult local microbiologist if cefalexin is not suitable

Trimethoprim may be considered or advised by specialists. It is recommended that women who need to take trimethoprim during the first trimester also take high dose folic acid (5mg daily) until week 12 of pregnancy. Avoid trimethoprim if the woman has a low folate status or is on a folate antagonist (e.g. antiepileptic or proguanil)

See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim, and Resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation

Antibiotics for children and young people under 16 years

Children under 3 months of age

Infants and children under 3 months with a possible UTI should be referred to a paediatric specialist.

Children aged 3 months and over

Consider referring or seeking specialist advice for children aged 3 months and over

Cefalexin

• Maximum dose for any age is 1g four times a day
• 3 months to 4 years:
  • If no upper UTI symptoms: 12.5mg/kg or 125mg twice a day for 7 to 10 days
  • If upper UTI symptoms or severe infections: 25mg/kg two to four times a day for 7 to 10 days
• 1 to 4 years:
  • If no upper UTI symptoms: 12.5mg/kg twice a day or 125mg three times a day for 7 to 10 days
  • If upper UTI symptoms or severe infections: 25mg/kg two to four times a day for 7 to 10 days
• 5 to 11 years:
  • If no upper UTI symptoms: 12.5mg/kg twice a day or 250mg three times a day for 7 to 10 days
  • If upper UTI symptoms or severe infections: 25mg/kg two to four times a day for 7 to 10 days
• 12 to 15 years:
  • If no upper UTI symptoms: 500 mg twice or three times a day
  • If upper UTI symptoms or severe infections: 1g three times a day for 7 to 10 days

Trimethoprim

• Children and young people aged 3 months and over (doses given twice daily for 7 to 10 days):
  • 3 to 5 months: 4mg/kg (maximum 200mg per dose) or 25 mg
  • 6 months to 5 years: 4mg/kg (maximum 200mg per dose) or 50mg
  • 6 to 11 years: 4mg/kg (maximum 200mg per dose) or 100mg
  • 12 to 15 years: 200mg

Alternative option (use only if culture results available and susceptible):

Amoxicillin

• Children and young people aged 3 months and over (doses given three times a day for 7 to 10 days):
  • 3 to 11 months: 125mg
  • 1 to 4 years: 250mg
  • 5 to 15 years: 500mg

Co-amoxiclav

• Children and young people aged 3 months and over (doses given three times a day for 7 to 10 days):
  • 3 to 11 months: 0.25ml/kg (125/31 suspension) (dose doubled in severe infection)
  • 1 to 5 years: 5ml or 0.25ml/kg (125/31 suspension) (dose doubled in severe infection)
  • 6 to 11 years: 5ml or 0.15ml/kg (250/62 suspension) (dose doubled in severe infection)

See section: 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, and 5.1.8 Sulfonamides and trimethoprim

Recurrent 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

Recurrent UTI is particularly common in women and includes lower UTI and upper UTI (acute pyelonephritis), but repeated pyelonephritis should prompt further investigation.

Risk factors in young and pre-menopausal women include sexual intercourse, new sexual partner, mother with a history of UTI, and history of UTI as a child.

Risk factors in post-menopausal and elderly women include history of UTI before menopause, urinary incontinence, atrophic vaginitis due to oestrogen deficiency, increased post-void urine volume, and urine catheterisation and functional status deterioration in elderly institutionalised women.

Self-care advice:

• Consider self-care options as listed in the UTI section introduction (above)
• Some women with recurrent UTI may wish to try D mannose, if they are not pregnant. D-mannose is available to buy as powder or tablets (it is not a medicine)
• Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI

Consider giving advice about behavioural and personal hygiene measures that may help reduce the risk of recurrent infections, i.e. increasing fluid intake, not delaying habitual and post-coital urination and not wearing occlusive underwear.

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

• men aged 16 years and over
• people with recurrent upper UTI
• people with recurrent lower UTI when the underlying cause is unknown
• pregnant women
• children and young people under 16 years
• people with suspected cancer

Treatment with vaginal oestrogen for postmenopausal (non-pregnant) women

Consider the lowest effective dose of vaginal oestrogen, i.e. estriol cream, for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate.

Estriol cream 0.1%

• One applicator dose (0.5mg estriol) applied topically at night for 2 weeks then twice weekly (off-label indication)

Estradiol vaginal ring 7.5 micrograms/24 hours

• One ring (7.5 micrograms/24 hour) worn continuously for 12 weeks then replace, maximum duration of continuous treatment 36 weeks (off-label indication)

Review treatment within 12 months, or earlier if agreed with the woman.

Do not offer oral oestrogens (hormone replacement therapy) or oestrogen administered via a pessary.

See section 7.2.1 Preparations for vaginal and vulval changes

Antibiotic prophylaxis for women with recurrent UTI who are not pregnant

Take into account the considerations described above when prescribing antibiotics.

If behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate:

• Ensure that any current UTI has been adequately treated, then
• Consider single-dose antibiotic prophylaxis for use when exposed to an identifiable trigger or
• Consider self-start antibiotic therapy as an alternative option for women with the ability to recognise UTI symptomatically and start antibiotics at home. Inform patient to seek advice if symptoms do not improve within 48 hours

If there is no improvement after single-dose antibiotic prophylaxis or there are no identifiable triggers, a trial of daily antibiotic prophylaxis may be appropriate (consider seeking specialist advice).

Review antibiotic prophylaxis for recurrent UTI at least every 3 months, with the review to include:

• assessing the success of prophylaxis
• discussion of continuing, stopping or changing prophylaxis
• a reminder about behavioural and personal hygiene measures and self-care treatments

Consider seeking specialist advice if patient develops an acute UTI during treatment with daily antibiotic prophylaxis

1st line

Nitrofurantoin

• 100mg modified release as a single dose when exposed to a trigger (off-label) or
• 100mg modified release at night (if eGFR ≥ 45ml/min/1.73m²)

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 45 mL/min/1.73m² when the duration of the course is more than 7 days
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection or suspected upper urinary tract infections
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

2nd line

Amoxicillin

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

Notes

• Off-label indication

Cefalexin

• 500mg single dose when exposed to a trigger or
• 125mg at night (off-label)

3rd line

Methenamine hippurate

• 1g twice daily
• Urine acidification advised

See section 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.13 Urinary-tract infections

The information below is based on NICE Guideline NG110 Prostatitis (acute): antimicrobial prescribing (October 2018)

Acute prostatitis is a bacterial infection of the prostate which needs treatment with antibiotics. It is caused by bacteria entering the prostate from the urinary tract and can last several weeks.

Self-care advice:

• Consider paracetamol or if preferred and suitable, ibuprofen for pain or fever
• Drink adequate fluids to avoid dehydration
• If defecation is painful — a stool softener such as lactulose or docusate may be helpful

Suspect acute prostatitis in a man who presents with signs and symptoms of:

• A urinary tract infection (UTI):
  • Dysuria, frequency, urgency
• Prostatitis:
  • Perineal, penile, or rectal pain
  • Acute urinary retention, obstructive voiding symptoms (difficulty voiding, hesitancy, straining to urinate, weak stream).
  • Low back pain, pain on ejaculation
  • Tender, swollen, warm prostate (on gentle rectal examination)
• Bacteraemia:
  • Rigors, arthralgia, or myalgia
  • Fever, tachycardia

Consider acute prostatitis as a sexually transmitted infection (STI) in younger adults, and those with a clinical history (i.e. high-risk sexual behaviour or symptoms suggesting a possible STI for example urethral discharge). People with risk factors and a clinical history of an STI should be screened for chlamydia and gonorrhoea, and if an STI is suspected a referral to a Genito-Urinary Medicine (GUM) clinic is the most appropriate action.

Considerations when prescribing antibiotics:

When considering antibiotics (see specifics below), take account of severity of symptoms, risk of complications or having treatment failure (particularly after medical procedures such as prostate biopsy), previous urine culture and susceptibility results, and previous antibiotic use which may have led to resistant bacteria.

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

• Alternative diagnoses
• Any symptoms or signs suggesting a more serious illness or condition, such as acute urinary retention, prostatic abscess, or sepsis
• Previous antibiotic use, which may lead to resistant organisms
• Consider CRGs if referral required:
  • Prostatitis Suspected - West Devon, South Devon
  • Chronic Pelvic Pain Syndrome - West Devon, South Devon

Offer immediate antibiotic prescription to men with acute prostatitis, taking account of the considerations above.

Send midstream urine for culture and susceptibility and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Refer to hospital if the patient:

• cannot take oral antibiotics, or
• has symptoms which are not improving 48 hours after starting antibiotic, or
• is severely unwell / has any symptoms or signs suggesting a more serious illness or condition (see above)

Review antibiotic treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed, based on an assessment of the person's history, symptoms, clinical examination, urine and blood tests (4 weeks treatment may prevent chronic prostatitis).

Where antibiotics are indicated

For ciprofloxacin and ofloxacin:

• MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
• MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects
  • Take account the severity of symptoms and do not prescribe fluoroquinolones for mild to moderate or non-severe infections, unless other antibiotics that are commonly recommended are considered inappropriate
  • Advise patients to stop treatment at the first signs of a serious adverse reaction, refer to the MHRA Drug Safety Update for details

Ciprofloxacin

• 500mg twice a day for 14 days (extend for a further 14 days if needed, see above)

Ofloxacin

• 200mg twice a day for 14 days (extend for a further 14 days if needed, see above)

If quinolones not tolerated, contraindicated or used within the previous 6 months

Trimethoprim

• 200mg twice a day for 14 days (extend for a further 14 days if needed, see above)

See sections 5.1.8 Sulfonamides and trimethoprim and 5.1.12 Quinolones

Alternative antibiotic choice

If worsening of symptoms on antibiotic treatment options above, consult local microbiologist.

The information below is based on the European Association of Urology Guideline for Chronic Pelvic Pain (2019).

Self-care advice:

• Consider paracetamol or if preferred and suitable, ibuprofen for pain or fever
• Drink adequate fluids to avoid dehydration
• If defecation is painful — a stool softener such as lactulose or docusate may be helpful

Chronic Pelvic Pain Syndrome (CPPS) is characterized by at least 3 months of pain in the perineum or pelvic floor, often associated with lower urinary tract symptoms, and sexual dysfunction (erectile dysfunction, painful ejaculation, or postcoital pelvic discomfort).

CPPS is the occurrence of chronic pelvic pain when there is no proven infection or other obvious local pathology that may account for the pain.

For over 90% of men with chronic pelvic pain syndrome there is no proven bacterial infection.

A diagnosis is made based on the man's history, physical examination, and the exclusion of other conditions. Before considering antibiotic treatment for CPPS, exclude (or treat) the following other conditions that may be causing symptoms, such as:

• Prostatitis (acute)
• Urinary tract infections (UTI)
• Benign prostatic hyperplasia (BPH) / Lower urinary tract symptoms (LUTS)
• Epididymitis / Urethritis
• Sexual dysfunction
• Cancer of the prostate, bladder or colon
• Urethral stricture
• Obstructive calculus or a foreign body in the urinary tract

Consider a referral to specialist if there is diagnostic uncertainty, or if symptoms are severe.

If all other causes have been excluded, consider antibiotic treatment (see below).

Considerations when prescribing antibiotics:

When considering antibiotics (see specifics below), take account of severity of symptoms, risk of complications or having treatment failure (particularly after medical procedures such as prostate biopsy), previous urine culture and susceptibility results, and previous antibiotic use which may have led to resistant bacteria.

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

• Alternative diagnoses
• Any symptoms or signs suggesting a more serious illness or condition, such as acute urinary retention, prostatic abscess, or sepsis
• Previous antibiotic use, which may lead to resistant organisms
• Consider CRGs if referral required:
  • Prostatitis Suspected - West Devon, South Devon
  • Chronic Pelvic Pain Syndrome - West Devon, South Devon

Where oral antibiotics are indicated

Patients can be advised to continue self-care options during antibiotic treatment

Consider referral to specialist if symptoms are not resolved after a course of antibiotics (see local referral guideline)

Trimethoprim

• 200mg twice daily for 4 to 6 weeks

OR

Azithromycin

• 500mg once daily, three times a week, for 3 weeks
• Caution in people with a prolonged QT interval or who have risk factors for QT interval prolongation or those taking other drugs that prolong the QT interval

Doxycycline

• 100mg twice daily for 4 to 6 weeks

See sections: 5.1.3 Tetracyclines, 5.1.5 Macrolides, and 5.1.8 Sulfonamides and trimethoprim

Acute pyelonephritis is an infection of one or both kidneys usually caused by bacteria travelling up from the bladder.

Supporting advice:

• Drink adequate fluids to avoid dehydration
• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are generally not recommended for people with acute pyelonephritis because of concerns about renal safety

In people aged 16 years and over with acute pyelonephritis, obtain a midstream urine sample before antibiotics are taken and send for culture and susceptibility testing.

In children and young people under 16 years with acute pyelonephritis, obtain a urine sample before antibiotics are taken and send for culture and susceptibility testing in line with NICE CG54 Urinary tract infection in under 16s: diagnosis and management (August 2007 [updated October 2018]).

For children under 5 years with acute pyelonephritis who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2019)

When results are available:

• review antibiotic choice and
• change antibiotic if bacteria resistant and symptoms not improving

Referral and seeking specialist advice

Refer people aged 16 years and over with acute pyelonephritis to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis, or acute prostatitis in men/people with prostates).

Consider referring or seeking specialist advice for people aged 16 years and over with acute pyelonephritis if they:

• have recurrent infections or
• are pregnant or
• are men, following a single episode without an obvious cause or
• have a higher risk of developing complications (for example, people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease [such as diabetes or immunosuppression])

Refer children and young people with acute pyelonephritis to hospital in line with NICE CG54 Urinary tract infection in under 16s: diagnosis and management (August 2007 [updated October 2018]).

Seek specialist advice if the patient cannot take oral antibiotics to explore options for giving intravenous antibiotics at home or in the community, rather than in hospital, where this is appropriate e.g. via outpatient or home parenteral antibiotic therapy service where available

Antibiotics for non-pregnant women and men aged 16 years and over

Offer an antibiotic to people with acute pyelonephritis; taking into account the considerations described above when prescribing antibiotics.

• The risk of developing complications is higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression

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Cefalexin

• 1g three times a day for 7 to 10 days

Ciprofloxacin

• 500mg twice a day for 7 days
• See MHRA Drug Safety Updates below

University Hospitals Plymouth NHS Trust laboratory tests and reports levofloxacin: where susceptibility is identified with levofloxacin, ciprofloxacin may be prescribed.

Levofloxacin

• 500mg once daily for 7 days
• See MHRA Drug Safety Updates below

For Ciprofloxacin and Levofloxacin:

• MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
• MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects

Alternative option (use only if culture results available and susceptible):

Co-amoxiclav

• 500/125mg three times a day for 7 to 10 days

Trimethoprim

• 200mg twice daily for 14 days

See section: 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim, and 5.1.12 Quinolones

Antibiotics for pregnant women aged 12 years and over

Consider referring or seeking specialist advice for pregnant women aged 12 years and over

Cefalexin

• 1g three times a day for 7 to 10 days

Consult local microbiologist if cefalexin is not suitable.

Trimethoprim may be considered or advised by specialists. It is recommended that women who need to take trimethoprim during the first trimester also take high dose folic acid (5mg daily) until week 12 of pregnancy. Avoid trimethoprim if the woman has a low folate status or is on a folate antagonist (e.g. antiepileptic or proguanil)

See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim, and Resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation

Antibiotics for children and young people under 16 years

Children under 3 months of age

Infants and children under 3 months with a possible UTI should be referred to a paediatric specialist.

Children aged 3 months and over

Consider referring or seeking specialist advice for children aged 3 months and over

Cefalexin

• 3 months to 11 years:
  • 25mg/kg two to four times a day for 7 to 10 days
  • Maximum 1g per dose four times a day
• 12 to 15 years
  • 1g three times a day for 7 to 10 days
  • Maximum 1g per dose four times a day

Alternative option (use only if culture results available and susceptible):

Co-amoxiclav

• Use only if culture results available and susceptible
• Children and young people aged 3 months and over (doses given three times a day for 7 to 10 days):
  • 3 to 11 months: 0.25ml/kg (125/31 suspension) (dose doubled in severe infection)
  • 1 to 5 years: 5ml or 0.25ml/kg (125/31 suspension) (dose doubled in severe infection)
  • 6 to 11 years: 5ml or 0.15ml/kg (250/62 suspension) (dose doubled in severe infection)
  • 12 to 15 years: 250/125mg or 500/125mg

See section: 5.1.1 Penicillins and 5.1.2 Cephalosporins, carbapenems, and other beta-lactams,

NICE CG54 Urinary tract infection in under 16s: diagnosis and management (August 2007 [updated October 2018]).

NICE NG15: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (August 2015)

NICE NG63: Antimicrobial stewardship: changing risk-related behaviours in the general population (January 2017)

NICE NG109: Urinary tract infection (lower): antimicrobial prescribing (October 2018)

NICE NG109: Urinary tract infection (lower): antimicrobial prescribing – Visual summary (October 2018)

NICE NG110: Prostatitis (acute): antimicrobial prescribing (October 2018)

NICE NG111: Pyelonephritis (acute): antimicrobial prescribing (October 2018)

NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing (October 2018)

NICE NG113: Urinary tract infection (catheter-associated): antimicrobial prescribing (November 2018)

NICE NG143: Fever in under 5s: assessment and initial management (November 2019)

NICE QS90: Urinary tract infections in adults (June 2015)

European Association of Urology Guideline for Chronic Pelvic Pain (2019)

Royal College of General Practitioners: TARGET toolkit - UTI Resource Suite – Treating your infection Patient Information Leaflets

GOV.UK: Urinary tract infection: diagnostic tools for primary care - Quick reference materials