NICE Guidelines on Managing Recurrent UTIs

NICE has today published its updated guideline NG112 on “Urinary tract infection (recurrent): antimicrobial prescribing.” In this post we look at the key recommendations. As usual, we recommend reading the full guideline if you wish to adopt the recommendations in clinical practice. You can find our other summaries of NICE updates and guidelines here. Please subscribe to our podcast on Apple Podcasts, Amazon Music, or Spotify. We discuss various topics and show visual aids for visual learners. Just search for “The GP Pharmacy Club Pod,” on any of these platforms.

Urinary tract infections (UTIs) are among the most common bacterial infections, affecting millions worldwide. Recurrent UTIs, defined as multiple episodes over six months to a year, can be particularly challenging. The latest guidance from the National Institute for Health and Care Excellence (NICE) offers strategies. It helps prevent recurrent UTIs. It also provides management approaches, optimises antibiotic use and minimizes resistance risks.

Understanding Recurrent UTIs

Recurrent UTIs can be caused by either relapse (same bacterial strain) or reinfection (different strain). They are notably more prevalent among women, trans men, and non-binary individuals with a female urinary system. The guidance categorizes UTIs into lower (bladder infections) and upper (kidney infections or pyelonephritis), with tailored management approaches for each.

Referral and Specialist Consultation

For recurrent UTI cases, referral to a specialist is recommended in specific situations, including:

• Men, trans women, and non-binary individuals with a male urinary system aged 16 and over.
• People with recurrent upper UTI, as this may indicate a more serious underlying condition.
• Individuals with recurrent lower UTI when the underlying cause is unknown, necessitating further investigation.
• Pregnant women, trans men, and non-binary individuals who are pregnant, as UTIs during pregnancy require special management.
• Children and young people under 16 years, following guidelines outlined in NICE’s UTI guideline for pediatric cases.
• People with suspected cancer, in line with NICE’s guideline on cancer recognition and referral.
• Anyone who has undergone gender reassignment surgery that involved structural changes to the urethra.

Seeking specialist advice ensures appropriate diagnostic testing, consideration of structural abnormalities, and an individualized treatment approach.

Prevention Strategies

NICE recommends a combination of behavioral, non-antibiotic, and antibiotic approaches to reduce recurrence risk:

1. Behavioral and Hygiene Measures

Simple lifestyle adjustments can help reduce UTI risk. These include:

• Staying well-hydrated
• Urinating after sexual activity
• Avoiding irritants such as perfumed soaps
• Maintaining good personal hygiene
• Wearing loose-fitting clothing and breathable underwear
• Avoiding spermicide-containing products, which may disrupt the natural vaginal microbiome

2. Hormonal Therapy with Vaginal Oestrogen

For individuals experiencing perimenopause or menopause, NICE suggests vaginal oestrogen if hygiene measures alone are ineffective. This treatment can improve vaginal health and potentially reduce UTI frequency.

Key considerations when discussing vaginal oestrogen:

• It is absorbed locally with minimal systemic impact.
• Serious side effects are rare.
• Different application forms (cream, gel, tablet, pessary, ring) allow for personalized treatment.
• Systemic hormone replacement therapy (HRT) is not recommended solely for UTI prevention.
• Treatment should be reviewed within 12 months to assess effectiveness.

Medical Treatments for Recurrent UTIs

When non-antibiotic strategies are insufficient, pharmacological options include:

1. Single-Dose Antibiotic Prophylaxis

For non-pregnant individuals who identify specific UTI triggers, a single-dose antibiotic after exposure (e.g., after intercourse) may help prevent recurrence. NICE advises careful consideration of:

• The frequency and severity of symptoms
• Risks of antibiotic resistance
• Previous antibiotic responses
• Individual preferences regarding antibiotic use

Individuals prescribed single-dose prophylaxis should receive guidance on:

• How to properly use the antibiotic
• Potential side effects, such as nausea and diarrhea
• The importance of seeking medical help if an acute UTI develops
• Scheduling a review within six months to reassess the treatment plan

2. Methenamine Hippurate as an Alternative

Methenamine hippurate, a urinary antiseptic, may be considered for individuals who cannot use antibiotics. However, NICE suggests specialist consultation before prescribing it for complex cases, including during pregnancy or in men, children, and those with recurrent upper UTIs or complicated lower UTIs.

Key patient guidance for methenamine hippurate:

• Avoid over-the-counter urine alkalizing sachets (e.g., potassium citrate or sodium citrate) as they may reduce effectiveness.
• Seek medical help if acute UTI symptoms develop.
• Treatment should be reviewed after six months and annually thereafter.

3. Daily Antibiotic Prophylaxis

If other measures fail, a low-dose daily antibiotic regimen may be trialed. NICE emphasizes regular reassessment (at least every six months) to evaluate its effectiveness and monitor for antimicrobial resistance.

When considering daily antibiotic prophylaxis, factors to assess include:

• Frequency and severity of previous UTIs
• Risks associated with long-term antibiotic use
• Previous urine culture and antibiotic susceptibility results
• Possible underlying causes requiring further investigation
• The patient’s preferences for antibiotic use

If daily prophylaxis is initiated, patients should be educated on:

• The risk of developing antibiotic resistance
• The potential side effects of long-term antibiotic use
• The importance of regular medical reviews

Self-Care and Alternative Remedies

While clinical evidence is mixed, some individuals may wish to try:

• D-mannose: A sugar believed to help prevent bacterial adherence to the bladder lining. Studies have shown it may be effective when taken as a 200ml solution daily.
• Cranberry products: While evidence on their effectiveness is uncertain, they may be considered, especially for younger individuals. However, there is no demonstrated benefit for older women and trans men.
• Probiotics: The role of lactobacillus in UTI prevention remains uncertain, but ongoing research explores its potential benefits.

NICE advises patients considering these remedies to be mindful of the sugar content in cranberry products and D-mannose, as excessive intake could impact overall health.

Choosing the Right Antibiotic

For individuals requiring antibiotics, NICE advises selection based on:

• Local antimicrobial resistance data
• Culture and susceptibility results
• Individual patient history

Recommended Antibiotics

For adults aged 16 and over, first-choice antibiotics include:

• Trimethoprim (200mg single dose or 100mg at night) – Not recommended in early pregnancy due to teratogenic risk.
• Nitrofurantoin (100mg single dose or 50-100mg at night) – Avoid near term in pregnancy.

Second-choice antibiotics include:

• Amoxicillin (250mg at night or 500mg single dose)
• Cefalexin (125mg at night or 500mg single dose)

For children under 16, dosages are adjusted based on age and weight, with recommendations for specialist consultation before initiating treatment.

Reassessing UTI Prevention Strategies

All treatments, including antibiotic and non-antibiotic prophylaxis, should be reassessed regularly to ensure effectiveness and prevent unnecessary antibiotic use. NICE recommends:

• Reviewing daily antibiotic prophylaxis at least every six months.
• Ensuring that patients have rapid access to treatment for acute UTIs if prophylaxis is discontinued.
• Reinforcing the importance of behavioral and hygiene measures.

Final Thoughts

NICE’s latest guidance underscores a multifaceted approach to managing recurrent UTIs. Healthcare providers can combine behavioral strategies, non-antibiotic options, and prudent antibiotic use. This approach helps reduce infection recurrence. It also mitigates the growing threat of antimicrobial resistance.