In an era of increasing resistance to antibiotics and an increasing awareness of the need for shared decision making in healthcare it is important for patients presenting with UTI symptoms to have the opportunity to discuss options with their healthcare professional to determine the best approach. Some patients may prefer to avoid taking antibiotics and prefer a ‘watch and wait’ approach if symptoms are not severe.

All women who are symptomatic of UTI should receive appropriate verbal and/or written self-care advice at every consultation regardless of diagnosis and treatment.

Fluid intake
Increasing fluid intake is thought to reduce UTI by dilution and flushing of bacteriuria. This reduces attachment to uroepithelial cells, reduces growth nutrients and/or improves clearance (see section 5.1.1).

While no evidence was identified for benefit, increasing fluid intake with water in women with urinary symptoms is a low-cost intervention without evidence of harm that may provide symptomatic relief.

Discuss steps women can take to reduce the chances of having further UTIs, including:

• drinking plenty of fluid.
• avoidance of spermicide containing contraceptives.
• personal hygiene.
• voiding behaviours.

Non-steroidal anti-inflammatory drugs (NSAIDs) have been investigated as an alternative strategy to antibiotics in the treatment of uncomplicated LUTI in women. The rationale is to minimise self-limiting symptoms, avoid the need for antibiotic therapy and reduce risk of subsequent antimicrobial resistance.

Recommendations

Recommendation
Consider NSAIDs as first-line treatment in women aged <65 years with suspected uncomplicated lower UTI who describe their symptoms as mild.

Good practice point
Consider NSAIDs as an alternative to an antibiotic following a discussion of risks and benefits in women aged <65 years with suspected uncomplicated lower UTI when symptoms are moderate to severe.

Good practice point
The decision to use an NSAID or antibiotic should be shared between patient and prescriber and risks and benefits should be fully discussed and considered. This is particularly important in women with comorbidities that increase renal impairment.  

Good practice point
Duration of NSAIDs should be limited to three days to minimise adverse effects.

Good practice point
Patients receiving NSAIDs should be informed to contact their prescriber if UTI symptoms do not resolve within three days or worsen.

Evidence - see section 3.2.2 in full guideline

Antimicrobials achieve clinical and microbiological cure of disease more rapidly than placebo⁵⁶ and are able to shorten the duration of symptoms such as dysuria, frequency, and urgency by half and shorten the average period with symptoms which the patient perceives to be moderately bad or worse by a third.

Treating patients who have LUTI with antimicrobials does not significantly affect risk of pyelonephritis compared with treatment with placebo (OR 0.33, 95% CI 0.04 to 2.7)⁵⁶ and results in equal or lower risk compared with treatment with NSAIDs (see Table 3 -  RCTs of non-antibiotic pharmacological and non-pharmacological treatments v antibiotic treatment of uncomplicated LUTI in women).

Choice of antimicrobial agent

Recommendation

Use a narrow-spectrum antimicrobial with activity against common uropathogens (see Table 4) for empirical treatment of LUTI in suitable patients.

Recommendation
Do not use fluroroquinolones or co-amoxiclav empirically for LUTI unless other narrow-spectrum agents are contraindicated due to comorbidity, toxicity or resistance.

Good practice point
Advise women with LUTI, who are prescribed nitrofurantoin, not to take alkalinising agents (such as potassium citrate, sodium citrate, or sodium bicarbonate).

Good practice point
The choice of agent for an individual patient should be based on available microbiological results, tolerability and balance of risk versus benefit.

Good practice point
Local guidance should take local resistance patterns and risk stratification into account.

Evidence - See section 3.2.4.1 in full guideline.

Comparison of selected antimicrobial agents for treatment of LUT (see Table 4).

Duration of treatment

Recommendation

Use short (3-day) courses of antimicrobials for treatment for LUTI, as this is clinically effective and minimises the risk of adverse events.

Evidence - See section 3.2.4.2 in full guideline.

Adverse events

No recommendations defined.

Adverse events are significantly more likely in individuals treated with antimicrobials.

Adverse effects from any class of antimicrobial were significantly less common with 3-day treatment courses compared with 5–7 day courses.

Evidence - See section 3.2.4.3 in full guideline.

Asymptomatic bacteriuria in non-pregnant women

Recommendation
Do not treat asymptomatic bacteriuria in non-pregnant women of any age.

Evidence - See section 3.2.4.4 in full guideline.

Delayed prescription of antimicrobials

Insufficient evidence about the impact of delayed prescription of antimicrobials was identified to support the development of recommendations.

Evidence - See section 3.2.4.5 in full guideline.

Good practice point

Decision making should be shared between patient and prescriber and risks and benefits should be fully discussed and considered.

Evidence - See section 3.2.5 in full guideline.

Follow link to 'Provision of Information' section to view checklist.