• Scenario: Acute cystitis (not pregnant): covers the management of acute cystitis (including treatment failure) in women who are not pregnant.
• Scenario: Recurrent cystitis: covers the assessment and management of recurrent cystitis, including lifestyle measures (such as using cranberry products) and preventive treatments.
• Scenario: Asymptomatic bacteriuria and cystitis in pregnancy: covers screening for and treating asymptomatic bacteriuria in pregnancy, and the management of acute cystitis in pregnancy.
• Scenario: Lower UTI with catheter: covers the management of lower urinary tract infection in women with an indwelling urinary catheter.

• Convey a positive approach and reassure the woman that cystitis is generally self-limiting.
• Without antibiotics, symptoms can be expected to resolve in 4–9 days.
• With antibiotics, symptoms can be expected to resolve in 3–8 days.
• On average, antibiotics shorten the duration of symptoms by about a day.
• Relieve symptoms with paracetamol or ibuprofen — do not recommend urine alkalinizing agents or cranberry products.
• If cystitis symptoms are moderate or severe:
• Offer an antibiotic.
• Do not dipstick test the urine, as the decision to offer an antibiotic is not influenced by urine dipstick test results. Even if the tests for nitrite, and leucocyte esterase, and blood are all negative, an antibiotic should still be offered.
• If the woman prefers not to take an antibiotic, offer a delayed antibiotic prescription to be dispensed if the symptoms become worse, or last more than 48 hours.
• If cystitis symptoms are mild:
• Dipstick test the urine to guide treatment decisions.
• Discuss not using an antibiotic, especially if the urine dipstick test is negative for nitrites and leucocyte esterase and blood.
• 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.
• Advise the woman to seek medical attention if she develops a high fever or becomes systemically unwell.

In depth

• Follow local guidelines when available.
• If local guidelines are not available:
• For an uncomplicated infection, prescribe either:
• Trimethoprim 200 mg twice daily, for 3 days, or
• Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 3 days.
• For a complicated infection, prescribe a 5–10-day course of trimethoprim or nitrofurantoin.

In depth

• Urine microscopy and culture are not routinely required for women with uncomplicated cystitis.
• Send urine for microscopy and culture if any of the following apply:
• There are risk factors for a complicated urinary tract infection — for example the woman has recently had urological instrumentation, or is immunocompromised, or has been in hospital recently.
• Confirmation of the diagnosis or exclusion of other conditions is required.
• The woman has not responded to antibiotic treatment.
• The woman has recurrent episodes of cystitis and this has not been investigated.
• When underlying causes of recurrent cystitis and other conditions have been excluded, it is not necessary to routinely culture the urine for further episodes.

In depth

• Follow up is not routinely required for uncomplicated cystitis, but should be considered for women with a potentially complicated infection.
• If haematuria was found, follow up to re-test the urine and check that the infection and haematuria have resolved.

In depth

• If the woman fails to respond to two courses of antibiotics shown by urine culture results to be appropriate treatment, refer for specialist assessment.
• If urological cancer is suspected (for example haematuria persists after successful treatment of cystitis), refer urgently to a team specializing in the management of urological cancer.

In depth

• Continue symptomatic treatment with paracetamol or ibuprofen.
• Check compliance with antibiotic treatment.
• Send a urine sample for culture.
• If symptoms are troublesome, offer a different antibiotic (nitrofurantoin or trimethoprim) while waiting for the culture results — see Choice of antibiotic.
• If infection is confirmed on culture, treat with an antibiotic to which the organism is sensitive.
• If infection is not confirmed on culture, consider other possible causes for the symptoms — see Differential diagnosis.
• If cystitis symptoms fail to respond to two courses of antibiotic shown by culture to be appropriate treatment, refer for specialist assessment.

In depth

• Review the diagnosis.
• Culture the urine to confirm infection and exclude other causes.
• Refer urgently if urological cancer is suspected.
• Review the woman's medical and surgical history to assess risk factors for recurrent cystitis such as stones, papillary necrosis, and vesicoureteric reflux — this assessment may require imaging and urological referral.
• Relieve symptoms with paracetamol or ibuprofen.
• If symptoms are moderate or severe, offer an antibiotic immediately.
• If symptoms are mild, suggest delaying antibiotic treatment until culture results are available to guide choice of antibiotic.
• Advise on lifestyle measures such as high-strength cranberry capsules to reduce the risk of recurrent episodes.
• If troublesome cystitis recurs frequently:
• Consider offering a prescription for a 'stand-by' antibiotic to be used for future episodes.
• Consider preventive treatments.
• Refer or seek specialist advice if these measures are not successful.

In depth

• Follow local guidelines when available. Otherwise:
• For empirical treatment, prescribe either:
• Trimethoprim 200 mg twice daily, for 3 days, or
• Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 3 days.
• If the woman has been treated with trimethoprim recently (up to a year previously), consider prescribing nitrofurantoin instead of trimethoprim.

In depth

Advise women with recurrent cystitis that:

• Cranberry products reduce the recurrence rate of cystitis, and are available from shops (but not on the NHS).
• Cranberry products should not be taken if warfarin is being used.
• High strength capsules (containing at least 200 mg of cranberry extract) are recommended because they may be more effective and acceptable than cranberry juice.
• If cystitis is related to sexual intercourse, advise:
• Using a different contraceptive method if a diaphragm is being used.
• Voiding soon after intercourse.
• Using a lubricant if symptoms could be due to mild trauma rather than infection.

In depth

• Consider offering a prescription for a 'stand-by' antibiotic to be used for future episodes of cystitis before prescribing prophylactic drug treatment.
• When deciding to offer prophylactic drug treatment, consider the frequency, severity, and impact of recurrent cystitis, and whether referral for urological investigation would be appropriate.
• For recurrent cystitis associated with sexual intercourse, offer trimethoprim 100 mg to be taken within 2 hours of intercourse (off-label use).
• For recurrent cystitis not associated with sexual intercourse offer a 6-month trial of low-dose continuous antibiotic treatment: trimethoprim 100 mg every night, or nitrofurantoin (immediate-release) 50–100 mg every night.

In depth

• If prophylactic antibiotics are prescribed, follow up to review progress after 6 months, or sooner if clinically indicated.
• If haematuria was found, follow up to re-test the urine and check that the infection and haematuria have resolved.

In depth

• Refer urgently, to a team specializing in the management of urological cancer, if urological cancer is suspected (for example if haematuria persists after successful treatment of acute cystitis).
• Refer the woman if:
• Risk factors for recurrent cystitis (such as urinary tract abnormalities, stones, vesicoureteric reflux, papillary necrosis) are present or suspected.
• There is any known abnormality on ultrasound of kidneys, ureters, and bladder.
• The response to preventive treatments and lifestyle measures is ineffective.

In depth

• 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.
• Preferred options when sensitivities are known are (in order of preference):
• Amoxicillin: 250 mg three times daily, for 7 days.
• Nitrofurantoin: 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days.
• Trimethoprim: 200 mg twice daily, for 7 days (unless the woman is folate deficient or taking a folate antagonist).
• Cefalexin (500 mg twice daily, or 250 mg 6-hourly, for 7 days) may be used but is less preferred.
• 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.

In depth

• Convey a positive approach and reassure the woman that treatment with an antibiotic will prevent any harm to her baby, and will shorten the duration of symptoms.
• If the women has fever or loin tenderness, suspect upper urinary tract infection and admit or seek urgent specialist opinion.
• Offer paracetamol for symptomatic relief. Do not recommend urine alkalinizing agents or cranberry products. Do not recommend urine alkalinizing agents or cranberry products.
• Send a urine sample for culture before starting antibiotic treatment.
• Prescribe an antibiotic empirically. If local guidelines are not available, suitable first-line antibiotics are (in order of preference):
• Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days.
• Trimethoprim 200 mg twice daily, for 7 days (if the person is not folate deficient or taking a folate antagonist, and has not been treated with trimethoprim in the past year).
• Cefalexin 500 mg twice daily, or 250 mg 6-hourly, for 7 days.
• Follow up after 48 hours (or according to the clinical situation) to check response to treatment and the urine culture results.
• Amoxicillin 250 mg three times daily, for 7 days, is recommended only if the organism is reported to be susceptible on the culture results.

In depth

• Review culture results when available and, if necessary, change to an antibiotic that the organism is sensitive to.
• Send urine cultures to screen for asymptomatic bacteriuria 7 days after completion of treatment, and 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.

In depth

• Admit, or seek urgent specialist opinion, if upper urinary tract infection is suspected (fever, loin tenderness, and pain).
• Seek specialist advice if symptoms fail to respond to antibiotic treatment guided by urine culture results, and if other causes have been excluded — see Differential diagnosis.

In depth

• Check compliance with antibiotic treatment.
• Continue symptomatic treatment with paracetamol or, in the first or second trimesters, ibuprofen.
• Send a urine sample for culture.
• If symptoms are troublesome, offer a different antibiotic (nitrofurantoin or trimethoprim) while waiting for the culture results — see Managing suspected acute cystitis during pregnancy.
• If infection is confirmed on culture, treat with an antibiotic to which the organism is sensitive.
• If infection is not confirmed on culture, consider other possible causes for the symptoms — see Differential diagnosis.
• If cystitis symptoms fail to respond to a second antibiotic shown by urine culture results to be appropriate treatment, seek specialist advice.

In depth

• 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