Current standard treatment of UTIs

All patients with a UTI should be advised on self-care strategies:^4,5,8

• They should drink plenty of fluids to avoid dehydration, but avoid drinks that may irritate their bladder, like fruit juices, coffee and alcohol
• For pain relief, recommend an analgesic such as paracetamol or ibuprofen
• A hot water bottle held over the lower tummy might also help with pain relief

Additional strategies to reduce the risk of recurrent infections include:^4,5,8,9

• Wipe from front to back when going to the toilet
• Treat constipation and diarrhoea – constipation is a common underlying cause of recurrent UTIs, particularly in the elderly
• Do not delay habitual or post-coital urination
• Do not wear occlusive underwear
• Avoid douching
• Avoid the use of spermicide
• Have a shower rather than a bath and avoid scented soap
• Keep the genital area clean and dry
• Wash the skin around the vagina with water before and after sex
• Optimise diabetic control

Diagnosing a UTI correctly will enable appropriate management. When considering antibiotic treatment, the severity of symptoms, risk of developing complications, previous urine culture and susceptibility results and previous antibacterial use should be taken into consideration.⁵

If an antibiotic is deemed suitable, the shortest course that is likely to be effective should be prescribed.⁶ This will limit the risks of side effects and reduce the risk of antimicrobial resistance.

A short course of an antimicrobial therapy (3 days) is sufficient for treating acute uncomplicated lower UTIs in non-pregnant women.⁶

Oral first line: A 3-day course of antibiotic:^4,5

• Nitrofurantoin 100mg modified release twice a day, or
• Trimethoprim 200mg twice a day (if the risk of resistance is low)

Oral second line therapy (if first line treatment is not suitable or no improvement has been seen after 48 hours):⁵

• Nitrofurantoin (if not already used first line)
• Fosfomycin
• Pivmecillinam
• Amoxicillin (rate of resistance is high, so only suitable if the culture is susceptible)

Delayed antibiotics can be considered for mild symptoms when there are no other risk factors for a complicated infection. In this case the woman should be advised to start taking the medication if symptoms do not improve within 48 hours or if they get worse.⁴

Prophylaxis may be considered if the underlying cause has been investigated and behavioural and lifestyle measures have not been effective.^4,5 Single-dose antibiotic prophylaxis may be considered for use when exposed to an identifiable trigger (e.g. post-coital use) and if there is no improvement, a trial of daily prophylaxis may be appropriate.^4,5 Although they are used, trimethoprim and nitrofurantoin are not licensed as single dose prophylactic treatments and amoxicillin and cefalexin are not licensed for prophylaxis of rUTIs.¹⁰