Recommendations | Urinary tract infection (catheter-associated): antimicrobial prescribing | Guidance | NICE (2024)

1.1 Managing catheter-associated urinary tract infection

1.1.1

Be aware that:

  • a catheter-associated urinary tract infection (UTI) is a symptomatic infection of the bladder or kidneys in a person with a urinary catheter

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

  • antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter (see the NICE guideline on lower UTI: antimicrobial prescribing for managing asymptomatic bacteriuria in pregnant women).

1.1.2

Give advice about managing symptoms with self-care (see the recommendations on self-care) to all people with catheter-associated UTI.

Treatment

1.1.3

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

1.1.4

Obtain a urine sample before antibiotics are taken. Take the sample from the catheter, via a sampling port if provided, and use an aseptic technique (in line with the NICE guideline on healthcare-associated infections).

  • 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.

1.1.5

Send the urine sample for culture and susceptibility testing, noting a suspected catheter-associated infection and any antibiotic prescribed.

1.1.6

Offer an antibiotic (see the recommendations on choice of antibiotic) to people with catheter-associated UTI. Take account of:

  • the severity of symptoms

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

  • previous urine culture and susceptibility results

  • previous antibiotic use, which may have led to resistant bacteria.

1.1.7

Advice when an antibiotic prescription is given

1.1.8

When an antibiotic is given, as well as the general advice on self-care, give advice about:

  • possible adverse effects of antibiotics, particularly diarrhoea and nausea

  • seeking medical help if:

    • symptoms worsen at any time or

    • symptoms do not start to improve within 48hours of taking the antibiotic or

    • the person becomes systemically very unwell.

Reassessment

1.1.9

Reassess people with catheter-associated UTI if symptoms worsen at any time, or do not start to improve within 48hours of taking the antibiotic, taking account of:

  • other possible diagnoses

  • any symptoms or signs suggesting a more serious illness or condition, such as sepsis

  • previous antibiotic use, which may have led to resistant bacteria.

Referral and seeking specialist advice

1.1.10

Refer people with catheter-associated UTI to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis).

1.1.11

Consider referring or seeking specialist advice for people with catheter-associated UTI 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 catheter-associated UTIs or

  • have bacteria that are resistant to oral antibiotics.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on antibiotics for managing catheter-associated UTI.

Full details of the evidence and the committee's discussion are in the evidence review.

1.2 Self-care

1.2.1

Advise people with catheter-associated UTI about using paracetamol for pain.

1.2.2

Advise people with catheter-associated UTI about drinking enough fluids to avoid dehydration.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on self-care.

Full details of the evidence and the committee's discussion are in the evidence review.

1.3 Choice of antibiotic

1.3.1

When prescribing an antibiotic for catheter-associated UTI, take account of local antimicrobial resistance data and:

  • follow table1 for non-pregnant women and men aged 16years and over

  • follow table2 for pregnant women aged 12years and over

  • follow table3 for children and young people under 16years.

1.3.2

Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

1.3.3

Review intravenous antibiotics by 48hours and consider stepping down to oral antibiotics where possible.

Table1 Antibiotics for non-pregnant women and men aged 16years and over
Treatment Antibiotic, dosage and course length

First-choice oral antibiotics if no upper urinary tract infection (UTI) symptoms

Nitrofurantoin (if estimated glomerular filtration rate [eGFR] is 45ml/minute or more):

100mg modified-release twice a day (or if unavailable 50mg four times a day) for 7days

Trimethoprim (if low risk of resistance):

200mg twice a day for 7days

Amoxicillin (only if culture results available and susceptible):

500mg three times a day for 7days

Second-choice oral antibiotic if no upper UTI symptoms (when first‑choice not suitable)

Pivmecillinam (a penicillin):

400mg initial dose, then 200mg three times a day for a total of 7days

First-choice oral antibiotics if upper UTI symptoms

Cefalexin:

500mg twice or three times a day (up to 1g to 1.5g three or four times a day for severe infections) for 7to 10days

Co‑amoxiclav (only if culture results available and susceptible):

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

Trimethoprim (only if culture results available and susceptible):

200mg twice a day for 14days

Ciprofloxacin (only if other first-choice antibiotics are unsuitable):

500mg twice a day for 7days

See the MHRA January 2024 advicefor restrictions and precautions on using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate

First-choice intravenous antibiotics (if vomiting, unable to take oral antibiotics or severely unwell). Antibiotics may be combined if susceptibility or sepsis a concern

Co‑amoxiclav (only in combination, unless culture results confirm susceptibility):

1.2g three times a day

Cefuroxime:

750mg to 1.5g three or four times a day

Ceftriaxone:

1g to 2g once a day

Gentamicin:

Initially, 5mg/kg to 7mg/kg once a day, subsequent doses if needed adjusted according to serum gentamicin concentration (see the BNF for information on monitoring serum gentamicin concentration)

Amikacin:

Initially, 15mg/kg once a day (maximum per dose 1.5g once a day, subsequent doses if needed adjusted according to serum amikacin concentration (maximum 15g per course; see the BNF for information on monitoring serum amikacin concentration)

Ciprofloxacin (only if other first-choice antibiotics are unsuitable):

400mg twice or three times a day

See the MHRA January 2024 advicefor restrictions and precautions on using fluoroquinolone antibiotics because of the risk of disabling and potentially long‑lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate

Second-choice intravenous antibiotics

Consult local microbiologist

See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment and breastfeeding, and administering intravenous antibiotics.

Check any previous urine culture and susceptibility results, and antibiotic prescribing, and choose antibiotics accordingly.

Nitrofurantoin may be used with caution if eGFR is 30ml/minute to 44ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug-resistant bacteria and only if potential benefit outweighs risk (BNF, nitrofurantoin, August2018).

Nitrofurantoin and pivmecillinam are only licensed for uncomplicated lower UTIs, and are not suitable for people with upper UTI symptoms or a blocked catheter.

A lower risk of resistance to trimethoprim is likely if it was not used in the past 3months, 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 is likely with recent use and in older people in care homes.

Review intravenous antibiotics by 48hours and consider stepping down to oral antibiotics where possible.

Table2 Antibiotics for pregnant women aged 12years and over
Treatment Antibiotic, dosage and course length

First-choice oral antibiotic

Cefalexin:

500mg twice or three times a day (up to 1g to 1.5g three or four times a day for severe infections) for 7to 10days

First-choice intravenous antibiotic (if vomiting, unable to take oral antibiotics, or severely unwell)

Cefuroxime:

750mg to 1.5g three or four times a day

Second-choice antibiotics or combining antibiotics if susceptibility or sepsis is a concern

Consult local microbiologist

See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics.

Check any previous urine culture and susceptibility results, and antibiotic prescribing and choose antibiotics accordingly.

Review intravenous antibiotics by 48hours and consider stepping down to oral antibiotics where possible.

Table3 Antibiotics for children and young people under 16years
Treatment Antibiotic, dosage and course length

Children under 3months

Refer to paediatric specialist and treat with intravenous antibiotics in line with the NICE guideline on fever in under5s

First-choice oral antibiotics in children aged 3months and over

Trimethoprim (if low risk of resistance):

3months to 5months, 4mg/kg (maximum 200mg per dose) or 25mg twice a day for 7to 10days

6months to 5years, 4mg/kg (maximum 200mg per dose) or 50mg twice a day for 7to 10days

6years to 11years, 4mg/kg (maximum 200mg per dose) or 100mg twice a day for 7to 10days

12years to 15years, 200mg twice a day for 7to 10days

Amoxicillin (only if culture results available and susceptible):

3months to 11months, 125mg three times a day for 7to 10days

1year to 4years, 250mg three times a day for 7to 10days

5years to 15years, 500mg three times a day for 7to 10days

Cefalexin:

3months to 11months, 12.5mg/kg or 125mg twice a day for 7to 10days (25mg/kg two to four times a day [maximum 1g per dose four times a day] for severe infections)

1year to 4years, 12.5mg/kg twice a day or 125mg three times a day for 7to 10days (25mg/kg two to four times a day [maximum 1g per dose four times a day] for severe infections)

5years to 11years, 12.5mg/kg twice a day or 250mg three times a day for 7to 10days (25mg/kg two to four times a day [maximum 1g per dose four times a day] for severe infections)

12years to 15years, 500mg twice or three times a day (up to 1g to 1.5g three or four times a day for severe infections) for 7to 10days

Co‑amoxiclav (only if culture results available and susceptible):

3months to 11months, 0.25ml/kg of 125/31 suspension three times a day for 7to 10days (dose doubled in severe infection)

1year to 5years, 0.25ml/kg of 125/31 suspension or 5ml of 125/31 suspension three times a day for 7to 10days (dose doubled in severe infection)

6years to 11years, 0.15ml/kg of 250/62 suspension or 5ml of 250/62 suspension three times a day for 7to 10days (dose doubled in severe infection)

12years to 15years, 250/125mg or 500/125mg three times a day for 7to 10days

First-choice intravenous antibiotics (if vomiting, unable to take oral antibiotics or severely unwell) in children aged 3months and over.

Antibiotics may be combined if susceptibility or sepsis a concern

Co‑amoxiclav (only in combination unless culture results confirm susceptibility):

3months to 15years, 30mg/kg three times a day (maximum 1.2g three times a day)

Cefuroxime:

3months to 15years, 20mg/kg three times a day (maximum 750mg per dose); (50to 60mg/kg three or four times a day [maximum 1.5g per dose] for severe infections)

Ceftriaxone:

3months to 11years (up to 50kg), 50to 80mg/kg once a day (maximum 4g per day)

9years to 11years (50kg and above), 1g to 2g once a day

12years to 15years, 1g to 2g once a day

Gentamicin:

Initially, 7mg/kg once a day, subsequent doses if needed adjusted according to serum gentamicin concentration (see the BNF for children for information on monitoring serum gentamicin concentration)

Amikacin:

Initially, 15mg/kg once a day, subsequent doses adjusted according to serum amikacin concentration (see the BNF for children for information on monitoring serum amikacin concentration)

Second-choice intravenous antibiotic

Consult local microbiologist

See the BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics. See table2 if a young woman is pregnant.

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 being treated and the child's size in relation to the average size of children of the same age.

Check any previous urine culture and susceptibility results, and antibiotic prescribing and choose antibiotics accordingly. If a child or young person is receiving prophylactic antibiotics, treatment should be with a different antibiotic, not a higher dose of the same antibiotic.

A lower risk of resistance to trimethoprim is likely if it was not used in the past 3months, 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 is likely with recent use.

Review intravenous antibiotics by 48hours and consider stepping down to oral antibiotics where possible for a total antibiotic course of 10days.

If intravenous treatment is not possible, consider intramuscular treatment if suitable.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on antibiotics for managing catheter-associated UTI.

Full details of the evidence and the committee's discussion are in the evidence review.

1.4 Preventing catheter-associated urinary tract infections

1.4.1

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

1.4.2

Give advice about seeking medical help if symptoms of an acute UTI develop.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on antibiotic prophylaxis for preventing catheter-associated UTI and the NICE guideline on healthcare-associated infections.

Full details of the evidence and the committee's discussion are in the evidence review.

Recommendations | Urinary tract infection (catheter-associated): antimicrobial prescribing | Guidance | NICE (2024)
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