Specific measures including antibiotic treatment

Recurrent 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 (1).

Recurrent UTI is diagnosed in children and young people under 16 years if they have (1):

• 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

Recurrent UTI includes lower UTI and upper UTI (acute pyelonephritis) (1)

• may be due to relapse (with the same strain of organism) or reinfection (with a different strain or species of organism)
• is particularly common in women, and trans men and non-binary people with a female urinary system

Refer or seek specialist advice on further investigation and management for:

• men, and trans women and non-binary people with a male genitourinary system, aged 16 and over
• people with recurrent upper UTI
• people with recurrent lower UTI when the underlying cause is unknown
• pregnant women, and pregnant trans men and non-binary people
• children and young people aged under 16 years, in line with NICE's guideline on urinary tract infection in under 16s
• people with suspected cancer
• anyone who has had gender reassignment surgery that involved structural alteration of the urethra

Self-care

• non-pregnant women may wish to try D-mannose
• non-pregnant women may wish to try cranberry products (evidence uncertain)
• advise people taking cranberry products or D-mannose about the sugar content of these products
  • the evidence for D‑mannose was based on a study in which it 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
• consider vaginal (not oral) oestrogen for postmenopausal women if behavioural and personal hygiene measures not effective or appropriate
  • consider vaginal (not oral) oestrogen for postmenopausal women if behavioural and personal hygiene measures not effective or appropriate
    
    
    • the lowest effective dose of vaginal oestrogen should be considered (for example, estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate
      
      
    • the following points should be discussed 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
      • that serious side effects are very rare
      • that vaginal oestrogen is absorbed locally – a minimal amount is absorbed into the bloodstream, but this is unlikely to have a significant effect throughout the body
      • the person's preferred treatment option for vaginal oestrogen (for example, a cream, gel, tablet, pessary or ring)
        
  • review within 12 months (or earlier if agreed)

Single-dose antibiotic prophylaxis

• consider a trial of single-dose antibiotic prophylaxis (a one-off dose of an antibiotic) for recurrent UTI only if behavioural and personal hygiene measures, and vaginal oestrogen, are not effective or not appropriate
• ensure that any current UTI has been adequately treated, then consider single-dose antibiotic prophylaxis for recurrent UTI for use when there has been exposure to an identifiable trigger (for example, sexual intercourse)

Methenamine hippurate

• methenamine hippurate should as an alternative to daily antibiotic prophylaxis for recurrent UTI in women, and trans men and non-binary people with a female urinary system, if:
  • they are not pregnant and
  • any current UTI has been adequately treated and
  • they have recurrent UTI that has not been adequately improved by behavioural and personal hygiene measures, vaginal oestrogen or single-dose antibiotic prophylaxis (if any of these have been appropriate and are applicable)
• seek specialist advice if considering methenamine hippurate as an alternative to daily antibiotic prophylaxis for recurrent UTI:
  • during pregnancy
  • in people with recurrent upper UTI or complicated lower UTI
  • in men, and trans women and non-binary people with a male genitourinary system
  • in children and young people

Choice of antibiotic: people aged 16 years and over

First choice antibiotic 1,2

• trimethoprim4
  • 200 mg single dose when exposed to a trigger, or 100 mg at night
• OR
  
  
• nitrofurantoin - if eGFR >=45 ml/minute5
  • 100 mg single dose when exposed to a trigger, or 50 to 100 mg at night

Second choice antibiotic

• amoxicillin 6 500 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 breast-feeding.
• 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.

Details if use single-dose or daily antibiotic prophylaxis:

• when single-dose antibiotic prophylaxis given, advise:
  • how to use
  • possible adverse effects of antibiotics, particularly diarrhoea and nausea
  • returning for review within 6 months
  • seeking medical help if symptoms of an acute UTI develop
    
    
• when a trial of daily antibiotic prophylaxis given, advise:
  • risk of resistance with long-term antibiotics
  • possible adverse effects of long-term antibiotics
  • returning for review within 6 months
  • seeking medical help if symptoms of an acute UTI develop
    
    
• review at least every 6 months should include:
  • assessing prophylaxis success
  • reminders about behavioural and personal hygiene measures, and self-care
  • discussing whether to continue, stop or change antibiotic prophylaxis

Notes:

• a systematic review concluded that (2)
  • continuous antibiotic prophylaxis for 6-12 months reduced the rate of UTI during prophylaxis when compared to placebo; however there were more adverse events in the antibiotic group
  • one RCT compared postcoital versus continuous daily ciprofloxacin and found no significant difference in rates of UTIs, suggesting that postcoital treatment could be offered to woman who have UTI associated with sexual intercourse

Reference:

1. NICE (December 2024). Urinary tract infection (recurrent): antimicrobial prescribing
2. Huertas AX et el. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Huertas. Cochrane Database Syst Rev. 2004;(3):CD001209.