Recommendations

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 1 month nearly all people have bacteriuria

  • antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter[1].

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 7 days. 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 When urine culture and susceptibility results are available:

  • review the choice of antibiotic and

  • change the antibiotic according to susceptibility results if the bacteria are resistant, using narrow-spectrum antibiotics wherever possible.

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 48 hours 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 48 hours 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.

See the evidence and committee discussion on antibiotics for managing catheter-associated UTI.

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.

See the evidence and committee discussion on self-care.

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 table 1 for non-pregnant women and men aged 16 years and over

  • follow table 2 for pregnant women aged 12 years and over

  • follow table 3 for children and young people under 16 years.

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

Table 1 Antibiotics for non-pregnant women and men aged 16 years and over

Antibiotic 1

Dosage and course length

First-choice oral antibiotic if no upper UTI symptoms 2

Nitrofurantoin – if eGFR ≥45 ml/minute3,4

100 mg modified-release twice a day for 7 days

Trimethoprim – if low risk of resistance5

200 mg twice a day for 7 days

Amoxicillin (only if culture results available and susceptible)

500 mg three times a day for 7 days

Second-choice oral antibiotic if no upper UTI symptoms (when first-choice not suitable) 2

Pivmecillinam (a penicillin)4

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

First-choice oral antibiotic if upper UTI symptoms 2

Cefalexin

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

Co-amoxiclav (only if culture results available and susceptible)

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

Trimethoprim (only if culture results available and susceptible)

200 mg twice a day for 14 days

Ciprofloxacin (consider safety issues6)

500 mg twice a day for 7 days

First-choice intravenous antibiotic (if vomiting, unable to take oral antibiotics or severely unwell). Antibiotics may be combined if susceptibility or sepsis a concern 2,7

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

1.2 g three times a day

Cefuroxime

750 mg to 1.5 g three or four times a day

Ceftriaxone

1 to 2 g once a day

Ciprofloxacin (consider safety issues6)

400 mg twice or three times a day

Gentamicin

Initially 5 to 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration8

Amikacin

Initially 15 mg/kg once a day (maximum per dose 1.5 g once a day), subsequent doses adjusted according to serum amikacin concentration (maximum 15 g per course)8

Second-choice intravenous antibiotic

Consult local microbiologist

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

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

3 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).

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

5 A lower risk of resistance is 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 is likely with recent use and in older people in care homes.

6 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are an option in catheter-associated UTI with upper UTI symptoms, which is a severe infection.

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

8 Therapeutic drug monitoring and assessment of renal function is required (BNF, August 2018).

Abbreviations: BNF, British national formulary; eGFR, estimated glomerular filtration rate; UTI, urinary tract infection.

Table 2 Antibiotics for pregnant women aged 12 years and over

Antibiotic 1

Dose and course length

First-choice oral antibiotic 2

Cefalexin

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

First-choice intravenous antibiotic (if vomiting, unable to take oral antibiotics, or severely unwell) 2,3

Cefuroxime

750 mg to 1.5 g three or four times a day

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

Consult local microbiologist

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

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

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

Table 3 Antibiotics for children and young people under 16 years

Antibiotic 1

Dosage and course length 2

Children under 3 months

Refer to paediatric specialist and treat with intravenous antibiotics in line with the NICE guideline on fever in under 5s.

Children aged 3 months and over

First-choice oral antibiotics 3

Trimethoprim – if low risk of resistance4

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

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

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

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

Amoxicillin (only if culture results available and susceptible)

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

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

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

Cefalexin

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

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

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

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

Co-amoxiclav (only if culture results available and susceptible)

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

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

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

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

First-choice intravenous antibiotics (if vomiting, unable to take oral antibiotics or severely unwell). Antibiotics may be combined if susceptibility or sepsis a concern 3,5,6

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

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

Cefuroxime

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

Ceftriaxone

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

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

12 to 15 years, 1 to 2 g once a day

Gentamicin

Initially 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration7

Amikacin

Initially 15 mg/kg once a day, subsequent doses adjusted according to serum amikacin concentration7

Second-choice intravenous antibiotic

Consult local microbiologist

1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics. See table 2 if a young woman is pregnant.

2 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.

3 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.

4 A lower risk of resistance is 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 is likely with recent use.

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

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

7 Therapeutic drug monitoring and assessment of renal function is required (BNFC, August 2018).

See the evidence and committee discussion on antibiotics for managing catheter-associated UTI.

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.

See the evidence and committee discussion on antibiotic prophylaxis for preventing catheter-associated UTI and the NICE guideline on healthcare-associated infections.



[1] See the NICE guideline on lower UTI: antimicrobial prescribing for managing asymptomatic bacteriuria in pregnant women.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)