• Do not treat asymptomatic bacteriuria.
• Remember that considerable clinical judgement is required to diagnose urinary tract infection (UTI) in women with an indwelling urinary catheter.
• If symptoms are severe (for example, severe nausea and vomiting, confusion, tachypnoea, tachycardia, hypotension, reduced urine output), admit to hospital as intravenous antibiotics may be required.
• Check that the catheter is correctly positioned and not blocked.
• If the catheter has been in place for more than a week, consider changing it before starting antibiotic treatment.
• If there is fever, or loin pain, or both, manage as upper UTI, see the CKS topic on Pyelonephritis - acute.
• Otherwise, treat for lower UTI:
• Relieve symptoms with paracetamol or ibuprofen.
• Send urine for culture and microscopy before starting antibiotic treatment.
• Prescribe an antibiotic for 7 days, following local guidelines when available.
• If symptoms are mild, consider withholding antibiotics until the result of urine culture is available to guide choice of antibiotic.
• If symptoms are moderate or severe, empirically prescribe an antibiotic.
• Follow up after 48 hours (or according to the clinical situation) to check response to treatment and the result of urine culture.

In depth

• Follow local guidelines when available. Otherwise:
• For empirical treatment, prescribe either:
• Trimethoprim 200 mg twice daily, for 7 days, or
• Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days.
• If the woman has a history of recurrent infections, or has recently (within the past year) taken trimethoprim, do not use trimethoprim for empirical treatment.

In depth

• Ensure an indwelling urinary catheter is appropriate.
• Use an indwelling catheter only after alternative methods of management have been considered.
• Regularly review the clinical need for catheterization and remove the catheter as soon as possible.
• Use intermittent catheterization in preference to an indwelling catheter if this is clinically appropriate and is a practical option for the person.
• Prevent the introduction of infection.
• Healthcare personnel should be trained and assessed in their competence to perform urethral catheterization using aseptic procedures.
• Urine samples should be obtained from a sampling port using an aseptic technique.
• Catheters should be changed only when clinically necessary (for example, to prevent blockage), or according to the manufacturer's recommendations.
• When changing catheters, antibiotic prophylaxis should only be used for people with a history of catheter-associated urinary tract infection following catheter change.
• Do not use:
• Bladder instillations or washouts.
• Prophylactic antibiotics when changing catheters in women with a heart valve lesion, septal defect, patent ductus, or prosthetic valve.
• Topical antiseptics or antibiotics applied to the catheter, urethra, or meatus; daily washing of the meatus with soap and water is sufficient.

In depth

• Review after 48 hours, or according to the clinical situation, to ensure the woman is responding to treatment, and to check the results of the urine culture.
• If urine culture shows that the organism is resistant to the current antibiotic, and:
• If symptoms have not resolved, change to an antibiotic that the organism is sensitive to.
• If symptoms have resolved, consider continuing with the current antibiotic.
• If symptoms recur, start treat with an antibiotic shown in the culture to cover the infecting organism.
• If the woman fails to respond to two courses of antibiotic shown by urine culture to be appropriate treatment, and compliance has been checked, consider referring for assessment and investigation.

In depth

• Consider referring for assessment and investigation if the woman fails to respond to two courses of antibiotic shown by urine culture to be appropriate treatment, and compliance has been verified.
• If urological cancer is suspected (for example if haematuria persists after successful treatment of cystitis), refer urgently to a team specializing in the management of urological cancer.

In depth