Summary of the evidence

Self-care

  • 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).

  • No systematic reviews or RCTs of any other non-antimicrobial treatments were identified that met the inclusion criteria.

Committee discussion on self-care

  • There was no evidence for the use of oral analgesia in catheter-associated-UTI. However, paracetamol has a well-established efficacy and safety profile for managing pain. The committee agreed that it was reasonable to consider paracetamol for managing pain in people with a catheter-associated UTI.

  • Based on committee experience that dehydration is often cited as a cause of UTIs, the committee agreed that people should be advised about drinking enough fluids to avoid dehydration.

  • The committee agreed that the evidence for use of cranberry in preventing catheter-associated UTI (which showed no effect) was limited to a specific population in the immediate postoperative period, and could not be extrapolated to other populations or settings. The committee was, therefore, unable to make a recommendation on its use.

Antibiotics for managing catheter-associated UTI

  • In most cases, managing symptomatic catheter-associated UTI will require antibiotics.

  • 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).

  • 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

  • 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).

  • 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

  • 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

  • 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).

  • 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).

  • 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.

  • People with a history of immediate hypersensitivity to penicillins may also react to cephalosporins and other beta‑lactam antibiotics (BNF, August 2018).

  • 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).

  • 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).

  • 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.

  • Aminoglycosides doses are based on weight and renal function and whenever possible treatment should not exceed 7 days (BNF, August 2018).

  • 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

  • Based on evidence and experience, the committee agreed that people with a symptomatic catheter-associated UTI should be offered an antibiotic.

  • Urine should be sent for culture to confirm susceptibility of the bacteria and inform treatment decisions. The committee discussed and agreed that a comment should be added to the microbiology request form to alert the laboratory to a suspected catheter-associated infection and the name of any antibiotic prescribed.

  • The committee agreed that the evidence for antibiotic treatment for catheter-associated UTI specifically was limited, but that evidence for antibiotic treatment for acute pyelonephritis could be extrapolated. The evidence for acute pyelonephritis included some people with complicated UTI, some of whom had a catheter (see the NICE guideline on acute pyelonephritis: antimicrobial prescribing).

  • Limited evidence suggested that catheters should be removed or changed before antibiotics are given, but the committee discussed safety concerns with this approach and practical considerations about possible delays in primary care settings. They agreed that catheter removal or change should not delay treatment with antibiotics. The longer a catheter is in place, the more likely bacteria will be found in the urine, and the committee agreed that catheters should be removed rather than changed, where possible. Changing the catheter is based on evidence from 1 small RCT, which found higher cure or improvement rates and reduced mortality (from urosepsis) when the catheter was changed before starting antibiotics. The committee based when to remove or change the catheter (after 7 days) on their experience.

  • Based on evidence and experience, the committee agreed that screening and antibiotic treatment for asymptomatic bacteriuria is not routine in people with a catheter because it is not generally a risk factor for harm. Pregnant women (including those with a catheter) have routine screening and antibiotic treatment for asymptomatic bacteriuria because it is a risk factor for pyelonephritis and preterm labour.

Committee discussion on choice of antibiotic

  • The committee agreed, based on evidence, experience and resistance data, that several oral and intravenous antibiotics should be available for people with a catheter-associated UTI. Having a choice enables antibiotics to be selected based on the severity of illness, presence or absence of upper UTI symptoms, antibiotic susceptibilities from culture results when available, local resistance patterns, risk of resistant bacteria, setting and known patient factors. In line with antimicrobial stewardship, narrower-spectrum antibiotics should be used wherever possible.

  • Nationally for England, resistance of E. coli (the main causative organism of UTIs) in laboratory-processed urine specimens to the following antibiotics is:

    • nitrofurantoin: 2.5% (varies by area from 2.0 to 3.6%)

    • trimethoprim: 30.3% (varies by area from 27.1 to 33.4%)

    • pivmecillinam: 7.5% (varies by area from 4.1 to 15.7%)

    • cefalexin: 9.9% (varies by area from 8.1 to 11.4%)

    • ciprofloxacin: 10.6% (varies by area from 7.8 to 13.7%)

    • co-amoxiclav: 19.8% (varies by area from 10.8 to 30.7%).

      (Public Health England. Antimicrobial resistance quarterly surveillance: March 2018)

  • The committee also discussed that prescribers should be aware of their local antimicrobial prescribing data, because resistance rates do vary by area.

  • The committee agreed that any recent previous urine culture and susceptibility results, and antibiotic prescribing, should be reviewed before choosing an antibiotic.

  • Based on experience, the committee agreed that when results of urine cultures are available, if the results suggest the bacteria are resistant to the antibiotic given, the antibiotic should be changed, using a narrow-spectrum antibiotic where possible.

Non-pregnant women and men with catheter-associated UTI

  • Based on evidence, their experience and resistance data, the committee agreed to recommend nitrofurantoin, trimethoprim or amoxicillin at usual doses as first-choice oral antibiotics for adults with a catheter-associated UTI but no upper UTI symptoms.

    • Nitrofurantoin is not recommended for people with an eGFR <45 ml/minute. It may be used with caution if eGFR is 30 to 44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug-resistant bacteria, and only if the potential benefit outweighs risk (BNF, August 2018). The committee noted that nitrofurantoin is only licensed for uncomplicated lower UTI. However, they agreed that for adults with a catheter-associated UTI without upper UTI symptoms, nitrofurantoin is an option (unless they have a blocked catheter, where Proteus mirabilis could be the causative organism). Based on experience, the committee felt it was important to offer 'lower UTI' antibiotics as an option for adults with catheter-associated UTI without upper UTI symptoms, otherwise all adults with a catheter-associated UTI would need to be offered a broader-spectrum 'upper UTI' antibiotic, where their symptoms may not warrant this.

    • The committee agreed to recommend either the modified-release preparation of nitrofurantoin or the immediate-release preparation. However, because of its twice-daily dosing and, in their experience, better tolerability the committee was keen to point out that the modified-release preparation was preferred unless it was unavailable. The committee also discussed that, in their experience, immediate-release preparations containing nitrofurantoin in a macrocrystalline form may be better tolerated than those containing nitrofurantoin in a microcrystalline form.

    • Trimethoprim has high resistance levels nationally and should only be prescribed if a lower risk of resistance is thought to be likely. A lower risk of resistance is likely if trimethoprim has not been used in the past 3 months, if previous urine culture results suggest trimethoprim susceptibility (but this was not used as treatment) and in younger people in areas where local epidemiology data suggest resistance is lower. There is a higher risk of trimethoprim resistance with recent use and in older people in care homes.

    • Amoxicillin is recommended only if culture results are available and bacteria are susceptible because resistance rates are high.

  • If nitrofurantoin, trimethoprim or amoxicillin are not suitable, the second-choice oral antibiotic for adults with a catheter-associated UTI but no upper UTI symptoms is pivmecillinam (a penicillin) at its usual dose. The committee acknowledged that prescribers may be less familiar with this antibiotic, but it is often used in other European countries. The committee noted that pivmecillinam is only licensed for uncomplicated lower UTI. However, as with nitrofurantoin, they agreed that for adults with a catheter-associated UTI without upper UTI symptoms, 'lower UTI' antibiotics are an option.

  • For adults with upper UTI symptoms, nitrofurantoin, amoxicillin and pivmecillinam are not appropriate, and cefalexin (a first-generation cephalosporin), co‑amoxiclav (a penicillin with a beta‑lactamase inhibitor), trimethoprim or ciprofloxacin (a fluoroquinolone), at usual doses, are recommended to cover a broader range of bacterial pathogens. Co‑amoxiclav and trimethoprim are only suitable if culture results are available and bacteria are susceptible, because resistance rates are high.

  • The committee noted that use of broad-spectrum antibiotics, such as later-generation cephalosporins, fluoroquinolones or co‑amoxiclav, can create a selective advantage for bacteria resistant to these second-line broad-spectrum agents, allowing such strains to proliferate and spread. By disrupting normal flora, broad-spectrum antibiotics can leave people susceptible to harmful bacteria such as Clostridium difficile in community settings. However, these antibiotics are appropriate for the empirical treatment of catheter-associated UTI with upper UTI symptoms, where coverage of more resistant strains of common bacterial pathogens is required.

  • The committee was aware of the European Medicines Agency's Pharmacovigilance Risk Assessment Committee recommendation to restrict the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects, mainly involving muscles, tendons and bones, and the nervous system. However, they discussed that fluoroquinolone antibiotics are a valuable option for the treatment of catheter-associated UTI with upper UTI symptoms, which is a severe infection, and it is appropriate to reserve fluoroquinolone use for such conditions. Resistant gram-negative organisms are a particular concern in catheter-associated UTI with upper UTI symptoms, and the committee agreed that ciprofloxacin should remain a first-choice option to cover what can be a complex infection. The committee was keen to point out, however, that cefalexin, co‑amoxiclav and trimethoprim are also first-choice options, and antibiotics should be chosen on an individual patient basis, taking fluoroquinolone safety concerns, as well as susceptibility and resistance, into account.

  • Based on evidence, experience and resistance data, the committee agreed to recommend a choice of first-line intravenous antibiotics, at usual doses, for adults who are unable to take oral antibiotics because of nausea and vomiting, or are more severely unwell. These are:

    • co-amoxiclav (only in combination unless culture results confirm bacteria are susceptible)

    • cefuroxime (a second-generation cephalosporin) or ceftriaxone (a third-generation cephalosporin)

    • ciprofloxacin (taking safety concerns into account)

    • gentamicin or amikacin (aminoglycosides); which may be appropriate for some people with catheter-associated UTI, particularly those with severe infection or sepsis, but that efforts should be made to identify the causal bacteria and use reviewed by 48 hours. Gentamicin is the preferred aminoglycoside in the UK, but shortages of certain antibiotics may result in the use of alternatives; for example, amikacin in place of gentamicin.

  • The committee agreed, based on experience, that it may be necessary to combine antibiotics in the care of people with suspected sepsis. This should be done according to local policy or on the advice of a microbiologist, taking into account local antimicrobial resistance data.

Pregnant women with catheter-associated UTI

  • Based on evidence, experience and resistance data, the committee agreed to recommend cefalexin (a first-generation cephalosporin) as the first-choice oral antibiotic for pregnant women who don't need intravenous antibiotics, and cefuroxime (a second-generation cephalosporin) as the first-choice intravenous antibiotic.

  • Ciprofloxacin and trimethoprim are not recommended because they should be avoided in pregnancy. Co‑amoxiclav was not recommended because of high resistance levels nationally and the risks of treatment failure in pregnancy.

  • The committee agreed, based on experience, that local microbiologists should be consulted for advice on second-choice antibiotics, or combining antibiotics, if susceptibility or sepsis is a concern.

Children and young people with catheter-associated UTI

  • Based on evidence, experience and resistance data, the committee agreed to recommend trimethoprim (if low risk of resistance), amoxicillin (only if culture results are available and bacteria are susceptible), cefalexin or co‑amoxiclav (only if culture results are available and bacteria are susceptible) at usual doses as first-choice oral antibiotics for children and young people with catheter-associated UTI.

  • Based on evidence, experience and resistance data, the committee agreed to recommend a choice of first-line intravenous antibiotics at usual doses for children and young people who are unable to take oral antibiotics because of nausea and vomiting, or are more severely unwell. These are:

    • co-amoxiclav (only in combination unless culture results confirm bacteria are susceptible); which can be given intravenously

    • cefuroxime (a second-generation cephalosporin) or ceftriaxone (a third-generation cephalosporin)

    • gentamicin or amikacin (aminoglycosides); which may be appropriate for some children and young people with upper UTI symptoms, particularly those with severe infection or sepsis, but that efforts should be made to identify the causal bacteria and use reviewed at 48 hours.

  • The committee agreed, based on experience, that it may be necessary to combine antibiotics in the care of children and young people with suspected sepsis. This should be done according to local policy or on the advice of a microbiologist, taking into account local antimicrobial resistance data.

Committee discussions on antibiotic course length

  • The committee agreed that the shortest course that is likely to be effective should be prescribed to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects.

  • In line with the NICE guideline on antimicrobial stewardship and Public Health England's Start smart – then focus, the committee agreed that the use of intravenous antibiotics should be reviewed by 48 hours (taking into account the response to treatment and susceptibility results from urine culture) and switched to oral treatment where possible.

Course length for non-pregnant women, pregnant women, men, children and young people with catheter-associated UTI

  • Based on evidence, experience and resistance data, the committee agreed that, for oral treatment, at least a 7‑day course of all the recommended antibiotics was needed to treat catheter-associated UTI to ensure complete cure. This is because people with a catheter are more at risk of complications from a UTI. For adults with a catheter-associated UTI and upper UTI symptoms, pregnant women, and children and young people, course lengths are the same as those for acute pyelonephritis (see the NICE guideline on acute pyelonephritis: antimicrobial prescribing).

  • For intravenous treatment, antibiotics should be reviewed by 48 hours and stepped down to oral antibiotics where possible.

Antibiotic prophylaxis for preventing catheter-associated UTI

Antibiotic prophylaxis for people with a long-term (indwelling or intermittent) catheter

  • 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.

  • 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.

  • 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).

  • 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.

  • 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).

  • 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).

  • 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.

  • 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).

  • 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

  • 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]).

  • 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).

  • 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).

  • 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.

  • 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).

  • 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

  • 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]).

  • 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).

  • 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

  • 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.

  • 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

  • The committee discussed the evidence on antibiotic prophylaxis for catheter-associated UTI in various populations.

  • Based on evidence, their experience and resistance data, the committee agreed that antibiotic prophylaxis should not be routinely offered to people with a long-term (indwelling or intermittent) catheter.

    • The benefit of antibiotic prophylaxis for symptomatic bacteriuria was mixed.

    • The committee noted that although there was evidence of benefit (reduced rate of UTIs per year) from 1 RCT in adults who used intermittent self-catheterisation and had recurrent UTI, there was also evidence of increasing antibiotic resistance in the microorganisms found in the group taking antibiotics for prophylaxis. The committee discussed that routine antibiotic prophylaxis would be a change in practice, which is not warranted because of increasing resistance. Decisions around prophylaxis for people who self-catheterise and have recurrent UTIs may, however, be made on an individual basis, with shared decision-making and a discussion of the risks and benefits.

    • The committee discussed that people should be advised to seek medical help if symptoms of a UTI develop, which would be managed as an acute UTI, rather than people receiving long-term antibiotic prophylaxis.

    • The committee was aware of recommendations in the NICE guideline on healthcare-associated infections that antibiotic prophylaxis should not be offered routinely when changing long-term indwelling catheters, but should be considered for people with a history of symptomatic UTI after catheter change or an experience of trauma (frank haematuria after catheterisation or 2 or more attempts of catheterisation). The committee for the healthcare-associated infections guideline agreed that for these groups, the benefits of antibiotic prophylaxis outweigh the risks of antimicrobial resistance. These groups are likely to be at high risk of a UTI and at risk of complications if a UTI develops.

  • Based on evidence, the committee agreed not to recommend routine antibiotic prophylaxis to prevent catheter-associated UTI in people with a short-term catheter in hospital. Prophylaxis is not recommended routinely before insertion of a short-term catheter for surgical, non-surgical or urodynamic procedures, while the catheter is in place, or at the time of removal.

    • Before or during short-term catheterisation, there is only limited evidence of benefit with antibiotic prophylaxis for symptomatic bacteriuria in surgical patients.

    • During short-term catheterisation for urodynamic studies, antibiotic prophylaxis did not reduce episodes of symptomatic UTI.

    • At the time of catheter removal, there is evidence of benefit for antibiotic prophylaxis for symptomatic UTI, but in subgroup analysis this was limited to surgical patients, and predominantly those who had either prostate surgery or had a catheter in place for longer than 5 days. The committee discussed that antibiotic prophylaxis for all short-term catheter removal in hospital would be a change in practice, and widespread prophylaxis is not warranted taking into account the principles of antimicrobial stewardship.

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