NICE interactive flowchart - Urinary tract infections. If suspected UTI, offer immediate treatment according to NICE/PHE guideline on lower UTI: antimicrobial prescribing and review choice of antibiotic with pre-treatment culture results Algorithm 2: Flowchart for suspected UTI in catheterised adults or those over 65 years UTI in children under 16 years of age, UTI in pregnant women, UTI in men, interstitial cystitis and bladder pain syndrome. Category: Clinical guidelines, Conditions, NICE Guidelines . 1.1.6 Do not offer oral oestrogens (hormone replacement therapy) specifically to reduce the risk of recurrent UTI in postmenopausal women. Scenario: Recurrent UTI in men: Covers the management of recurrent urinary tract infection in men without an indwelling urinary catheter. the woman's preferences for antibiotic use. Guidance. 1.2.3 Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI. Recognise the different categories of UTIs . We found no new evidence that affects the recommendations in this guideline. There are other guidelines and publications regarding recurrent UTIs in women from other countries or urological/gynaecological associations which are helpful. 3. Incidence is higher in older men[4]. 3, 200 mg single dose when exposed to a trigger or 100 mg at night, 100 mg single dose when exposed to a trigger or 50 to 100 mg at night, 500 mg single dose when exposed to a trigger or 250 mg at night, 500 mg single dose when exposed to a trigger or 125 mg at night. Most recurrences are thought to be re-infection with the same organism. 1.1.8 For women with recurrent UTI who are not pregnant, ensure that any current UTI has been adequately treated then consider single-dose antibiotic prophylaxis for use when exposed to an identifiable trigger (see the recommendations on choice of antibiotic prophylaxis). Doses given are by mouth using immediate release medicines, unless otherwise stated. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. 1.1.14 For children and young people under 16 years with recurrent UTI, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis) if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. In recurrent UTI: Referral should be made if cause is unknown, the woman is catheterized or malignancy suspected. 6 Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off‑label. seeking medical help if there are symptoms of an acute UTI. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. 1.2.3.3 Asymptomatic bacteriuria in infants and children should not be treated with prophylactic antibiotics. Have you? Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. For people with recurrent urinary tract infection (UTI), preferred treatment options are: Trimethoprim 200 mg single dose when exposed to a trigger, or 100 mg at night. Scenario: Recurrent UTI (no visible haematuria, not pregnant or catheterized): Covers the management of recurrent UTIs that are not associated with haematuria in women who are not pregnant or catheterized. 1.1.15 When a trial of daily antibiotic prophylaxis is given, give advice as in recommendation 1.1.11. 1.2.3.2 This recommendation has been replaced by the NICE guideline on urinary tract infection (recurrent): antimicrobial prescribing. A research librarian conducted searches in Ovid MEDLINE (1946 to January Week 1 2018), Cochrane Central Register of … It aims to optimise antibiotic use and reduce antibiotic resistance. It also includes the diagnosis and management of recurrent UTI in these groups. Are older than 65 years. Scenario: UTI in men with an indwelling catheter: Covers the management of lower urinary tract infection in men with an indwelling urinary catheter. There are currently no NICE guidelines in the UK for UTIs in adults, however, there are developments in guidance for this underway due at some point in 2015. This guideline sets out an antimicrobial prescribing strategy for preventing recurrent urinary tract infections in children, young people and adults who do not have a catheter. Table 1 is a guide to the symptoms and signs that infants and children present with. preferences of the woman for treatment with vaginal oestrogen.Review treatment within 12 months, or earlier if agreed with the woman. 1.1.13 When a trial of daily antibiotic prophylaxis is given, give advice as in recommendation 1.1.11. 3 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 and the child's size in relation to the average size of children of the same age. 5 Avoid at term in pregnancy; may produce neonatal haemolysis (BNFC, August 2018). includes lower UTI and upper UTI (acute pyelonephritis), may be due to relapse (with the same strain of organism) or reinfection (with a different strain or species of organism). UTIs are considered recurrent after at least two episodes within 6 months or three or more episodes within 12 months. This guideline covers diagnosing and managing first or recurrent upper or lower urinary tract infections in infants, children and young people. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. It can occur spontaneously or after certain medical procedures and can last for several weeks. 1.1.9 When single-dose antibiotic prophylaxis is given, give advice about: possible adverse effects of antibiotics, particularly diarrhoea and nausea. Guidelines for Recurrent Urinary Tract Infections in Adults: Antibiotic Prophylaxis Definition The symptoms of a lower urinary tract infection include: frequency, dysuria, urgency and suprapubic pain. NICE Bites Jan 2019, No 114, includes four antimicrobial prescribing guidelines: Pyelonephritis; Lower Urinary Tract Infection (UTI) Recurrent UTI; Catheter-associated UTI; Attachments. Women have a lifetime risk of UTI of 1 in 2, and incidence increases with age[3]. NICE guidance for recurrent UTI (NG112) Author: Shannen Stevens . A sample should be sent for urine culture in all women with suspected lower UTI who: Are pregnant. Published: Effective interventions library. 1.1.12 For men and pregnant women with recurrent UTI, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis) if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. RECURRENT UTI? 5 Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, August 2018). Select a different antibiotic for prophylaxis if treating an acute UTI. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Prior to onward referral, please ensure you have followed the NICE guidance provided in these guidelines and the below steps have been taken. The systematic review utilized to inform this guideline was conducted by a methodology team at the Pacific Northwest Evidence-based Practice Center. 1.3.1 When prescribing antibiotic prophylaxis for recurrent UTI, take account of local antimicrobial resistance data and: follow the recommendations in table 1 for people aged 16 years and over. If 100 women with recurrent UTI use vaginal oestrogen we would expect that, over 8 months on average about: 40 women don’t get a UTI, but would not have done anyway 45 women avoid getting a UTI because they use vaginal oestrogen 15 women get a UTI even though they use vaginal oestrogen b b If 100 women with recurrent UTI use an antibiotic Children aged 3 months and over (specialist advice only), 3 to 5 months, 2 mg/kg at night (maximum 100 mg per dose) or 12.5 mg at night, 6 months to 5 years, 2 mg/kg at night (maximum 100 mg per dose) or 25 mg at night, 6 to 11 years, 2 mg/kg at night (maximum 100 mg per dose) or 50 mg at night, 3 months to 15 years, 12.5 mg/kg at night (maximum 125 mg per dose). some women with recurrent UTI may wish to try D‑mannose[2] if they are not pregnant, some women with recurrent UTI may wish to try cranberry products if they are not pregnant (evidence of benefit is uncertain and there is no evidence of benefit for older women). Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost. Management of Recurrent Lower UTI’s (in non-pregnant adults) Referral Pro-forma STOP! Antibiotic prophylaxis
Have recurrent UTI (2 episodes in 6 months or 3 in 12 months). 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding. NICE Bites is a monthly bulletin from the North West Medicines Information Centre that summarises key prescribing points from NICE guidance. See the evidence and committee discussion on self-care. Take account of: the person's preferences for antibiotic use. NICE guideline [NG112] Recurrent urinary tract infection (UTI) in adults is defined as repeated UTI with a frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months (European Association of Urology [EAU] guidelines on urological infections). follow the recommendations in table 2 for children and young people under 16 years. 1.1.7 For women with recurrent UTI who are not pregnant, consider a trial of antibiotic prophylaxis only if behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate. Effective interventions library. 1,2, Dosage
1.1.5 Consider the lowest effective dose of vaginal oestrogen[1] (for example, estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate. 2. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline J Urol. For women with recurrent UTI … Abbreviations: BNFC, British natural formulary for children; eGFR, estimated glomerular filtration rate. 1.1.10 For women with recurrent UTI who are not pregnant and have had no improvement after single-dose antibiotic prophylaxis or have no identifiable triggers, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis). Recurrent UTI Two or more episodes of proven UTI per year (three or more if afebrile/mild) Asymptomatic bacteriuria Bacteriuria in the absence of pyuria/active infection does NOT suggest UTI. Published: •No universally accepted definition •Most commonly used is “2 in 6 months or 3 in a year” Schoof and Hill 2005 Hooton and Stamm 2006 •Estimated 20-50% of young women with UTI will have another within a year Mabeck et al Postgrad Med J … Take account of: 2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. For women with recurrent UTI who are not pregnant, consider a trial of antibiotic prophylaxis only if behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate. Check Offered verbal advice to the patient about behavioural and personal hygiene measures, and self-care to reduce the risk of UTI. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. some children and young people under 16 years with recurrent UTI may wish to try cranberry products with the advice of a paediatric specialist (evidence of benefit is uncertain). Select a different antibiotic for prophylaxis if treating an acute UTI. 1.1.1 Manage an acute UTI as outlined in the NICE guidelines on urinary tract infection (lower): antimicrobial prescribing or pyelonephritis (acute): antimicrobial prescribing. Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics). people with suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral. See the evidence and committee discussion on antibiotic prophylaxis. When a trial of daily antibiotic prophylaxis is given, provide advice about: The risk of resistance with … 1. Have a urinary catheter in situ or have recently been catheterised. 4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNFC, August 2018). Oral antibiotics are appropriate for most children with UTI. 3 Doses given are by mouth using immediate release medicines, unless otherwise stated. [1] Vaginal oestrogen products are not licensed for preventing recurrent UTI, so use for this indication would be off‑label. NICE interactive flowchart - Urinary tract infections, antimicrobial stewardship: systems and processes for effective antimicrobial medicine use, treatment for children and young people under 16 years, assess and reduce the environmental impact of implementing NICE recommendations, People with recurrent urinary tract infection, their families and carers. All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme. D‑mannose is a sugar that is available to buy as powder or tablets; it is not a medicine. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 1.1.1 Manage an acute UTI as outlined in the NICE guidelines on lower UTI (cystitis), acute pyelonephritis or catheter-associated UTI. UTI is uncommon in otherwise healthy young and middle-aged men. a reminder about behavioural and personal hygiene measures and self-care treatments (see the recommendations on self-care).If antibiotic prophylaxis is stopped, ensure that people have rapid access to treatment if they have an acute UTI. 1.1.11 When a trial of daily antibiotic prophylaxis is given, give advice about: the risk of resistance with long-term antibiotics, which means they may be less effective in the future, possible adverse effects of long-term antibiotics. Date: February 8, 2019 . See the evidence and committee discussion on antibiotic prophylaxis and antibiotic dosing and course length. This is most often found in school aged and older girls but may also be found in infants. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service.
1.1.16 Review antibiotic prophylaxis for recurrent UTI at least every 6 months, with the review to include: discussion of continuing, stopping or changing prophylaxis (taking into account the person's preferences for antibiotic use and the risk of antimicrobial resistance). Next. Discuss the following with the woman to ensure shared decision-making: the severity and frequency of previous symptoms, the risk of developing complications from recurrent UTIs, the possible benefits of treatment, including for other related symptoms, such as vaginal dryness, the possible adverse effects such as breast tenderness and vaginal bleeding (which should be reported because it may require investigation), the uncertainty of endometrial safety with long-term or repeated use. Acute prostatitis is an infection of the prostate gland and is usually caused by a UTI. The NICE guideline on urinary tract infection in under 16sspecifies atypical causes of urinary tract infection, and includes non-E. coliorganisms as an atypical cause in infants, children and young people. Definition of recurrent lower urinary tract infection: The symptoms of a lower urinary tract infection include: frequency, dysuria, urgency and suprapubic pain. 1. Take account of: any further investigations (for example, ultrasound) that may be needed to identify an underlying cause. 1.2.2 Advise people taking cranberry products or D‑mannose about the sugar content of these products, which should be considered as part of the person's daily sugar intake. 2019 Aug ... (UTI) events. Children who are seriously unwell and most infants under 3 months usually require IV antibiotics. NICE worked with Public Health England to develop this guidance. Preventative measures such as behaviour and personal hygiene should be discussed — topical vaginal oestrogen and antibiotic prophylaxis may be appropriate. 1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic and renal impairment. 1.1.14 For children and young people under 16 years with recurrent UTI, ensure that any current UTI has been adequately treated then consider a trial of daily antibiotic prophylaxis (see the recommendations on choice of antibiotic prophylaxis) if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. This guideline includes recommendations on: We checked this guideline in April 2019 to assess the impact of the 2018 English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) report. Studies have shown between 30-44% of non-pre… 1.1.2 Be aware that recurrent UTI: includes lower UTI (cystitis) and upper UTI (acute pyelonephritis) may be due to relapse (with the same strain of organism) or Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics). It includes recommendations on measures to prevent recurrent UTIs and when to refer to a specialist for investigation of possible underlying causes. 1.1.8 . 31 October 2018. NICE has released its 2018 guidelines on recurrent Urinary tract infection. RESULTS: • In accordance with the NICE guidelines patients were divided by age. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. NICE Guideline 109, Urinary tract infection (lower): antimicrobial prescribing. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. It aims to optimise antibiotic use and reduce antibiotic resistance. 1.1.3 Give advice to people with recurrent UTI about behavioural and personal hygiene measures and self‑care treatments (see the recommendations on self-care) that may help to reduce the risk of UTI. [2] The evidence was based on a study where D‑mannose was taken as 200 ml of 1% solution once daily in the evening. Take account of: underlying causes following specialist assessment and investigations, the uncertain evidence of benefit of antibiotic prophylaxis for reducing the risk of recurrent UTI and the rate of deterioration of renal scars. https://radiopaedia.org/articles/paediatric-urinary-tract-infection-nice-guideline Nitrofurantoin (if eGFR ≥ 45ml/minute) 100 mg single dose when exposed to a trigger, or 50–100 mg at night.
1.1.4 Refer or seek specialist advice on further investigation and management for: people with recurrent lower UTI when the underlying cause is unknown, children and young people under 16 years in line with the NICE guideline on urinary tract infection in under 16s. See the evidence and committee discussion on oestrogens. 4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNF, August 2018). Abbreviations: BNF, British natural formulary; eGFR, estimated glomerular filtration rate. Manage an acute urinary tract infection (UTI) as outlined in the NICE guidelines on urinary tract infection (lower): antimicrobial prescribing or pyelonephritis (acute): antimicrobial prescribing This guideline sets out an antimicrobial prescribing strategy for preventing recurrent urinary tract infections in children, young people and adults who do not have a catheter. See the evidence and committee discussion on choice of antibiotic prophylaxis and antibiotic dosing and course length. In updated NICE guidelines for treating recurrent UTIs, published in October 2018, information about d-mannose was included as a self-care option: “…some women with recurrent UTI may wish to try D‑mannose if they are not pregnant” as well as “The evidence was based on a study where D‑mannose was taken as 200 ml of 1% solution once daily in the evening. This guideline does not cover the following: diagnosis and management of upper UTI, UTI in children under 16 years of age, UTI in pregnant women, UTI in men, interstitial cystitis and bladder pain syndrome. It aims to achieve more consistent clinical practice, based on accurate diagnosis and effective management. 1.4 - 1.9% prevalence in childhood. Have symptoms that are persistent or do not resolve with antibiotic treatment. NICE Guideline 109, Urinary tract infection (lower): antimicrobial prescribing. Recurrent lower urinary tract infection (rUTI) is defined as: 2 or more episodes of lower urinary tract infection in the last 6 months, or NICE guideline [NG112] 31 October 2018. Informed consent should be obtained and documented. 1.1 Preventing recurrent urinary tract infections, urinary tract infection (lower): antimicrobial prescribing, pyelonephritis (acute): antimicrobial prescribing, suspected cancer: recognition and referral, trimethoprim summary of product characteristics, Good practice in prescribing and managing medicines and devices. Informed consent should be obtained and documented. 2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Take account of: previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria. Guidelines for Recurrent Urinary Tract Infections in Adults: Antibiotic Prophylaxis. 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