Antimicrobials in recurrent UTI : NICE 2018 Guideline

Written by Hina Zahid Published On 2018-11-02T19:00:48+05:30 | Updated On 2 Nov 2018 7:00 PM IST

NICE has released its 2018 guidelines on recurrent Urinary tract infection.

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 [2017]).

Recurrent UTI is diagnosed in children and young people under 16 years if they have:

2 or more episodes of UTI with acute pyelonephritis/upper UTI or

1 episode of UTI with acute pyelonephritis plus 1 or more episode of UTI with cystitis/lower UTI or

3 or more episodes of UTI with cystitis/lower UTI.

Following are the major recommendations:

Manage an acute UTI as outlined in the NICE guidelines on urinary tract infection (lower): antimicrobial prescribing or pyelonephritis (acute): antimicrobial prescribing.

Be aware that recurrent UTI: 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) and is particularly common in women.

Give advice to people with recurrent UTI about behavioural and personal hygiene measures and self‑care treatments that may help to reduce the risk of UTI.

Refer or seek specialist advice on further investigation and management for: men aged 16 years and over,people with recurrent upper UTI,people with recurrent lower UTI when the underlying cause is unknown,pregnant women,children and young people under 16 years in line with the NICE guideline on urinary tract infection in under 16s,people with suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral.

Consider the lowest effective dose of vaginal oestrogen (for example, estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate. 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, preferences of the woman for treatment with vaginal oestrogen. Review treatment within 12 months, or earlier if agreed with the woman.

Do not offer oral oestrogens (hormone replacement therapy) specifically to reduce the risk of recurrent UTI in postmenopausal women.

For women with recurrent UTI who are not pregnant, consider a trial of antibiotic prophylaxis only if behavioral and personal hygiene measures and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate.

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. Take account of the severity and frequency of previous symptoms, the risk of developing complications, previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria, the woman's preferences for antibiotic use.

When single-dose antibiotic prophylaxis is given, give advice about: how to use the antibiotic, possible adverse effects of antibiotics, particularly diarrhoea and nausea, returning for review within 6 months, seeking medical help if there are symptoms of an acute UTI.

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. Take account of: any further investigations (for example, ultrasound) that may be needed to identify an underlying cause, the severity and frequency of previous symptoms, the risks of long‑term antibiotic use, the risk of developing complications, previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria, the woman's preferences for antibiotic use.

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, returning for review within 6 months, seeking medical help if there are symptoms of an acute UTI.

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 if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. Take account of: any further investigations (for example, ultrasound) that may be needed to identify an underlying cause, the severity and frequency of previous symptoms, the risks of long‑term antibiotic use, the risk of developing complications, previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria, the person's preferences for antibiotic use.

When a trial of daily antibiotic prophylaxis is given, give advice as in recommendation.

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 if behavioural and personal hygiene measures alone are not effective or not appropriate, with specialist advice. Take account of: underlying causes following specialist assessment and investigations, the uncertain evidence of the benefit of antibiotic prophylaxis for reducing the risk of recurrent UTI and the rate of deterioration of renal scars, the severity and frequency of previous symptoms, the risks of long‑term antibiotic use, the risk of developing complications, previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria, preferences for antibiotic use.

When a trial of daily antibiotic prophylaxis is given, give advice as in recommendation.

Review antibiotic prophylaxis for recurrent UTI at least every 6 months, with the review to include: assessing the success of prophylaxis, discussion of continuing, stopping or changing prophylaxis (taking into account the person's preferences for antibiotic use and the risk of antimicrobial resistance), a reminder about behavioural and personal hygiene measures and self-care treatments. If antibiotic prophylaxis is stopped, ensure that people have rapid access to treatment if they have an acute UTI.

1.2 Self-care

Be aware that: some women with recurrent UTI may wish to try D‑mannose 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), 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).

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.

Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI.

1.3 Choice of antibiotic prophylaxis

When prescribing antibiotic prophylaxis for recurrent UTI, take account of local antimicrobial resistance data and:.

Table 1 People aged 16 years and over

Antibiotic prophylaxis	Dosage
First choice
Trimethoprim	200 mg single dose when exposed to a trigger or 100 mg at night
Nitrofurantoin – if eGFR ≥45 ml/minute	100 mg single dose when exposed to a trigger or 50 to 100 mg at night
Second choice
Amoxicillin	500 mg single dose when exposed to a trigger or 250 mg at night
Cefalexin	500 mg single dose when exposed to a trigger or 125 mg at night
¹ See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding. ² Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI. ³ Doses given are by mouth using immediate release medicines, unless otherwise stated. ⁴ Teratogenic risk in first trimester of pregnancy (folate antagonist; BNF, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics). ⁵ Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, August 2018). ⁶ Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off‑label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.
Abbreviations: BNF, British natural formulary; eGFR, estimated glomerular filtration rate.

Table 2 Children and young people under 16 years

Antibiotic prophylaxis	Dosage
Children under 3 months
Refer to paediatric specialist
Children aged 3 months and over (specialist advice only)
First choice
Trimethoprim	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 12 to 15 years, 100 mg at night
Nitrofurantoin – if eGFR ≥45 ml/minute	3 months to 11 years, 1 mg/kg at night 12 to 15 years, 50 to 100 mg at night
Second choice
Cefalexin	3 months to 15 years, 12.5 mg/kg at night (maximum 125 mg per dose)
Amoxicillin	3 to 11 months, 62.5 mg at night 1 to 4 years, 125 mg at night 5 to 15 years, 250 mg at night
¹ See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic and renal impairment. ² Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI. If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost. 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. Doses given are by mouth using immediate release medicines unless otherwise stated. ⁴ Teratogenic risk in first trimester of pregnancy (folate antagonist; BNFC, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics). ⁵ Avoid at term in pregnancy; may produce neonatal haemolysis (BNFC, August 2018). ⁶ Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off‑label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.
Abbreviations: BNFC, British natural formulary for children; eGFR, estimated glomerular filtration rate.

See the evidence and committee discussion on choice of antibiotic prophylaxis and antibiotic dosing and course length.

Vaginal oestrogen products are not licensed for preventing recurrent UTI, so use for this indication would be off label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

The evidence was based on a study where D‑mannose was taken as 200 ml of 1% solution once daily in the evening. D‑mannose is a sugar that is available to buy as powder or tablets; it is not a medicine.

For full guidelines log on to:

https://www.nice.org.uk/guidance/ng112

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Source : With inputs from NICE

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Hina Zahid