Pregnant woman, or man, or child or young person under 16 years, or any person with recurrent upper UTI

Recurrent UTI in adults is defined as repeated UTI with a frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months (1,2).

Recurrent UTI is diagnosed in children and young people under 16 years if they have (2):

• 2 or more episodes of UTI with acute pyelonephritis/upper UTI or
• 1 episode of UTI with acute pyelonephritis plus 1 or more episode of UTI with cystitis/lower UTI or
• 3 or more episodes of UTI with cystitis/lower UTI

Referral and seeking specialist advice for recurrent UTI (2):

Refer or seek specialist advice on further investigation and management for:

• men, and trans women and non-binary people with a male genitourinary system, aged 16 and over
• people with recurrent upper UTI
• people with recurrent lower UTI when the underlying cause is unknown
• pregnant women, and pregnant trans men and non-binary people
• children and young people aged under 16 years, in line with NICE's guideline on urinary tract infection in under 16s
• people with suspected cancer, in line with NICE's guideline on suspected cancer: recognition and referral
• anyone who has had gender reassignment surgery that involved structural alteration of the urethra

General management (2,3)

• first advise about behavioural and personal hygiene measures, and self-care (with D-mannose or cranberry products) to reduce the risk of UTI
• for postmenopausal women, if no improvement, consider vaginal oestrogen (review within 12 months)
• for non-pregnant women, if no improvement, consider single-dose antibiotic prophylaxis for exposure to a trigger (review within 6 months)
  • recommendations are for women, and trans men and non-binary people with a female urinary system, who are not pregnant
• for non-pregnant women (if no improvement or no identifiable trigger) or with specialist advice for pregnant women, men, children or young people, consider a trial of daily antibiotic prophylaxis (review within 6 months)

Methenamine hippurate (2)

• methenamine hippurate should be considered as an alternative to daily antibiotic prophylaxis for recurrent UTI in women, and trans men and non-binary people with a female urinary system, if:
  • they are not pregnant and
  • any current UTI has been adequately treated and
  • they have recurrent UTI that has not been adequately improved by behavioural and personal hygiene measures, vaginal oestrogen or single-dose antibiotic prophylaxis (if any of these have been appropriate and are applicable).

Choice of antibiotic: people aged 16 years and over

First choice antibiotic 1,2

• trimethoprim4
  • 200 mg single dose when exposed to a trigger, or 100 mg at night
• OR
  
  
• nitrofurantoin - if eGFR >=45 ml/minute5
  • 100 mg single dose when exposed to a trigger, or 50 to 100 mg at night

Second choice antibiotic

• amoxicillin 6 500 mg single dose when exposed to a trigger, or 250 mg at night
• cefalexin 500 mg single dose when exposed to a trigger, or 125 mg at night
  
  
• 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding.
• 2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI.
• 3 Doses given are by mouth using immediate-release medicines, unless otherwise stated.
• 4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNF, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics).
• 5 Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, August 2018)
• 6 Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented.

Children under 3 months - Refer to paediatric specialist

Children aged 3 months and over (specialist advice only)

First choice

• Trimethoprim4
  • 3 to 5 months, 2 mg/kg at night (maximum 100 mg per dose) or 12.5 mg at night
  • 6 months to 5 years, 2 mg/kg at night (maximum 100 mg per dose) or 25 mg at night
  • 6 to 11 years, 2 mg/kg at night (maximum 100 mg per dose) or 50 mg at night
  • 12 to 15 years, 100 mg at night
    
    
  • OR
    
    
• Nitrofurantoin if eGFR >=45 ml/minute5
  • 3 months to 11 years, 1 mg/kg at night
  • 12 to 15 years, 50 to 100 mg at night

Children aged 3 months and over (specialist advice only)

Second choice

• Cefalexin
  • 3 months to 15 years, 12.5 mg/kg at night (maximum 125 mg per dose)
    
    
  • OR
    
    
• Amoxicillin6
  • 3 to 11 months, 62.5 mg at night;
  • 1 to 4 years, 125 mg at night;
  • 5 to 15 years, 250 mg at night
    
    
• 1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.
• 2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI. If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost.
• 3 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age. Doses given are by mouth using immediate release medicines, unless otherwise stated.
• 4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNFC, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics).
• 5 Avoid at term in pregnancy; may produce neonatal haemolysis (BNFC, August 2018).
• 6 Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information

Reference:

1. Dawson S et al. Guidelines for the diagnosis and management of recurrent urinary tract infection in women.Can Urol Assoc J. Oct 2011; 5(5): 316-322
2. NICE (December 2024). Urinary tract infection (recurrent): antimicrobial prescribing
3. Public Health England (June 2021). Managing common infections: guidance for primary care