Guidance
Summary of the evidence
Summary of the evidence
Self-care
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One randomised controlled trial (RCT; Gunnarsson et al. 2017) in adult females (n=92) who had a hip fracture and a perioperative urinary catheter with planned removal at 48 hours, compared cranberry juice concentrate (capsules) with placebo for the prevention of postoperative urinary tract infection (UTI). There were no significant differences in positive urine cultures (>104 colony-forming units per ml) at either 5 or 14 days after surgery (low quality evidence).
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No systematic reviews or RCTs of any other non-antimicrobial treatments were identified that met the inclusion criteria.
Committee discussion on self-care
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Antibiotics for managing catheter-associated UTI
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In most cases, managing symptomatic catheter-associated UTI will require antibiotics.
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Gram-negative bacteria, particularly Escherichia coli (E. coli), are the most common causative pathogens in UTIs. However, catheter-associated UTI can be associated with more than 1 bacterial species and is often caused by bacteria that are resistant to antibiotics (European Association of Urology guidelines on urological infections 2017).
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UTI is the most common healthcare-acquired infection, accounting for 19% of all healthcare-associated infections, with around half of these infections due to an indwelling urinary catheter (Health Protection Agency 2012). In some people, catheter-associated UTI can lead to a more serious systemic infection (urosepsis).
Efficacy of antibiotics
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One RCT (Leone et al. 2007) of adults with asymptomatic bacteriuria admitted to an intensive care unit with a short-term catheter found that a short course (3 days) of antibiotics and catheter change did not significantly reduce the proportion of patients with urosepsis (p=1, low quality evidence), or bacteraemia or severe sepsis (p>0.05, low quality evidence), compared with no antibiotics and no catheter change. Short-course antibiotics and catheter change significantly reduced the proportion of positive urine cultures (>105 colony-forming units/ml) at 7 days (30% versus 70%, number needed to treat [NNT] 3 [range 2 to 6], moderate quality evidence) but not at 15 days (very low quality evidence).
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One RCT (Darouiche et al. 2014) of hospitalised adults with a long-term catheter for spinal cord injury and catheter-associated UTI found that a shorter course (5 days) of antibiotics plus a catheter change was not significantly different to 10 days of antibiotics and no catheter change for clinical cure at the end of therapy (p<0.001 for non-inferiority, moderate quality evidence). However, for other outcomes (microbiological response and resolution of pyuria at the end of therapy), the short course and catheter change was not as effective as the long course and no catheter change. There were also significantly more episodes of recurrent UTI in the short course plus catheter change group compared with the long course and no catheter change group (32.1% versus 11.1%, p=0.043; low quality evidence).
Changing the catheter before antibiotics
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One prospective open-label RCT (Raz et al. 2000) in older adults in a long-stay care facility with a long-term catheter and catheter-associated UTI compared catheter change before antibiotics with no catheter change before antibiotics. Antibiotic therapy was ciprofloxacin or ofloxacin, initially intravenously then orally for 14 days. There was a significant difference in cure or improvement, favouring catheter change at 72 hours (92.6% versus 40.7%, NNT 2 [range 2 to 4]; moderate quality evidence) and 28 days (88.9% versus 59.3%, NNT 4 [range 2 to 14]; low quality evidence), but not at 7 days. There was no significant difference in recurrence or treatment failure at either 7 or 28 days, but mortality was significantly lower in the catheter change group (0% versus 7.4% [urosepsis in 1 person on day 2 and 1 person on day 3]; very low quality evidence).
Safety of antibiotics
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The RCT on duration of antibiotics (and catheter change) for people with spinal cord injury and catheter-associated UTI (Darouiche et al. 2014) found no significant difference in adverse events between the no catheter change and 10 days of antibiotics group, and the catheter change and 5 days of antibiotics group (40.7% versus 64.3%%; low quality evidence).
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Antibiotic-associated diarrhoea occurs in 2 to 25% of people taking antibiotics, depending on the antibiotic used (NICE clinical knowledge summary on diarrhoea – antibiotic associated).
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About 10% of the general population claim to have a penicillin allergy; this is often because of a skin rash that occurred while taking a course of penicillin as a child. Fewer than 10% of people who think they are allergic to penicillin are truly allergic. See the NICE guideline on drug allergy for more information.
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People with a history of immediate hypersensitivity to penicillins may also react to cephalosporins and other beta‑lactam antibiotics (BNF, August 2018).
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Nitrofurantoin should be used with caution in those with renal impairment. It should be avoided at term in pregnancy because it may produce neonatal haemolysis. Adults (especially older adults) and children on long-term therapy should be monitored for liver function and pulmonary symptoms (BNF, August 2018).
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Trimethoprim has a teratogenic risk in the first trimester of pregnancy (folate antagonist; BNF, August 2018). The manufacturers advise that it is contraindicated in pregnancy (trimethoprim summary of product characteristics).
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Fluoroquinolones are generally not recommended in children or young people who are still growing (BNF, August 2018). The manufacturers advise to avoid in pregnancy (ciprofloxacin summary of product characteristics). Tendon damage (including rupture) has been reported rarely in people receiving fluoroquinolones (BNF, August 2018), and the European Medicines Agency's Pharmacovigilance Risk Assessment Committee (press release October 2018) has recommended restricting the use of these antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons and bones and the nervous system. Fluoroquinolones remain an option in catheter-associated UTI with upper UTI symptoms, which is a severe infection.
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Aminoglycosides doses are based on weight and renal function and whenever possible treatment should not exceed 7 days (BNF, August 2018).
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See the summaries of product characteristics for information on contraindications, cautions and adverse effects of individual medicines.
Committee discussion on antibiotics for managing catheter-associated UTI
Committee discussion on choice of antibiotic
Non-pregnant women and men with catheter-associated UTI
Pregnant women with catheter-associated UTI
Children and young people with catheter-associated UTI
Committee discussions on antibiotic course length
Course length for non-pregnant women, pregnant women, men, children and young people with catheter-associated UTI
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Antibiotic prophylaxis for preventing catheter-associated UTI
Antibiotic prophylaxis for people with a long-term (indwelling or intermittent) catheter
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One systematic review (Niël-Weise et al. 2012) found that antibiotic prophylaxis for adults using intermittent self-catheterisation was associated with fewer episodes of either asymptomatic or symptomatic bacteriuria (incidence density rate [IDR] 0.61, 95% confidence interval [CI] 0.44 to 0.87, with significant heterogeneity, using a fixed-effect model; low quality evidence) compared with antibiotics only when microbiologically indicated. Another RCT (not included in the systematic review by Niël-Weise et al. 2012) also favoured antibiotic prophylaxis for a similar population (incidence rate ratio [IRR] 0.34, 95% CI 0.156 to 0.74; moderate quality evidence). However, 1 additional RCT included in the systematic review found no significant benefit of antibiotic prophylaxis compared with antibiotics when microbiologically indicated for the number of episodes of bacteriuria.
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Two RCTs in the systematic review (Niël-Weise et al. 2012) showed inconsistent results for antibiotic prophylaxis for symptomatic bacteriuria in adults using intermittent catheterisation compared with antibiotics when microbiologically indicated. In 1 RCT, fewer participants had at least 1 episode of symptomatic bacteriuria with antibiotic prophylaxis compared with antibiotics when microbiologically indicated (6.1% versus 31.7%, NNT 4 [range 3 to 8]; moderate quality evidence). In the other RCT, there was no significant difference in the rate of symptomatic bacteriuria between groups.
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One RCT in the systematic review (Niël-Weise et al. 2012) compared antibiotic prophylaxis with antibiotics when clinically indicated in older adults in nursing homes with indwelling urinary catheters. There were no statistically significant differences between groups for episodes of symptomatic UTI, rates of visual encrustation, or catheter obstructions (very low to low quality evidence). The prophylaxis group had a higher number of participants with improved general condition (52.2% versus 4.3%, NNT 3 [range 2 to 4]; very low quality evidence).
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Evidence from 2 RCTs in the systematic review (Niël-Weise et al. 2012) included children with neurogenic bladder using intermittent catheterisation and found no significant difference between antibiotic prophylaxis and antibiotics only when clinically indicated for symptomatic UTI.
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Evidence from 1 RCT in the systematic review (Niël-Weise et al. 2012) included children with spina bifida using intermittent catheterisation and found no significant difference in the risk of febrile symptomatic UTI when antibiotic prophylaxis was discontinued at 6 months compared with continued prophylaxis. However, there were significantly fewer afebrile symptomatic UTIs in the group continuing antibiotic prophylaxis (IDR 0.69, 95% CI 0.55 to 0.87; low quality evidence).
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The systematic review (Niël-Weise et al. 2012) found no significant difference in adverse events between antibiotic prophylaxis and antibiotics when microbiologically indicated in adults using intermittent catheterisation. There was also no significant difference between antibiotic prophylaxis and antibiotics when clinically indicated in the rates of adverse events in older people in nursing homes (low quality evidence).
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One open-label RCT (Fisher et al. 2018) in adults using clean intermittent self-catheterisation who had recurrent UTIs found antibiotic prophylaxis reduced symptomatic UTIs requiring antibiotic treatment by 48% compared with no prophylaxis at 6 months' follow‑up (IRR 0.52, 95% CI 0.44 to 0.61; moderate quality evidence). Prophylaxis also reduced the incidence of microbiologically confirmed symptomatic UTI requiring antibiotic treatment at 6 months' follow‑up compared with no prophylaxis (IRR 0.49, 95% CI 0.39 to 0.6; moderate quality evidence). Prophylaxis did not reduce the incidence of febrile UTI or asymptomatic bacteriuria.
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The RCT (Fisher et al. 2018) found that antibiotic prophylaxis increased adverse events, mainly nausea, diarrhoea and Candida infection, compared with no prophylaxis (9.4% versus 2.0%, number needed to harm 16 [95% CI 9 to 40]; low quality evidence).
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The RCT (Fisher et al. 2018) found that antibiotic prophylaxis increased antibiotic resistance to nitrofurantoin, trimethoprim and co‑trimoxazole compared with no prophylaxis, but not to amoxicillin, cefalexin, ciprofloxacin, co‑amoxiclav and mecillinam. There was an increasing trend towards antibiotic resistance at 12 months compared with baseline for amoxicillin, cefalexin, co‑trimoxazole and trimethoprim, but not for ciprofloxacin, co‑amoxiclav and nitrofurantoin. There was no increase in resistance over 12 months to any antibiotic in the 'no prophylaxis' group or in perianal swabs for E. coli for either the prophylaxis or 'no prophylaxis' groups.
Antibiotic prophylaxis before or during short-term catheterisation in hospital
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One systematic review (Lusardi et al. 2013) compared antibiotic prophylaxis with no prophylaxis in hospitalised adults with a short-term catheter. A meta-analysis of 3 RCTs of surgical patients showed a significant reduction in asymptomatic bacteriuria with antibiotics (8.2% versus 31.3%, NNT 5 [range 4 to 7]; moderate quality evidence). Two further RCTs of non-surgical patients could not be pooled for the outcome of asymptomatic bacteriuria because of heterogeneity. One study showed no reduction with antibiotics (low quality evidence) and the other a significant reduction with antibiotics (10% versus 53.7%, NNT 3 [range 2 to 4], moderate quality evidence). One RCT of surgical patients found significantly fewer cases of symptomatic bacteriuria with antibiotic prophylaxis (6.3% versus 31%, NNT 4 [range 3 to 11]).
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The systematic review (Lusardi et al. 2013) also found that antibiotic prophylaxis was associated with a significantly lower risk of pyuria (presence of white cells in the urine) in surgical patients (7.5% versus 32.9%, NNT 4 [range 3 to 7]; moderate quality evidence) and significantly reduced febrile (high temperature) morbidity (12.5% versus 23.2%, NNT 10 [range 6 to 52]; very low quality evidence).
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Evidence from 1 additional RCT (Dieter et al. 2014) found the risk of requiring antibiotic treatment for a UTI within 3 weeks of urinary catheterisation for pelvic organ prolapse or urinary incontinence surgery was not significantly associated with prophylactic use of nitrofurantoin compared with placebo (moderate quality evidence).
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The systematic review (Lusardi et al. 2013) found no significant difference between levofloxacin and ciprofloxacin (very low quality evidence) or between 2 different doses of ciprofloxacin (250 mg versus 1,000 mg daily; very low quality evidence) for asymptomatic bacteriuria at follow‑up.
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Evidence from 1 RCT in the systematic review (Lusardi et al. 2013) found that a single antibiotic dose at the time of catheterisation only compared with antibiotic prophylaxis throughout the entire period of catheterisation was associated with significantly fewer cases of bacteriuria (12.5% versus 42.9%, NNT 4 [range 2 to 13]; low quality evidence).
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The systematic review (Lusardi et al. 2013) included 3 RCTs that reported adverse reactions to antibiotics. One RCT reported 23 adverse reactions; none were judged to be treatment related and there were no serious adverse events. A second RCT reported no serious adverse reactions to co‑trimoxazole. The third RCT reported that 3 patients taking ciprofloxacin had moderate gastrointestinal symptoms on the second day of prophylaxis and the antibiotic was discontinued (very low quality evidence).
Antibiotic prophylaxis at the time of short-term catheter removal in hospital
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Evidence from a systematic review (Marschall et al. 2013) in hospitalised patients found that antibiotic prophylaxis at the time of short-term catheter removal was associated with a significantly lower risk of symptomatic UTI at 2 to 42 days' follow‑up compared with placebo or other control intervention (4.7% versus 10.5%, NNT 18 [range 12 to 31]).
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In subgroup analyses, the effect was maintained for surgical patients (4.8% versus 10.3%, risk ratio [RR] 0.45, 95% CI 0.29 to 0.59; moderate quality evidence) but not for mixed hospital populations. Additional subgroup analysis of the surgical studies found significant benefit for people undergoing prostate surgery (3.57% versus 8.18%, RR 0.41, 95% CI 0.22 to 0.79; low quality evidence) but not for those undergoing other surgery (6.1% versus 14.1%, RR 0.45, 95% CI 0.18 to 1.14; low quality evidence).
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In further subgroup analyses of surgical studies without the studies of prostate surgery, there was a significant benefit of antibiotic prophylaxis with catheter duration longer than 5 days (3.8% versus 16.7%, RR 0.25, 95% CI 0.10 to 0.59; high quality evidence) but not with catheter duration less than 5 days (3.22% versus 12.3%, RR 0.41, 95% CI 0.02 to 10.96; very low quality evidence).
Antibiotic prophylaxis during short-term catheterisation for urodynamic procedures
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A systematic review (Foon et al. 2012) in people who had short-term catheterisation during urodynamic studies found that prophylactic antibiotics did not significantly reduce episodes of symptomatic UTI (low quality evidence) but did significantly reduce bacteriuria (4.1% versus 12.5%, NNT 12 [range 9 to 21]; moderate quality evidence) compared with placebo or no treatment. In a single study of people with spinal cord injury, antibiotic prophylaxis was not significantly different to placebo or no treatment for the outcome of bacteriuria (very low quality evidence). There was a significant reduction in the number of participants with haematuria with antibiotic prophylaxis (6.3% versus 13.7%, NNT 14 [range 8 to 89]; low quality evidence) but not fever or dysuria.
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The systematic review (Foon et al. 2012) found no significant difference in adverse events between antibiotics and placebo (very low quality evidence).
Committee discussion on antibiotic prophylaxis for catheter-associated UTI
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