Summary of antimicrobial guidance

Contents

Lower Urinary Tract Infection

Advise paracetamol or ibuprofen for pain.

Non-pregnant women: back up antibiotic (to use if no improvement in 48 hours or symptoms worsen at any time) or immediate antibiotic.

Pregnant women, men, children, or young people: immediate antibiotic.

When considering antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data.

If people have symptoms of pyelonephritis (such as fever) or a complicated UTI, see acute pyelonephritis (upper urinary tract infection) for antibiotic choices.

Non-pregnant adult women first choice:

nitrofurantoin (if eGFR ≥45 ml/minute) 100mg m/r BD (or if unavailable 50mg QDS) for 3 days

OR

trimethoprim (if low risk of resistance) 200mg BD for 3 days

Non-pregnant adult women second choice:

nitrofurantoin (if eGFR ≥45 ml/minute) 100mg m/r BD (or if unavailable 50mg QDS) for 3 days

OR

pivmecillinam (a penicillin) 400mg initial dose, then 200mg TDS for 3 days

OR

fosfomycin 3g single dose sachet single dose

Pregnant adult women first choice:

nitrofurantoin (avoid at term) – if eGFR ≥45 ml/minute 100mg m/r BD (or if unavailable 50mg QDS) for 7 days

Pregnant adult women second choice:

amoxicillin (only if culture results available and susceptible) 500mg TDS for 7 days

OR

cefalexin 500mg BD for 7 days

Treatment of asymptomatic bacteriuria in pregnant adult women:

choose from nitrofurantoin (avoid at term), amoxicillin or cefalexin based on recent culture and susceptibility results

Adult men first choice:

trimethoprim 200mg BD for 7 days

OR

nitrofurantoin (if eGFR ≥45 ml/minute) 100mg m/r BD (or if unavailable 50mg QDS) for 7 days

Adult men second choice:   

consider alternative diagnoses basing antibiotic choice on recent culture and susceptibility results

Children and young people (3 months and over) first choice:

trimethoprim (if low risk of resistance)

OR

nitrofurantoin (if eGFR ≥45 ml/minute)

Children and young people (3 months and over) second choice:

nitrofurantoin (if eGFR ≥45 ml/minute and not used as first choice)

OR

amoxicillin (only if culture results available and susceptible)

OR

cefalexin

For information on children’s dosage see the guidance visual summary or  https://www.nice.org.uk/guidance/ng138/.

NICE

For detailed information see the guidance visual summary or  https://www.nice.org.uk/guidance/ng138/.

See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management and the UK Health Security Agency urinary tract infection: diagnostic tools for primary care.

Section last updated Oct 2018

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Acute Pyelonephritis (Upper Urinary Tract)

Advise paracetamol (+/- low-dose weak opioid) for pain for people over 12.

Offer an antibiotic.

When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data.

Avoid antibiotics that don’t achieve adequate levels in renal tissue, such as nitrofurantoin.

Non-pregnant women and men first choice:

cefalexin 500mg BD or TDS (up to 1g to 1.5g TDS or QDS for severe infections) for 7 to 10 days

OR

co-amoxiclav (only if culture results available and susceptible) 500/125mg TDS for 7 to 10 days

OR

trimethoprim (only if culture results available and susceptible) 200mg BD for 14 days

OR

ciprofloxacin (only if other first choice antibiotics are unsuitable) 500mg BD for 7 days 

See the MHRA January 2024 advice on restrictions and precautions for using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate.

Non-pregnant women and men IV antibiotics:

see the guidance visual summary

Pregnant women first choice:

cefalexin 500mg BD or TDS (up to 1g to 1.5g TDS or QDS for severe infections) for 7 to 10 days

Pregnant women second choice or IV antibiotics:

see the guidance visual summary

Children and young people (3 months and over) first choice: 

cefalexin

OR

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

Children and young people (3 months and over) IV antibiotics: see the guidance visual summary

For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng111/.

NICE

For detailed information click on the guidance visual summary. See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management and the UK Health Security Agency urinary tract infection: diagnostic tools for primary care.

Section last updated September 2024

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Acute Prostatitis

Advise paracetamol (+/- low-dose weak opioid) for pain, or ibuprofen if preferred and suitable.

Offer antibiotic.

Review antibiotic treatment after 14 days and either stop antibiotics or continue for a further 14 days if needed (based on assessment of history, symptoms, clinical examination, urine, and blood tests).

First choice adult (guided by susceptibilities when available):

ciprofloxacin 500mg BD for 14 days then review

See the MHRA January 2024 advice on restrictions and precautions for using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects.

OR

ofloxacin 200mg BD for 14 days then review

See the MHRA January 2024 advice on restrictions and precautions for using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects.

Alternative first choice if fluoroquinolone antibiotic is not appropriate (seek specialist advice; guided by susceptibilities when available):

trimethoprim (if fluoroquinolone not appropriate; seek specialist advice) 200mg BD for 14 days then review

Second choice adult (after discussion with specialist):

levofloxacin 500mg OD for 14 days then review 

See the MHRA January 2024 advice on restrictions and precautions for using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects.

OR

co-trimoxazole 960mg BD for 14 days then review

IV antibiotics: see the guidance visual summary

For detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng110.

NICE

Section last updated September 2024

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Recurrent Urinary Tract Infections

First advise about behavioural and personal hygiene measures, and self-care (with D-mannose or cranberry products) to reduce the risk of UTI.

For postmenopausal women, if no improvement, consider vaginal oestrogen (review within 12 months).

For non-pregnant women, if no improvement, consider single-dose antibiotic prophylaxis for exposure to a trigger (review within 6 months).

For non-pregnant women (if no improvement or no identifiable trigger) or with specialist advice for pregnant women, men, children, or young people, consider a trial of daily antibiotic prophylaxis (review within 6 months).

First choice adult antibiotic prophylaxis:

trimethoprim (avoid in pregnancy) 200mg single dose when exposed to a trigger or 100mg at night

OR

nitrofurantoin (avoid at term) - if eGFR ≥45 ml/minute 100mg single dose when exposed to a trigger or 50 to 100mg at night

Second choice adult antibiotic prophylaxis:

amoxicillin 500mg single dose when exposed to a trigger or 250mg at night

OR

cefalexin 500mg single dose when exposed to a trigger or 125mg at night

For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng112

NICE

For detailed information click on the visual summary. See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management and the UK Health Security Agency urinary tract infection: diagnostic tools for primary care.

Section last updated Oct 2018

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Catheter-Associated Urinary Tract Infection

Antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a urinary catheter.

Consider removing or, if not possible, changing the catheter if it has been in place for more than 7 days. But do not delay antibiotic treatment.

Advise paracetamol for pain.

Advise drinking enough fluids to avoid dehydration.

Offer an antibiotic for a symptomatic infection. When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data.

Do not routinely offer antibiotic prophylaxis to people with a short-term or long-term catheter.

Non-pregnant women and men first choice if no upper UTI symptoms:

nitrofurantoin (if eGFR ≥45 ml/minute) 100mg m/r BD (or if unavailable 50mg QDS) for 7 days

OR

trimethoprim (if low risk of resistance) 200mg BD for 7 days

OR

amoxicillin (only if culture results available and susceptible) 500mg TDS for 7 days

Non-pregnant women and men second choice if no upper UTI symptoms:

pivmecillinam (a penicillin) 400mg initial dose, then 200mg TDS for 7 days

Non-pregnant women and men first choice if upper UTI symptoms:

cefalexin 500mg BD or TDS (up to 1g to 1.5g TDS or QDS for severe infections) for 7 to 10 days

OR

co-amoxiclav (only if culture results available and susceptible) 500/125mg TDS for 7 to 10 days

OR

trimethoprim (only if culture results available and susceptible) 200mg BD for 14 days

OR

ciprofloxacin (only if other first-choice antibiotics are unsuitable) 500mg BD for 7 days  

See the MHRA January 2024 advice for restrictions and precautions on using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate.

Non-pregnant women and men IV antibiotics:

see the guidance visual summary

Pregnant women first choice:

cefalexin 500mg BD or TDS (up to 1g to 1.5g TDS or QDS for severe infections) for 7 to 10 days

Pregnant women second choice or IV antibiotics:

see the guidance visual summary

Children and young people (3 months and over) first choice:

trimethoprim (if low risk of resistance)

OR

amoxicillin (only if culture results available and susceptible)

OR

cefalexin

OR

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

Children and young people (3 months and over) IV antibiotics:

see the guidance visual summary

For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng113

NICE

See also the UK Health Security Agency urinary tract infection: diagnostic tools for primary care.

Section last updated September 2024