NICE antimicrobial prescribing guidelines

Key points

1. No evidence found for cranberry products or urine alkalinising agents to treat lower UTI

2. Screen and treat for asymptomatic bacteriuria in pregnant women to reduce the risk of pyelonephritis and preterm delivery

3. Seek medical help if symptoms do not improve by 48hr

4. In non-pregnant women offer back-up or immediate antibiotic, in all other individuals (men, children, pregnant women) offer immediate antibiotic.

5. Use MSU culture and sensitivity results to:

   Change antibiotic for pregnant women if bacteria resistant

   Consider changing antibiotic in men, women, children if bacteria resistant AND symptoms not improving

Lower urinary tract infection in adults

Non-pregnant women —> 3-day course
nitrofurantoin (eGFR>45) 100mg MR BD
trimethoprim 200mg BD
[2nd line: pivmecillinam (400mg+200mg TDS 3 days) or fosfomycin (3g single dose)]

Pregnant women OR asymptomatic bacteriuria in pregnancy —-> 7-day course
nitrofurantoin (eGFR>45; avoid at term; 100mg MR BD)
[2nd line: amoxicillin (500mg TDS; sensitive on culture) or cefalexin (500mg BD)]

Men —-> 7-day course
nitrofurantoin (if eGFR>45; 100mg MR BD)
trimethoprim 200mg BD

Lower urinary tract infection in children

Age <3 months: refer to paediatrician, intravenous antibiotics

Age>3 months —> 3-day course

1st line
nitrofurantoin (if eGFR>45) 750mcg/kg QDS
trimethoprim 4mg/kg

2nd line
amoxicillin (sensitive on culture)
cefalexin 12.5mg/kg

Recurrent UTI in adults

Lifestyle (hydration, avoid constipation, post-coital voiding)

D-mannose (2g in divided doses)
Methenamine hippurate (1g BD) +/- Vitamin C supplement

Post-menopausal women: vaginal oestrogen

1. Long-term antibiotic prophylaxis:
   trimethoprim (100mg nocte)
   nitrofurantoin if eGFR>45 (50-100mg nocte)
   cefalexin 125mg or amoxicillin 250mg nocte

2. Single-dose trigger prophylaxis (e.g. post-coital)

3. Self-start antibiotic course (3-5 days)

4. Cystoscopy: Intravesical glycosaminoglycan layer therapy
   and/or intravesical antibiotics

Recurrent UTI in children (specialist advice)

Long-term antibiotic prophylaxis:

Age <3 months: specialist advice

Age>3 months
trimethoprim 2mg/kg nocte
nitrofurantoin 1mg/kg
cefalexin 12.5mg/kg
amoxicillin (off-label use)

Acute pyelonephritis in adults

Non-pregnant women and men
Oral (7-10 days)
cefalexin 500mg TDS
co-amoxiclav (sensitive on culture) 500/125mg

IV
iv cefuroxime 1.5g TDS
iv co-amoxiclav 1.2g TDS (sensitive on culture)
iv ceftriaxone 1g BD

Pregnant women
cefalexin 500mg TDS 7-10 days
iv cefuroxime 1.5g TDS

Acute pyelonephritis in children

Age<3m refer to paediatrician for iv antibiotics

Age>3m

Oral (7-10 days)
cefalexin 12.5mg/kg
co-amoxiclav (sensitive on culture)

IV
iv co-amoxiclav (sensitive on culture)
iv cefuroxime 20mg/kg
iv: ceftriaxone