Acute cystitis in non-pregnant women

• Convey a positive approach and reassure the woman that cystitis is generally self-limiting.
• Relieve the symptoms with paracetamol or ibuprofen.
• If cystitis symptoms are moderate or severe, offer a 3-day course of:
• Trimethoprim 200 mg twice daily, or
• Nitrofurantoin 50 mg four times a day, or 100 mg (modified-release) twice daily.
• If cystitis symptoms are mild:
• Dipstick test the urine and if results are negative, discuss not treating the cystitis with an antibiotic.
• Have a lower threshold for offering an antibiotic if there are risk factors for persistent infection, recurrent infection, or treatment failure.
• If there are concerns about not taking an antibiotic, offer a delayed antibiotic prescription to be dispensed if the symptoms become worse, or last more than 48 hours.
• Urine culture is not routinely required.
• Urine culture is useful to confirm the diagnosis and to guide choice of antibiotic when there are risk factors for more severe illness or treatment has failed.
• If cystitis symptoms fail to respond to an antibiotic chosen according to the urine culture result, check compliance, repeat the urine culture, change to another antibiotic, and consider referring for specialist assessment.

Recurrent cystitis

• Review the diagnosis.
• Review the medical and surgical history to assess risk factors for recurrent cystitis such as stones, papillary necrosis, and vesicoureteric reflux — this may require imaging or urological referral.
• Relieve the symptoms with paracetamol or ibuprofen.
• Treat the infection with a 3-day course of trimethoprim or nitrofurantoin (as above) if the symptoms are severe.
• Advise on lifestyle measures for prevention, such as use of cranberry products. High strength (at least 200 mg) capsules may be more effective and better tolerated than cranberry drinks.
• For women with troublesome recurrent cystitis, consider:
• A prescription for a 'stand-by' antibiotic to be used for future episodes of cystitis.
• Trimethoprim 200 mg to be taken within 2 hours of intercourse (off-label use).
• A 6-month trial of low-dose continuous antibiotic treatment: trimethoprim 100 mg or nitrofurantoin (immediate-release) 50–100 mg, every night.

Asymptomatic bacteriuria in pregnancy

• Screen for asymptomatic bacteriuria on the first antenatal visit by sending urine for culture.
• If asymptomatic bacteriuria is found, send a second urine sample for culture.
• If the second urine culture confirms asymptomatic bacteriuria, treat for 7 days with an antibiotic to which the organism is sensitive. Do not use trimethoprim first-line if there is a suitable alternative.
• After treatment, send urine for culture to screen for asymptomatic bacteriuria at every antenatal visit until delivery.
• If a group B streptococcus is isolated, inform the antenatal care service, as prophylactic antibiotics may be indicated during labour and delivery.

Cystitis during pregnancy

• Culture the urine.
• Relieve the symptoms with paracetamol.
• Treat the infection with an appropriate antibiotic for 7 days (in order of preference: nitrofurantoin, trimethoprim [if the woman is not folate deficient or taking a folate antagonist], amoxicillin, cefalexin).
• Have a low threshold for admitting the woman if upper urinary tract infection (UTI) is suspected (fever, loin tenderness, and pain).
• After treatment, send urine for culture to screen for asymptomatic bacteriuria at every antenatal visit until delivery.
• If a group B streptococcus is isolated, inform the antenatal care service, as prophylactic antibiotics may be indicated during labour and delivery.

Lower UTI in women with an indwelling urinary catheter

• For women with an indwelling urinary catheter, considerable clinical judgement is required to diagnose UTI.
• Assess the severity of the infection and the presence of any comorbidities.
• Admit the woman to hospital if there are symptoms and signs of severe infection.
• If there is fever, and flank pain or tenderness, manage as for upper UTI — see the CKS topic on Pyelonephritis - acute.
• Check that the catheter is correctly positioned and not blocked.
• Send urine for culture before antibiotic treatment is started.
• If it is practical, withhold antibiotics until the result of urine culture is available to guide the choice of antibiotic. Otherwise, empirically prescribe trimethoprim or nitrofurantoin for 7 days.
• Relieve the symptoms with paracetamol or ibuprofen.
• Check the urine culture report. If necessary, change the antibiotic to one to which the organism is sensitive.
• To prevent UTI:
• Use an indwelling urinary catheter only after alternative methods of management have been considered, and regularly review the need for a catheter.
• Ensure high standards of hygiene with catheter care: obtain urine samples from a sampling port using an aseptic technique, and change catheters only when necessary.
• When changing catheters, only use antibiotic prophylaxis for people with a history of catheter-associated UTI following catheter change.