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

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 (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 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.

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 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**
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 45 ml/minute or more: 100 mg modified-release twice a day (or if unavailable 50 mg four times a day) for 7 days Trimethoprim (if low risk of resistance): 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)	Pivmecillinam (a penicillin): 400 mg initial dose, then 200 mg three times a day for a total of 7 days
First-choice oral antibiotics if upper UTI symptoms	Cefalexin: 500 mg twice or three times a day (up to 1 g 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 issues): 500 mg twice a day for 7 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	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 g to 2 g once a day Ciprofloxacin (consider safety issues): 400 mg twice or three times a day Gentamicin: Initially, 5 mg/kg to 7 mg/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, 15 mg/kg once a day (maximum per dose 1.5 g once a day, subsequent doses if needed adjusted according to serum amikacin concentration (maximum 15 g per course; see the BNF for information on monitoring serum amikacin concentration)
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 30 ml/minute to 44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug-resistant bacteria and only if potential benefit outweighs risk (BNF, nitrofurantoin, August 2018).

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 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.

See the Medicines and Healthcare products Regulatory Agency advice for restrictions and precautions for using fluoroquinolone antibiotics because of very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

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

**Table 2 Antibiotics for pregnant women aged 12 years and over**
Treatment	Antibiotic, dosage and course length
First-choice oral antibiotic	Cefalexin: 500 mg twice or three times a day (up to 1 g 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)	Cefuroxime: 750 mg to 1.5 g 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 48 hours and consider stepping down to oral antibiotics where possible.

**Table 3 Antibiotics for children and young people under 16 years**
Treatment	Antibiotic, dosage and course length
Children under 3 months	Refer to paediatric specialist and treat with intravenous antibiotics in line with the NICE guideline on fever in under 5s
First-choice oral antibiotics in children aged 3 months and over	Trimethoprim (if low risk of resistance): 3 months 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 years to 11 years, 4 mg/kg (maximum 200 mg per dose) or 100 mg twice a day for 7 to 10 days 12 years to 15 years, 200 mg twice a day for 7 to 10 days Amoxicillin (only if culture results available and susceptible): 3 months to 11 months, 125 mg three times a day for 7 to 10 days 1 year to 4 years, 250 mg three times a day for 7 to 10 days 5 years to 15 years, 500 mg three times a day for 7 to 10 days Cefalexin: 3 months 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 year 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 years 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 years to 15 years, 500 mg twice or three times a day (up to 1 g 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 months 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 year 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 years 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 years 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) in children aged 3 months and over Antibiotics may be combined if susceptibility or sepsis a concern	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 years to 11 years (50 kg and above), 1 g to 2 g once a day 12 years to 15 years, 1 g to 2 g once a day Gentamicin: Initially, 7 mg/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, 15 mg/kg once a day, subsequent doses adjusted according to serum amikacin concentration (see the 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 table 2 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 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.

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

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.