Urinary Tract Infection (Recurrent): Antimicrobial Prescribing

1.1.1
Manage an acute urinary tract infection (UTI) as outlined in NICE's guideline on UTI (lower): antimicrobial prescribing or pyelonephritis (acute): antimicrobial prescribing. [2018]

1.1.2
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)
• is particularly common in women, and trans men and non-binary people with a female urinary system. [2018]

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. [2018]

Referral and seeking specialist advice for recurrent UTI
1.1.4
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, in line with NICE's guideline on suspected cancer: recognition and referral
• anyone who has had gender reassignment surgery that involved structural alteration of the urethra. [2018, amended 2024]

Oestrogen
In December 2024, this was an off-label use of vaginal oestrogen products. See NICE's information on prescribing medicines.
See also the recommendations on genitourinary symptoms associated with menopause in NICE's guideline on menopause. This section of the menopause guideline, which includes advice on the use of vaginal oestrogen for people with a personal history of breast cancer, should be read in conjunction with the recommendations in this guideline.
These recommendations are for women, and trans men and non-binary people with a female urinary system, who are experiencing perimenopause or menopause, or who have already experienced menopause.

1.2.1
Consider vaginal oestrogen for recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate. [2018, amended 2024]

1.2.2
When discussing vaginal oestrogen for preventing recurrent UTI, cover the following 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). [2018, amended 2024]

1.2.3
Review treatment with vaginal oestrogen within 12 months, or earlier if agreed with the person. [2018]

1.2.4
Do not offer systemic hormone replacement therapy specifically to reduce the risk of recurrent UTI. [2018, amended 2024]

Single-dose antibiotic prophylaxis
These recommendations are for women, and trans men and non-binary people with a female urinary system, who are not pregnant.

1.2.5
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. [2018]

1.2.6
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 (see the recommendations on choice of antibiotic or antiseptic prophylaxis). 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 person's preferences for antibiotic use. [2018]

1.2.7
When single-dose antibiotic prophylaxis is offered, 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. [2018]

Methenamine hippurate

1.2.8
Consider methenamine hippurate 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).
Also see the sections on daily antibiotic prophylaxis and choice of antibiotic or antiseptic prophylaxis. For those with recurrent upper UTI or complicated lower UTI, follow recommendation 1.2.9. [2024]

1.2.9
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. [2024]
In December 2024, the use of methenamine hippurate as prophylaxis for recurrent upper UTI or complicated lower UTI, and for recurrent UTI in children aged under 6, was off label. See NICE's information on prescribing medicines.

1.2.10
If discussing methenamine hippurate as a preventative treatment, explain that:

• over-the-counter sachets that make urine more alkaline (such as sachets used to relieve UTI symptoms that contain potassium citrate or sodium citrate) should not be used while taking methenamine hippurate because these can make the medicine less effective
• medical help should be sought for acute UTI symptoms. [2024]

1.2.11
Review treatment with methenamine hippurate within 6 months, and then every 12 months, or earlier if agreed with the person. [2024]

Daily antibiotic prophylaxis
General principles for prescribing
These recommendations are for children, young people and adults with recurrent UTI.

1.2.12
When considering a trial of daily antibiotic prophylaxis, take account of:

• 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. [2018]

1.2.13
When offering a trial of daily antibiotic prophylaxis, 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. [2018]

For women, and trans men and non-binary people with a female urinary system, who are not pregnant

1.2.14

• If there has been no improvement after vaginal oestrogen, single-dose antibiotic prophylaxis or methenamine hippurate (if any of these have been appropriate and are applicable), ensure that any current UTI has been adequately treated, then consider a trial of daily antibiotic prophylaxis for recurrent UTI. Take account of the following:
• any further investigations (for example, ultrasound) that may be needed to identify an underlying cause
• the person's preferences for antibiotic use
• any other factors listed in recommendation 1.2.12 in the section on general principles for prescribing.
• Also see the recommendations on choice of antibiotic or antiseptic prophylaxis. [2018]

For advice to give when offering daily antibiotic prophylaxis, see the section on general principles for prescribing.

During pregnancy, or for men, and trans women and non-binary people with a male genitourinary system

1.2.15
Ensure that any current UTI has been adequately treated, then consider a trial of daily antibiotic prophylaxis for recurrent UTI if behavioural and personal hygiene measures alone, or methenamine hippurate (if used in line with recommendation 1.2.9), are not effective or not appropriate, with specialist advice. Take account of the following:

• any further investigations (for example, ultrasound) that may be needed to identify an underlying cause
• the person's preferences for antibiotic use
• any other factors listed in recommendation 1.2.12 in the section on general principles for prescribing.
• Also see the recommendations on choice of antibiotic or antiseptic prophylaxis. [2018]
• For advice to give when offering daily antibiotic prophylaxis, see the section on general principles for prescribing.
• For children and young people under 16 years

1.2.16
Ensure that any current UTI has been adequately treated, then consider a trial of daily antibiotic prophylaxis for recurrent UTI if behavioural and personal hygiene measures alone, or methenamine hippurate (if used in line with recommendation 1.2.9), are not effective or not appropriate, with specialist advice. Take account of the following:

• 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
• preferences for antibiotic use
• any other factors listed in recommendation 1.2.12 in the section on general principles for prescribing.

Also see the recommendations on choice of antibiotic or antiseptic prophylaxis. [2018]
For advice to give when offering daily antibiotic prophylaxis, see the section on general principles for prescribing.

Reassessing the use of daily antibiotic prophylaxis in all people

1.2.17
Review daily 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 (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. [2018]

1.3.1
Be aware that some women, and trans men and non-binary people with a female urinary system, who have recurrent UTI and are not pregnant may wish to try:

• D‑mannose (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
• cranberry products (evidence of benefit is uncertain and there is no evidence of benefit for older women, or older trans men or non-binary people with a female urinary system). [2018]

1.3.2
Be aware that 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). [2018]

1.3.3
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. [2018]

1.3.4
Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI. [2018]

1.4.1
When prescribing antibiotic prophylaxis for recurrent UTI, take account of local antimicrobial resistance (AMR) data from the UK Health Security Agency and:

• follow the recommendations in table 1 for people aged 16 years and over
• follow the recommendations in table 2 for children and young people under 16 years.

Also see tables 1 and 2 for information about methenamine hippurate, if thinking about this treatment as an alternative to daily antibiotics. [2018, amended 2024]