NICE publishes new antimicrobial prescribing guidance for urinary tract infections
NICE has published two new antimicrobial prescribing guidelines on the management of urinary tract infections (UTIs) – one for lower UTIs (also known as cystitis; NG109) and one for recurrent UTIs (NG112). NICE’s series of antimicrobial prescribing guidelines aim to provide evidence-based disease-specific advice to optimise antibiotic use and reduce antibiotic resistance.
The guidance on lower UTIs recommends that all patients should be offered advice on managing symptoms with self-care; this includes paracetamol or ibuprofen for pain and drinking enough fluids. NICE adds that there is no evidence for the efficacy of cranberry products or urine alkalinising agents. An antibiotic prescription (for use either immediately or as a back-up if symptoms fail to improve within 48 hours or worsen) should be considered for non-pregnant women with a lower UTI. In pregnant women, men and children (under 16 years), a urine sample should be sent for culture and an antibiotic offered immediately. A narrow-spectrum antibiotic should be used when possible. The antibiotics of first choice are nitrofurantoin (if eGFR ≥45ml/min) or (except in pregnant women) trimethoprim; second choices depend on the age and gender of the patient.
The guidance on recurrent UTIs recommends giving patients advice about behavioural and personal hygiene measures and self-care to prevent UTI. NICE suggests that non-pregnant women may wish to try D-mannose as a self-care option. Non-pregnant women and children may wish to try cranberry products, but NICE notes that the evidence for this is uncertain. There is also inconclusive evidence for the efficacy of probiotics. Vaginal (not oral) oestrogen can be considered for postmenopausal women if behavioural measures are not effective. In all patients with recurrent UTI, if there is no improvement following self-care, antibiotic prophylaxis can be considered, with the first choice being trimethoprim or nitrofurantoin and second choice amoxicillin or cefalexin.
Both sets of guidance are accompanied by a visual summary of the recommendations, which includes a treatment flowchart as well as tables outlining antibiotic choices in different patient groups.