management of uncomplicated UTI in a woman

Last edited 06/2021 and last reviewed 08/2023

General Principles of management of UTI in adults (no fever or flank pain) (1)

  • the diagnostic significance of symptoms is dependent on the age of the patient. See linked items for consideration of a possible UTI in woman under 65 years of age; possible UTI of woman over 65 years of age

  • always safety net

  • first line: nitrofurantoin if GFR over 45ml/min
    • GFR 30-45: only use if resistance & no alternative
    • in treatment failure: always perform culture

NICE guidance for management of UTI in an non-pregnant woman (2)

  • consider a back-up antibiotic prescription or immediate antibiotic, noting that the evidence for back-up antibiotics was from women not needing immediate treatment
    • if urine sent for culture and susceptibility, and antibiotic given:
        • review antibiotic choice when results available, and
        • change antibiotic for pregnant women if bacteria resistant
        • change antibiotic for children and young people, men and non-pregnant women if bacteria resistant and symptoms not improving
      • a narrow spectrum antibiotic should be used when possible

    • with all antibiotic prescriptions, advise:
      • possible adverse effects of antibiotics include diarrhoea and nausea
      • seeking medical help if symptoms worsen at any time, do not improve within 48 hours of taking the antibiotic, or the person becomes very unwell
    • with a back-up antibiotic prescription, also advise:
      • antibiotic is not needed immediately
      • use prescription if no improvement in 48 hours or symptoms worsen at any time

    • reassess at any time if symptoms worsen rapidly or significantly or do not improve in 48 hours of taking antibiotics, sending a urine sample for culture and susceptibility if not already done. Take account of:
      • other possible diagnoses
      • any symptoms or signs suggesting a more serious illness or condition
      • previous antibiotic use, which may have led to resistance

    • Refer to hospital if a person aged 16 or over has any symptoms or signs suggesting a more serious illness or condition (for example, sepsis)

Choice of antibiotic 1,2,3: non-pregnant women aged 16 years and over

  • First choice
    • nitrofurantoin - if eGFR >=45 ml/minute4
      • 100 mg modified-release twice a day for 3 days
    • OR
    • trimethoprim - if low risk of resistance5
      • 200 mg twice a day for 3 days
  • Second choice (no improvement in lower UTI symptoms on first choice taken for at least 48 hours, or when first choice not suitable)3, 6
    • nitrofurantoin - if eGFR >=45 ml/minute4 and not first choice
      • 100 mg modified-release twice a day for 3 days
    • OR
    • pivmecillinam (a penicillin)
      • 400 mg initial dose, then 200 mg three times a day for a total of 3 days
    • OR
    • fosfomycin
      • 3 g single dose sachet

Notes:

  • 1 check BNF for use and dosing in specific populations, for example, hepatic impairment, renal impairment and breast-feeding.
  • 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 antibiotics accordingly.
  • 4 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).
  • 5 alower 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 local epidemiology data suggest resistance is low. A higher risk of resistance may be more likely with recent use and in older people in residential facilities.
  • 6 ifthere 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.

Risk factors for increased resistance include:

  • care home resident,
  • recurrent UTI,
  • hospitalisation >7d in the last 6 months,
  • unresolving urinary symptoms,
  • recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related,
  • previous known UTI resistant to trimethoprim, cephalosporins or quinolones

More extensive details of drug treatment are provided in the BNF (section 5.1.13).

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