Clinical update

Identifying and treating urinary tract infections: new NICE guidelines

Recommendations on diagnosing and managing UTIs

Urine should be tested for nitrates and a sample sent off for a culture
before prescribing a course of antibiotics. Picture: iStock

Essential facts

Urinary tract infections (UTIs) are common infections that affect different parts of the urinary tract, including the bladder (cystitis), urethra and kidneys. UTIs are generally caused by bacteria from faeces entering the urethra.

The number of UTIs caused by drug-resistant bacteria is increasing, according to the English Surveillance Programme for Antimicrobial Utilisation and Resistance report last November. One in three (34%) of the samples analysed were found to be resistant to an antibiotic called trimethoprim, compared with 29.1% in 2015.

What’s new

New guidance intended to help combat drug-resistant urinary tract infections has been published by the National Institute for Health and Care Excellence (NICE). Separate draft guidance has been published for catheter-associated UTIs, recurrent UTIs, lower UTIs, acute prostatitis and acute pyelonephritis (infection in one or both kidneys).

‘Inappropriate and overuse use of antibiotics fuels drug resistance’

While most UTIs will require antibiotics, the guidance is intended to help healthcare professionals choose the most appropriate option. Inappropriate and overuse use of antibiotics fuels drug resistance. NICE says healthcare professionals should ask patients about the severity and regularity of their symptoms before they prescribe antibiotics.

Signs and symptoms

These include:

  • Needing to urinate more frequently or suddenly.
  • Pain or burning on urination.
  • Urine that is smelly, cloudy or contains blood.
  • Pain in the lower abdomen.
  • Feeling tired and unwell. 
  • In older people, changes in behaviour, such as severe confusion or agitation.

Causes and risk factors

Prevalence is higher in women because their shorter urethra makes it more likely that bacteria will reach the bladder or kidneys. Causes of UTIs include:

  • Pregnancy.
  • Conditions that block the urinary tract, such as kidney stones.
  • Conditions that make it difficult to fully empty the bladder, such as an enlarged prostrate in men.
  • Urinary catheters.
  • Having a weakened immune system, from diabetes or chemotherapy, for example.

Prevalence increases with age both in men and women.

How you can help your patient

  • Explain there is inconclusive evidence that cranberry products and probiotics reduce the risk of UTIs.
  • Advise patients that measures to reduce the risk of UTIs include: adequate fluid intake; not delaying urination; wiping from front to back; not douching or wearing tight underwear.
  • Consider paracetamol for pain or, if preferred and suitable, ibuprofen.
  • When prescribing antibiotics, take account of symptoms severity; risk of complications; previous urine culture results; and previous antibiotic use that may have led to resistant bacteria. Use narrow-spectrum antibiotics where possible.

Expert comment

Elaine Hazell, urology clinical nurse specialist and independent prescriber at Guy’s and St Thomas’ NHS Foundation Trust in London


‘UTIs can be debilitating, as those affected are stuck by the toilet and are often in pain, taking antibiotics frequently.

‘Urine should be tested for nitrates and a sample sent off for a culture before prescribing, if possible, to ensure people are on the correct antibiotic. If a patient needs immediate antibiotics, follow it up with a culture. Provide patients with general advice on avoiding UTIs. In my experience, GPs are not checking urine enough and are just prescribing antibiotics.

‘If someone is experiencing repeated UTIs they should be referred to a specialist service. UTIs should not be dismissed in older people – it is not normal, just because the person is older. UTIs can have a major effect on older people by causing confusion and leading to falls. If an older person becomes confused and disoriented the first thing to do is check their urine.’


Further information

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