Urinary tract infectin (lwer) - wmen - Management Scenari: Cystitis in wmen wh are nt pregnant Hw shuld I manage a wman with suspected cystitis? Cnvey a psitive apprach and reassure the wman that cystitis is generally self-limiting. Withut antibitics, symptms can be expected t reslve in 4 9 days. With antibitics, symptms can be expected t reslve in 3 8 days. On average, antibitics shrten the duratin f symptms by abut a day. Relieve symptms with paracetaml r ibuprfen d nt recmmend urine alkalinizing agents r cranberry prducts. If cystitis symptms are mderate r severe: Offer an antibitic. D nt dipstick test the urine, as the decisin t ffer an antibitic is nt influenced by urine dipstick test results. Even if the tests fr nitrite, and leuccyte esterase, and bld are all negative, an antibitic shuld still be ffered. If the wman prefers nt t take an antibitic, ffer a delayed antibitic prescriptin t be dispensed if the symptms becme wrse, r last mre than 48 hurs. If cystitis symptms are mild: Dipstick test the urine t guide treatment decisins. Discuss nt using an antibitic, especially if the urine dipstick test is negative fr nitrites and leuccyte esterase and bld. Have a lwer threshld fr ffering an antibitic if there are risk factrs fr persistent infectin, recurrent infectin, r treatment failure. If there are cncerns abut nt taking an antibitic, ffer a delayed antibitic prescriptin t be dispensed if the symptms becme wrse, r last mre than 48 hurs. Advise the wman t seek medical attentin if she develps a high fever r becmes systemically unwell. In depth 1
When prescribing empirically fr acute cystitis which antibitic shuld I chse? Fllw lcal guidelines when available. If lcal guidelines are nt available: Fr an uncmplicated infectin, prescribe either: Trimethprim 200 mg twice daily, fr 3 days, r Nitrfurantin 50 mg fur times daily, r 100 mg (mdified-release) twice daily, fr 3 days. Fr a cmplicated infectin, prescribe a 5 10-day curse f trimethprim r nitrfurantin. In depth When shuld I culture the urine f a wman with suspected cystitis? Urine micrscpy and culture are nt rutinely required fr wmen with uncmplicated cystitis. Send urine fr micrscpy and culture if any f the fllwing apply: There are risk factrs fr a cmplicated urinary tract infectin fr example the wman has recently had urlgical instrumentatin, r is immuncmprmised, r has been in hspital recently. Cnfirmatin f the diagnsis r exclusin f ther cnditins is required. The wman has nt respnded t antibitic treatment. The wman has recurrent episdes f cystitis and this has nt been investigated. When underlying causes f recurrent cystitis and ther cnditins have been excluded, it is nt necessary t rutinely culture the urine fr further episdes. In depth Hw shuld I fllw up a wman with cystitis? Fllw up is nt rutinely required fr uncmplicated cystitis, but shuld be cnsidered fr wmen with a ptentially cmplicated infectin. If haematuria was fund, fllw up t re-test the urine and check that the infectin and haematuria have reslved. In depth 2
When shuld I refer a wman with acute cystitis? If the wman fails t respnd t tw curses f antibitics shwn by urine culture results t be apprpriate treatment, refer fr specialist assessment. If urlgical cancer is suspected (fr example haematuria persists after successful treatment f cystitis), refer urgently t a team specializing in the management f urlgical cancer. In depth Hw shuld I manage a wman whse cystitis has failed t respnd t antibitics? Cntinue symptmatic treatment with paracetaml r ibuprfen. Check cmpliance with antibitic treatment. Send a urine sample fr culture. If symptms are trublesme, ffer a different antibitic (nitrfurantin r trimethprim) while waiting fr the culture results see Chice f antibitic. If infectin is cnfirmed n culture, treat with an antibitic t which the rganism is sensitive. If infectin is nt cnfirmed n culture, cnsider ther pssible causes fr the symptms see Differential diagnsis. If cystitis symptms fail t respnd t tw curses f antibitic shwn by culture t be apprpriate treatment, refer fr specialist assessment. In depth Prescriptins Antibitic treatment (UTI): trimethprim and nitrfurantin Age frm 14 years nwards Trimethprim tablets: 200mg twice a day fr 3 days Trimethprim 200mg tablets Take ne tablet twice a day fr 3 days. Supply 6 tablets. Trimethprim tablets: 200mg twice a day fr 7 days Trimethprim 200mg tablets Age: frm 14 years nwards NHS cst: 0.39 3
Take ne tablet twice a day fr 7 days. Supply 14 tablets. Age: frm 14 years nwards NHS cst: 0.91 Nitrfurantin tablets: 50mg fur times a day fr 3 days Nitrfurantin 50mg tablets Take ne tablet fur times a day fr 3 days. Supply 12 tablets. Age: frm 14 years nwards NHS cst: 1.21 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin tablets: 50mg fur times a day fr 7 days Nitrfurantin 50mg tablets Take ne tablet fur times a day fr 7 days. Supply 28 tablets. Age: frm 14 years nwards NHS cst: 2.83 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 50mg fur times a day fr 3 days Nitrfurantin 50mg capsules Take ne capsule fur times a day fr 3 days. Supply 12 capsules. Age: frm 14 years nwards NHS cst: 1.00 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 50mg fur times a day fr 7 days Nitrfurantin 50mg capsules Take ne capsule fur times a day fr 7 days. Supply 28 capsules. Age: frm 14 years nwards NHS cst: 2.32 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin m/r caps: 100mg twice a day fr 3 days Nitrfurantin 100mg mdified-release capsules Take ne capsule twice a day fr 3 days. Supply 6 capsules. Age: frm 14 years nwards NHS cst: 2.10 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin m/r caps: 100mg twice a day fr 7 days 4
Nitrfurantin 100mg mdified-release capsules Take ne capsule twice a day fr 7 days. Supply 14 capsules. Age: frm 14 years nwards NHS cst: 4.89 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Analgesia: use when required Age frm 16 years nwards Ibuprfen tablets: 200mg t 400mg three t fur times a day Ibuprfen 200mg tablets Take ne r tw tablets 3 t 4 times a day when required fr pain relief. D nt exceed the stated dse. Supply 56 tablets. Paracetaml tablets: 500mg t 1g up t fur times a day Age: frm 16 years nwards NHS cst: 1.38 OTC cst: 2.38 Paracetaml 500mg tablets Take ne r tw tablets every 4 t 6 hurs when required fr pain relief. Maximum f 8 tablets in 24 hurs. Supply 50 tablets. Urinary tract infectin (lwer) - wmen - Management Scenari: Recurrent cystitis in wmen wh are nt pregnant Hw shuld I manage an acute episde f recurrent cystitis? Age: frm 16 years nwards NHS cst: 0.78 OTC cst: 1.35 Review the diagnsis. Culture the urine t cnfirm infectin and exclude ther causes. Refer urgently if urlgical cancer is suspected. Review the wman's medical and surgical histry t assess risk factrs fr recurrent cystitis such as stnes, papillary necrsis, and vesicureteric reflux this assessment may require imaging and urlgical referral. Relieve symptms with paracetaml r ibuprfen. If symptms are mderate r severe, ffer an antibitic immediately. 5
If symptms are mild, suggest delaying antibitic treatment until culture results are available t guide chice f antibitic. Advise n lifestyle measures such as high-strength cranberry capsules t reduce the risk f recurrent episdes. If trublesme cystitis recurs frequently: Cnsider ffering a prescriptin fr a 'stand-by' antibitic t be used fr future episdes. Cnsider preventive treatments. Refer r seek specialist advice if these measures are nt successful. In depth Which antibitic shuld I prescribe fr a wman with recurrent cystitis? Fllw lcal guidelines when available. Otherwise: Fr empirical treatment, prescribe either: Trimethprim 200 mg twice daily, fr 3 days, r Nitrfurantin 50 mg fur times daily, r 100 mg (mdified-release) twice daily, fr 3 days. If the wman has been treated with trimethprim recently (up t a year previusly), cnsider prescribing nitrfurantin instead f trimethprim. In depth What lifestyle measures shuld I advise fr preventing cystitis? Advise wmen with recurrent cystitis that: Cranberry prducts reduce the recurrence rate f cystitis, and are available frm shps (but nt n the NHS). Cranberry prducts shuld nt be taken if warfarin is being used. High strength capsules (cntaining at least 200 mg f cranberry extract) are recmmended because they may be mre effective and acceptable than cranberry juice. If cystitis is related t sexual intercurse, advise: Using a different cntraceptive methd if a diaphragm is being used. 6
Viding sn after intercurse. Using a lubricant if symptms culd be due t mild trauma rather than infectin. In depth When shuld I ffer preventive treatments fr recurrent cystitis? Cnsider ffering a prescriptin fr a 'stand-by' antibitic t be used fr future episdes f cystitis befre prescribing prphylactic drug treatment. When deciding t ffer prphylactic drug treatment, cnsider the frequency, severity, and impact f recurrent cystitis, and whether referral fr urlgical investigatin wuld be apprpriate. Fr recurrent cystitis assciated with sexual intercurse, ffer trimethprim 100 mg t be taken within 2 hurs f intercurse (ff-label use). Fr recurrent cystitis nt assciated with sexual intercurse ffer a 6-mnth trial f lw-dse cntinuus antibitic treatment: trimethprim 100 mg every night, r nitrfurantin (immediate-release) 50 100 mg every night. In depth Hw shuld I fllw up a wman with recurrent cystitis? If prphylactic antibitics are prescribed, fllw up t review prgress after 6 mnths, r sner if clinically indicated. If haematuria was fund, fllw up t re-test the urine and check that the infectin and haematuria have reslved. In depth When shuld I refer a wman with recurrent cystitis? Refer urgently, t a team specializing in the management f urlgical cancer, if urlgical cancer is suspected (fr example if haematuria persists after successful treatment f acute cystitis). Refer the wman if: Risk factrs fr recurrent cystitis (such as urinary tract abnrmalities, stnes, vesicureteric reflux, papillary necrsis) are present r suspected. There is any knwn abnrmality n ultrasund f kidneys, ureters, and bladder. 7
The respnse t preventive treatments and lifestyle measures is ineffective. In depth Prescriptins Antibitic treatment (UTI): trimethprim and nitrfurantin Age frm 14 years nwards Trimethprim tablets: 200mg twice a day fr 3 days Trimethprim 200mg tablets Take ne tablet twice a day fr 3 days. Supply 6 tablets. Age: frm 14 years nwards NHS cst: 0.39 Trimethprim tablets: 200mg twice a day fr 7 days Trimethprim 200mg tablets Take ne tablet twice a day fr 7 days. Supply 14 tablets. Age: frm 14 years nwards NHS cst: 0.91 Nitrfurantin tablets: 50mg fur times a day fr 3 days Nitrfurantin 50mg tablets Take ne tablet fur times a day fr 3 days. Supply 12 tablets. Age: frm 14 years nwards NHS cst: 1.21 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin tablets: 50mg fur times a day fr 7 days Nitrfurantin 50mg tablets Take ne tablet fur times a day fr 7 days. Supply 28 tablets. Age: frm 14 years nwards NHS cst: 2.83 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 50mg fur times a day fr 3 days Nitrfurantin 50mg capsules Take ne capsule fur times a day fr 3 days. Supply 12 capsules. 8 Age: frm 14 years nwards NHS cst: 1.00
Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 50mg fur times a day fr 7 days Nitrfurantin 50mg capsules Take ne capsule fur times a day fr 7 days. Supply 28 capsules. Age: frm 14 years nwards NHS cst: 2.32 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin m/r caps: 100mg twice a day fr 3 days Nitrfurantin 100mg mdified-release capsules Take ne capsule twice a day fr 3 days. Supply 6 capsules. Age: frm 14 years nwards NHS cst: 2.10 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin m/r caps: 100mg twice a day fr 7 days Nitrfurantin 100mg mdified-release capsules Take ne capsule twice a day fr 7 days. Supply 14 capsules. Age: frm 14 years nwards NHS cst: 4.89 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Antibitic prphylaxis fr recurrent UTIs Age frm 14 years nwards Trimethprim tablets: 100mg at night Trimethprim 100mg tablets Take ne tablet at night. Supply 28 tablets. Nitrfurantin tablets: 50mg at night Nitrfurantin 50mg tablets Take ne tablet at night. Supply 28 tablets. 9 Age: frm 14 years nwards NHS cst: 0.98 Age: frm 14 years nwards NHS cst: 2.48 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 50mg at night Nitrfurantin 50mg capsules
Take ne capsule at night. Supply 28 capsules. Age: frm 14 years nwards NHS cst: 2.32 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin tablets: 100mg at night Nitrfurantin 100mg tablets Take ne tablet at night. Supply 28 tablets. Age: frm 14 years nwards NHS cst: 4.34 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 100mg at night Nitrfurantin 100mg capsules Take ne capsule at night. Supply 30 capsules. Age: frm 14 years nwards NHS cst: 4.81 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Antibitic prphylaxis: pst-cital Age frm 16 years nwards Trimethprim tablets: 100mg pst-cital Trimethprim 100mg tablets Take ne tablet within 2 hurs f intercurse. Supply 28 tablets. Age: frm 16 years nwards NHS cst: 0.99 Licensed use: n - ff-label indicatin Analgesia: use when required Age frm 16 years nwards Ibuprfen tablets: 200mg t 400mg three t fur times a day Ibuprfen 200mg tablets Take ne r tw tablets 3 t 4 times a day when required fr pain relief. D nt exceed the stated dse. Supply 56 tablets. Paracetaml tablets: 500mg t 1g up t fur times a day Age: frm 16 years nwards NHS cst: 1.38 OTC cst: 2.38 10
Paracetaml 500mg tablets Take ne r tw tablets every 4 t 6 hurs when required fr pain relief. Maximum f 8 tablets in 24 hurs. Supply 50 tablets. Urinary tract infectin (lwer) - wmen - Management Scenari: Asymptmatic bacteriuria and cystitis in wmen wh are pregnant Age: frm 16 years nwards NHS cst: 0.78 OTC cst: 1.35 Hw shuld I screen fr and manage asymptmatic bacteriuria during pregnancy? Screen fr asymptmatic bacteriuria n the first antenatal visit by sending urine fr culture. If asymptmatic bacteriuria is fund, send a secnd urine sample fr culture. If the secnd urine culture cnfirms asymptmatic bacteriuria, treat fr 7 days with an antibitic t which the rganism is sensitive. Preferred ptins when sensitivities are knwn are (in rder f preference): Amxicillin: 250 mg three times daily, fr 7 days. Nitrfurantin: 50 mg fur times daily, r 100 mg (mdified-release) twice daily, fr 7 days. Trimethprim: 200 mg twice daily, fr 7 days (unless the wman is flate deficient r taking a flate antagnist). Cefalexin (500 mg twice daily, r 250 mg 6-hurly, fr 7 days) may be used but is less preferred. After treatment, send urine fr culture t screen fr asymptmatic bacteriuria at every antenatal visit until delivery. If a grup B streptcccus is islated, infrm the antenatal care service, as prphylactic antibitics may be indicated during labur and delivery. In depth Cystitis in pregnancy Hw shuld I manage a pregnant wman with suspected acute cystitis? Cnvey a psitive apprach and reassure the wman that treatment with an antibitic will prevent any harm t her baby, and will shrten the duratin f symptms. 11
If the wmen has fever r lin tenderness, suspect upper urinary tract infectin and admit r seek urgent specialist pinin. Offer paracetaml fr symptmatic relief. D nt recmmend urine alkalinizing agents r cranberry prducts. D nt recmmend urine alkalinizing agents r cranberry prducts. Send a urine sample fr culture befre starting antibitic treatment. Prescribe an antibitic empirically. If lcal guidelines are nt available, suitable first-line antibitics are (in rder f preference): Nitrfurantin 50 mg fur times daily, r 100 mg (mdified-release) twice daily, fr 7 days. Trimethprim 200 mg twice daily, fr 7 days (if the persn is nt flate deficient r taking a flate antagnist, and has nt been treated with trimethprim in the past year). Cefalexin 500 mg twice daily, r 250 mg 6-hurly, fr 7 days. Fllw up after 48 hurs (r accrding t the clinical situatin) t check respnse t treatment and the urine culture results. Amxicillin 250 mg three times daily, fr 7 days, is recmmended nly if the rganism is reprted t be susceptible n the culture results. In depth Hw shuld I fllw up a pregnant wman with cystitis? Review culture results when available and, if necessary, change t an antibitic that the rganism is sensitive t. Send urine cultures t screen fr asymptmatic bacteriuria 7 days after cmpletin f treatment, and at every antenatal visit until delivery. If a grup B streptcccus is islated, infrm the antenatal care service, as prphylactic antibitics may be indicated during labur and delivery. In depth When shuld I refer a pregnant wman with cystitis? Admit, r seek urgent specialist pinin, if upper urinary tract infectin is suspected (fever, lin tenderness, and pain). 12
Seek specialist advice if symptms fail t respnd t antibitic treatment guided by urine culture results, and if ther causes have been excluded see Differential diagnsis. In depth Hw shuld I manage a pregnant wman whse cystitis has failed t respnd t antibitics? Check cmpliance with antibitic treatment. Cntinue symptmatic treatment with paracetaml r, in the first r secnd trimesters, ibuprfen. Send a urine sample fr culture. If symptms are trublesme, ffer a different antibitic (nitrfurantin r trimethprim) while waiting fr the culture results see Managing suspected acute cystitis during pregnancy. If infectin is cnfirmed n culture, treat with an antibitic t which the rganism is sensitive. If infectin is nt cnfirmed n culture, cnsider ther pssible causes fr the symptms see Differential diagnsis. If cystitis symptms fail t respnd t a secnd antibitic shwn by urine culture results t be apprpriate treatment, seek specialist advice. In depth Prescriptins Antibitics: urinary tract infectin in pregnancy Age frm 14 years nwards Nitrfurantin tablets: 50mg fur times a day fr 7 days Nitrfurantin 50mg tablets Take ne tablet fur times a day fr 7 days. Supply 28 tablets. Age: frm 14 years nwards NHS cst: 2.83 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 50mg fur times a day fr 7 days Nitrfurantin 50mg capsules Take ne capsule fur times a day fr 7 days. Supply 28 capsules. Age: frm 14 years nwards NHS cst: 2.32 13
Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin m/r caps: 100mg twice a day fr 7 days Nitrfurantin 100mg mdified-release capsules Take ne capsule twice a day fr 7 days. Supply 14 capsules. Age: frm 14 years nwards NHS cst: 4.89 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Trimethprim tablets: 200mg twice a day fr 7 days Trimethprim 200mg tablets Take ne tablet twice a day fr 7 days. Supply 14 tablets. Cefalexin tablets: 250mg fur times a day fr 7 days Cefalexin 250mg tablets Take ne tablet fur times a day fr 7 days. Supply 28 tablets. IF knwn t be sensitive: amxicillin 250mg three times a day fr 7 days Amxicillin 250mg capsules Take ne capsule three times a day fr 7 days. Supply 21 capsules. Cefalexin tablets: 500mg twice a day fr 7 days Cefalexin 500mg tablets Take ne tablet twice a day fr 7 days. Supply 14 tablets. Age: frm 14 years nwards NHS cst: 0.91 Age: frm 14 years nwards NHS cst: 2.19 Age: frm 14 years nwards NHS cst: 0.62 Age: frm 14 years nwards NHS cst: 1.79 Analgesia: use when required (paracetaml nly) Age frm 14 years nwards Paracetaml tablets: 500mg t 1g up t fur times a day Paracetaml 500mg tablets Take ne r tw tablets every 4 t 6 hurs when required fr pain relief. Maximum f 8 tablets in 24 hurs. Supply 50 tablets. 14
Age: frm 14 years nwards NHS cst: 0.79 Urinary tract infectin (lwer) - wmen - Management Scenari: Lwer urinary tract infectin in wmen with a chrnic indwelling urinary catheter Hw shuld I treat lwer UTI in a wman with an indwelling catheter? D nt treat asymptmatic bacteriuria. Remember that cnsiderable clinical judgement is required t diagnse urinary tract infectin (UTI) in wmen with an indwelling urinary catheter. If symptms are severe (fr example, severe nausea and vmiting, cnfusin, tachypnea, tachycardia, hyptensin, reduced urine utput), admit t hspital as intravenus antibitics may be required. Check that the catheter is crrectly psitined and nt blcked. If the catheter has been in place fr mre than a week, cnsider changing it befre starting antibitic treatment. If there is fever, r lin pain, r bth, manage as upper UTI, see the CKS tpic n Pyelnephritis - acute. Otherwise, treat fr lwer UTI: Relieve symptms with paracetaml r ibuprfen. Send urine fr culture and micrscpy befre starting antibitic treatment. Prescribe an antibitic fr 7 days, fllwing lcal guidelines when available. If symptms are mild, cnsider withhlding antibitics until the result f urine culture is available t guide chice f antibitic. If symptms are mderate r severe, empirically prescribe an antibitic. Fllw up after 48 hurs (r accrding t the clinical situatin) t check respnse t treatment and the result f urine culture. In depth 15
Which antibitic shuld I prescribe empirically fr UTI in a wman with an indwelling urinary catheter? Fllw lcal guidelines when available. Otherwise: Fr empirical treatment, prescribe either: Trimethprim 200 mg twice daily, fr 7 days, r Nitrfurantin 50 mg fur times daily, r 100 mg (mdified-release) twice daily, fr 7 days. If the wman has a histry f recurrent infectins, r has recently (within the past year) taken trimethprim, d nt use trimethprim fr empirical treatment. In depth Hw can I prevent urinary tract infectins in wmen with indwelling catheters? Ensure an indwelling urinary catheter is apprpriate. Use an indwelling catheter nly after alternative methds f management have been cnsidered. Regularly review the clinical need fr catheterizatin and remve the catheter as sn as pssible. Use intermittent catheterizatin in preference t an indwelling catheter if this is clinically apprpriate and is a practical ptin fr the persn. Prevent the intrductin f infectin. Healthcare persnnel shuld be trained and assessed in their cmpetence t perfrm urethral catheterizatin using aseptic prcedures. Urine samples shuld be btained frm a sampling prt using an aseptic technique. Catheters shuld be changed nly when clinically necessary (fr example, t prevent blckage), r accrding t the manufacturer's recmmendatins. When changing catheters, antibitic prphylaxis shuld nly be used fr peple with a histry f catheterassciated urinary tract infectin fllwing catheter change. D nt use: Bladder instillatins r washuts. Prphylactic antibitics when changing catheters in wmen with a heart valve lesin, septal defect, patent ductus, r prsthetic valve. 16
Tpical antiseptics r antibitics applied t the catheter, urethra, r meatus; daily washing f the meatus with sap and water is sufficient. In depth Hw shuld I fllw up a wman with an indwelling catheter and treated fr UTI? Review after 48 hurs, r accrding t the clinical situatin, t ensure the wman is respnding t treatment, and t check the results f the urine culture. If urine culture shws that the rganism is resistant t the current antibitic, and: If symptms have nt reslved, change t an antibitic that the rganism is sensitive t. If symptms have reslved, cnsider cntinuing with the current antibitic. If symptms recur, start treat with an antibitic shwn in the culture t cver the infecting rganism. If the wman fails t respnd t tw curses f antibitic shwn by urine culture t be apprpriate treatment, and cmpliance has been checked, cnsider referring fr assessment and investigatin. In depth When shuld I refer a wman with an indwelling catheter and treated fr UTI? Cnsider referring fr assessment and investigatin if the wman fails t respnd t tw curses f antibitic shwn by urine culture t be apprpriate treatment, and cmpliance has been verified. If urlgical cancer is suspected (fr example if haematuria persists after successful treatment f cystitis), refer urgently t a team specializing in the management f urlgical cancer. In depth Prescriptins Antibitics: UTI in wmen with catheters Age frm 14 years nwards Trimethprim tablets: 200mg twice a day fr 7 days Trimethprim 200mg tablets Take ne tablet twice a day fr 7 days. Supply 14 tablets. Nitrfurantin tablets: 50mg fur times a day fr 7 days 17 Age: frm 14 years nwards NHS cst: 0.91
Nitrfurantin 50mg tablets Take ne tablet fur times a day fr 7 days. Supply 28 tablets. Age: frm 14 years nwards NHS cst: 2.83 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin capsules: 50mg fur times a day fr 7 days Nitrfurantin 50mg capsules Take ne capsule fur times a day fr 7 days. Supply 28 capsules. Age: frm 14 years nwards NHS cst: 2.32 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Nitrfurantin m/r caps: 100mg twice a day fr 7 days Nitrfurantin 100mg mdified-release capsules Take ne capsule twice a day fr 7 days. Supply 14 capsules. Age: frm 14 years nwards NHS cst: 4.89 Patient infrmatin: This medicine may cause yur urine t turn mre yellw than nrmal. Analgesia: use when required Age frm 16 years nwards Ibuprfen tablets: 200mg t 400mg three t fur times a day Ibuprfen 200mg tablets Take ne r tw tablets 3 t 4 times a day when required fr pain relief. D nt exceed the stated dse. Supply 56 tablets. Paracetaml tablets: 500mg t 1g up t fur times a day Age: frm 16 years nwards NHS cst: 1.38 OTC cst: 2.38 Paracetaml 500mg tablets Take ne r tw tablets every 4 t 6 hurs when required fr pain relief. Maximum f 8 tablets in 24 hurs. Supply 50 tablets. Urinary tract infectin (lwer) - wmen - Management Detailed answers Age: frm 16 years nwards NHS cst: 0.78 OTC cst: 1.35 18
Overview f management Acute cystitis in nn-pregnant wmen Cnvey a psitive apprach and reassure the wman that cystitis is generally self-limiting. Relieve the symptms with paracetaml r ibuprfen. If cystitis symptms are mderate r severe, ffer a 3-day curse f: Trimethprim 200 mg twice daily, r Nitrfurantin 50 mg fur times a day, r 100 mg (mdified-release) twice daily. If cystitis symptms are mild: Dipstick test the urine and if results are negative, discuss nt treating the cystitis with an antibitic. Have a lwer threshld fr ffering an antibitic if there are risk factrs fr persistent infectin, recurrent infectin, r treatment failure. If there are cncerns abut nt taking an antibitic, ffer a delayed antibitic prescriptin t be dispensed if the symptms becme wrse, r last mre than 48 hurs. Urine culture is nt rutinely required. Urine culture is useful t cnfirm the diagnsis and t guide chice f antibitic when there are risk factrs fr mre severe illness r treatment has failed. If cystitis symptms fail t respnd t an antibitic chsen accrding t the urine culture result, check cmpliance, repeat the urine culture, change t anther antibitic, and cnsider referring fr specialist assessment. Recurrent cystitis Review the diagnsis. Review the medical and surgical histry t assess risk factrs fr recurrent cystitis such as stnes, papillary necrsis, and vesicureteric reflux this may require imaging r urlgical referral. Relieve the symptms with paracetaml r ibuprfen. Treat the infectin with a 3-day curse f trimethprim r nitrfurantin (as abve) if the symptms are severe. 19
Advise n lifestyle measures fr preventin, such as use f cranberry prducts. High strength (at least 200 mg) capsules may be mre effective and better tlerated than cranberry drinks. Fr wmen with trublesme recurrent cystitis, cnsider: A prescriptin fr a 'stand-by' antibitic t be used fr future episdes f cystitis. Trimethprim 200 mg t be taken within 2 hurs f intercurse (ff-label use). A 6-mnth trial f lw-dse cntinuus antibitic treatment: trimethprim 100 mg r nitrfurantin (immediaterelease) 50 100 mg, every night. Asymptmatic bacteriuria in pregnancy Screen fr asymptmatic bacteriuria n the first antenatal visit by sending urine fr culture. If asymptmatic bacteriuria is fund, send a secnd urine sample fr culture. If the secnd urine culture cnfirms asymptmatic bacteriuria, treat fr 7 days with an antibitic t which the rganism is sensitive. D nt use trimethprim first-line if there is a suitable alternative. After treatment, send urine fr culture t screen fr asymptmatic bacteriuria at every antenatal visit until delivery. If a grup B streptcccus is islated, infrm the antenatal care service, as prphylactic antibitics may be indicated during labur and delivery. Cystitis during pregnancy Culture the urine. Relieve the symptms with paracetaml. Treat the infectin with an apprpriate antibitic fr 7 days (in rder f preference: nitrfurantin, trimethprim [if the wman is nt flate deficient r taking a flate antagnist], amxicillin, cefalexin). Have a lw threshld fr admitting the wman if upper urinary tract infectin (UTI) is suspected (fever, lin tenderness, and pain). After treatment, send urine fr culture t screen fr asymptmatic bacteriuria at every antenatal visit until delivery. If a grup B streptcccus is islated, infrm the antenatal care service, as prphylactic antibitics may be indicated during labur and delivery. 20
Lwer UTI in wmen with an indwelling urinary catheter Fr wmen with an indwelling urinary catheter, cnsiderable clinical judgement is required t diagnse UTI. Assess the severity f the infectin and the presence f any cmrbidities. Admit the wman t hspital if there are symptms and signs f severe infectin. If there is fever, and flank pain r tenderness, manage as fr upper UTI see the CKS tpic n Pyelnephritis - acute. Check that the catheter is crrectly psitined and nt blcked. Send urine fr culture befre antibitic treatment is started. If it is practical, withhld antibitics until the result f urine culture is available t guide the chice f antibitic. Otherwise, empirically prescribe trimethprim r nitrfurantin fr 7 days. Relieve the symptms with paracetaml r ibuprfen. Check the urine culture reprt. If necessary, change the antibitic t ne t which the rganism is sensitive. T prevent UTI: Use an indwelling urinary catheter nly after alternative methds f management have been cnsidered, and regularly review the need fr a catheter. Ensure high standards f hygiene with catheter care: btain urine samples frm a sampling prt using an aseptic technique, and change catheters nly when necessary. When changing catheters, nly use antibitic prphylaxis fr peple with a histry f catheter-assciated UTI fllwing catheter change. Acute cystitis (nt pregnant) Hw shuld I manage a wman with suspected cystitis? Cnvey a psitive apprach and reassure the wman that cystitis is generally self-limiting: Withut antibitics, symptms can be expected t reslve in 4 9 days. With antibitics, symptms can be expected t reslve in 3 8 days. On average, antibitics shrten the duratin f symptms by abut a day. 21
Relieve symptms with paracetaml r ibuprfen d nt recmmend urine alkalinizing agents r cranberry prducts. If cystitis symptms are mderate r severe: Offer an antibitic. D nt dipstick test the urine, as the decisin t ffer an antibitic is nt influenced by urine dipstick test results. Even if the tests fr nitrite, and leuccyte esterase, and bld are all negative, an antibitic shuld still be ffered. If the wman prefers nt t take an antibitic, ffer a delayed antibitic prescriptin t be dispensed if the symptms becme wrse, r last mre than 48 hurs. If cystitis symptms are mild: Dipstick test the urine t guide treatment decisins. Discuss nt using an antibitic, especially if the urine dipstick test is negative fr nitrites and leuccyte esterase and bld. Have a lwer threshld fr ffering an antibitic if there are risk factrs fr persistent infectin, recurrent infectin, r treatment failure. If there are cncerns abut nt taking an antibitic, ffer a delayed antibitic prescriptin t be dispensed if the symptms becme wrse, r last mre than 48 hurs. Advise the wman t seek medical attentin if she develps a high fever r becmes systemically unwell. Basis fr recmmendatin These recmmendatins are in line with Scttish [SIGN, 2006], Eurpean [Eurpean Assciatin f Urlgy, 2009], and American [ICSI, 2004; American Cllege f Obstetricians and Gyneclgists, 2008] guidelines. The recmmendatins als take int accunt the evidence frm a Health Technlgy Assessment (HTA) cmmissined by the Natinal Institute fr Health Research (NIHR) t assess the diagnsis f cystitis, its prgnsis, and five different treatment strategies [Little et al, 2009]. A psitive apprach t prgnsis 22
A psitive apprach t diagnsis and prgnsis has been fund t be independently assciated with shrter duratin f symptms in bservatinal studies and in randmized cntrlled trials [Thmas, 1987; Little et al, 2001; Little et al, 2009]. The average duratin f symptms (that are at least mderately severe) is reprted in the NIHR HTA [Little et al, 2009] and summarized in the Prgnsis sectin. Use f an analgesic fr symptmatic relief CKS fund n trials f analgesics fr the painful symptms f cystitis. The recmmendatin t use paracetaml r ibuprfen t treat the painful symptms f cystitis is based n their use in ther painful infectins and the experience f experts [SIGN, 2006]. There is insufficient evidence t recmmend the use f: Urine alkalinizing agents (such as ptassium citrate r bicarbnate): CKS fund n cntrlled trials f urine alkalinizing agents. One bservatinal study fund n relatinship between symptms f cystitis and urine ph [Brumfitt et al, 1990]. Cranberry prducts: a Cchrane systematic review fund n gd evidence t supprt the use f cranberry juice r ther cranberry prducts fr treating acute UTIs [Jepsn et al, 1998]. Treatment strategy (t cnsider the ptins f an antibitic, n antibitic, r delayed antibitic prescriptin) The evidence that a curse f antibitics is effective is discussed in Chice f antibitic. The strategy fr antibitic prescribing is supprted by evidence frm a series f studies in the UK [Little et al, 2009], and a randmized cntrlled trial in New Zealand [Richards et al, 2005]. N clinically (r ecnmically) imprtant differences were fund between five different treatment strategies in which antibitics were ffered: (i) immediately, (ii) delayed fr 48 hurs, (iii) accrding t a symptm rule, (iv) accrding t a dipstick test rule, r (v) accrding t the results f urine culture. Wmen wh did nt meet the criteria fr immediate antibitic treatment were ffered a delayed antibitic prescriptin t use if their symptms did nt settle after 48 hurs. In each grup where wmen were ffered a delayed prescriptin, a high prprtin chse t use it. Wmen wh presented with mre severe symptms f dysuria, urgency, frequency, and ncturia recvered mre slwly. Antibitics shrtened the duratin f symptms (that were at least mderately severe) by abut 1 2 days. 23
CKS therefre recmmends ffering an antibitic when: Presenting symptms are mderate r severe because antibitics are likely t shrten the duratin f symptms by 1 2 days. The wman has a strng preference fr antibitic treatment because there is n evidence that treatment leads t prer utcmes, althugh there is als n evidence f effectiveness in wmen with less severe symptms. It may be a cmplicated infectin because there is a greater risk f adverse effects frm infectin. While CKS recmmends using severity f symptms as a key decisin criterin, ther guidelines (fr example [SIGN, 2006]) recmmend using number f symptms. CKS recmmends cnsidering a delayed antibitic prescriptin whenever an antibitic is nt prescribed, because this may give sme wmen the cnfidence needed t try nt using an antibitic, t see if the symptms reslve spntaneusly. When prescribing empirically fr acute cystitis which antibitic shuld I chse? Fllw lcal guidelines when available. If lcal guidelines are nt available: Fr an uncmplicated infectin, prescribe either: Trimethprim 200 mg twice daily, fr 3 days, r Nitrfurantin 50 mg fur times daily, r 100 mg (mdified-release) twice daily, fr 3 days. Fr a cmplicated infectin, prescribe a 5 10-day curse f trimethprim r nitrfurantin. Basis fr recmmendatin Antibitic treatment Fr wmen with urinary tract infectin (UTI), there is evidence frm a meta-analysis that antibitics are mre effective than placeb in eradicating bacteriuria and relieving UTI symptms [Falagas et al, 2009]. Duratin f antibitic treatment A 3-day curse f empirical treatment is recmmended because there is gd evidence frm Cchrane systematic reviews that this achieves symptmatic cure in peple with uncmplicated UTI; it is mre effective than single-dse treatment and as effective as 5 10-day curses. This is als in line with 24
recmmendatins frm the Scttish Intercllegiate Guidelines Netwrk (SIGN) [SIGN, 2006] and internatinal guidelines [American Cllege f Obstetricians and Gyneclgists, 2008; Eurpean Assciatin f Urlgy, 2009]. Fr peple with a cmplicated UTI, a lnger curse is recmmended because there is evidence frm a Cchrane systematic review that a 5 10-day curse prduced a higher bacterilgical cure rate (but mre adverse effects) than a 3-day regimen. The Cchrane systematic review cncluded that a 5 10-day curse may be cnsidered fr wmen in whm eradicatin f bacteriuria is imprtant. Rute f administratin The ral rute is recmmended, even fr severe cystitis. A Cchrane systematic review fund n evidence that ral antibitic treatment is less effective than intravenus antibitics fr treating severe UTIs [Phl, 2007]. Antibitic chice: trimethprim and nitrfurantin as first-line ptins Trimethprim and nitrfurantin (bth narrw spectrum antibitics) are generally recmmended as apprpriate first-line antibitics in the UK [SIGN, 2006; BNF 57, 2009]. Narrw spectrum antibitics are preferred ver brad spectrum antibitics such as c-amxiclav, quinlnes, and cephalsprins. This is in line with guidance issued by the Health Prtectin Agency which recmmends aviding the use f brad spectrum antibitics when narrw spectrum antibitics remain effective [HPA, 2009]. There are cncerns that brad spectrum antibitics increase the risk f Clstridium difficile, meticillin-resistant Staphylcccus aureus (MRSA), and resistant UTIs. Issues f antibitic resistance are discussed belw. Despite their widespread use, there are few cmparative trials cmparing these tw antibitics. There is evidence frm fur trials which fund trimethprim and nitrfurantin t be equally effective and generally well tlerated. The dsages recmmended are based n thse recmmended by the manufacturers f these antibitics and are in line with dses used in trials [Gldshield Pharmaceuticals, 2002a; Gldshield Pharmaceuticals, 2002b; Actavis, 2007]. Bacterial resistance There are cncerns that resistance t trimethprim and nitrfurantin is increasing, yet few data n the resistance patterns have been published. 25
Evidence frm lder studies indicated trimethprim resistance t be arund 20 30% (althugh higher levels have been reprted fr certain parts f the UK) with a lwer incidence fr nitrfurantin (less than 20%). Hwever, these data shuld be treated with cautin, because: Mst f these studies were perfrmed in the 1990s and resistance patterns may have changed. There are cnsiderable gegraphic variatins in antibitic resistance pattern. It is difficult t cmpare results frm different studies because f differences in ppulatins (fr example hspital r cmmunity) and differences in labratry standards. Rates f clinical resistance t trimethprim may be less cmmn than expected frm rates f resistance in labratry samples. Statistics frm labratries are likely t be biased by higher prprtins f samples frm wmen with resistant infectins [McNulty et al, 2006]. Cnsequently, CKS recmmends that, where available, lcal antibitic guidelines shuld be fllwed, taking int accunt lcal resistance patterns. Nitrfurantin frmulatins Bth immediate and mdified-release frmulatins f nitrfurantin are recmmended because CKS fund n evidence t prefer ne frmulatin ver anther. Fr further infrmatin, see Dsage. When shuld I culture the urine f a wman with suspected cystitis? Urine micrscpy and culture are nt rutinely required fr wmen with uncmplicated cystitis. Send urine fr micrscpy and culture if any f the fllwing apply: There are risk factrs fr a cmplicated urinary tract infectin fr example the wman has recently had urlgical instrumentatin, r is immuncmprmised, r has been in hspital recently. Cnfirmatin f the diagnsis r exclusin f ther cnditins is required. The wman has nt respnded t antibitic treatment. The wman has recurrent episdes f cystitis and this has nt been investigated. When underlying causes f recurrent cystitis and ther cnditins have been excluded, it is nt necessary t rutinely culture the urine fr further episdes. Basis fr recmmendatin 26
These recmmendatins are in line with Scttish Intercllegiate Guidelines Netwrk guidelines [SIGN, 2006]. Urine culture Urine culture is mainly useful fr identifying bacteria and their sensitivity t antibitics [SIGN, 2006]. Urine micrscpy and culture are nt rutinely recmmended fr wmen with uncmplicated cystitis because the results are nt available fr immediate decisin-making and, by the time they are available, mst wmen's symptms will be reslving. Three studies fund that, if urine were t be rutinely cultured fr all wmen with acute cystitis, the average duratin f symptms wuld be reduced by between 0.04 and 0.32 days [SIGN, 2006]. Similar evidence is prvided by a randmized cntrlled trial that cmpared different strategies fr antibitic treatment [Little et al, 2009]. An ecnmic analysis estimated the cst f preventing 1 day f symptms as 215, and the cst per QALY (quality adjusted life year gained) was 215,000 [SIGN, 2006]. Urine culture is recmmended fr wmen with a cmplicated infectin because the risks assciated with treatment failure are increased [SIGN, 2006]. Hw shuld I fllw up a wman with cystitis? Fllw up is nt rutinely required fr uncmplicated cystitis, but shuld be cnsidered fr wmen with a ptentially cmplicated infectin. If haematuria was fund, fllw up t re-test the urine and check that the infectin and haematuria have reslved. Basis fr recmmendatin This recmmendatin is pragmatic as CKS fund n published evidence n which t base recmmendatins [SIGN, 2006]. Fllw up is nt rutinely required fr uncmplicated cystitis as mst cases f uncmplicated urinary tract infectin reslve in abut 4 9 days withut antibitic treatment, and in abut 3 8 days with antibitic treatment see Prgnsis. When shuld I refer a wman with acute cystitis? 27
If the wman fails t respnd t tw curses f antibitics shwn by urine culture results t be apprpriate treatment, refer fr specialist assessment. If urlgical cancer is suspected (fr example haematuria persists after successful treatment f cystitis), refer urgently t a team specializing in the management f urlgical cancer. Basis fr recmmendatin Referral fr failure t respnd t apprpriate antibitics The recmmendatin t cnsider referring wmen wh have failed t respnd t an apprpriate antibitic (shwn by urine culture) is pragmatic, as there is n direct evidence frm clinical trials r recmmendatins in natinal guidelines. Urgent referral fr urlgical cancer The recmmendatin t refer wmen with suspected urlgical cancer is based n criteria in guidelines frm the Natinal Institute fr Health and Clinical Excellence [NICE, 2005b]. Hw shuld I manage a wman whse cystitis has failed t respnd t antibitics? Cntinue symptmatic treatment with paracetaml r ibuprfen. Check cmpliance with antibitic treatment. Send a urine sample fr culture. If symptms are trublesme, ffer a different antibitic (nitrfurantin r trimethprim) while waiting fr the culture results see Chice f antibitic. If infectin is cnfirmed n culture, treat with an antibitic t which the rganism is sensitive. If infectin is nt cnfirmed n culture, cnsider ther pssible causes fr the symptms see Differential diagnsis. If cystitis symptms fail t respnd t tw curses f antibitic shwn by culture t be apprpriate treatment, refer fr specialist assessment. Basis fr recmmendatin 28
These recmmendatins are in line with guidance frm the Scttish Intercllegiate Guidelines Netwrk [SIGN, 2006]. The recmmendatin t ffer a different antibitic if symptms persist is supprted by a study f the curse f uncmplicated cmmunity-acquired urinary tract infectin in wmen [McNulty et al, 2006]. The study fund that, after 5 days f antibitic treatment, symptms had reslved in 70% f wmen infected with an rganism sensitive t the antibitic, and 24% f wmen with a resistant islate. The study als fund that 50% f thse wh recnsulted in the first week had a resistant islate. Recurrent cystitis in wmen wh are nt pregnant Hw shuld I manage an acute episde f recurrent cystitis? Review the diagnsis. Culture the urine t cnfirm infectin and exclude ther causes. Refer urgently if urlgical cancer is suspected. Review the wman's medical and surgical histry t assess risk factrs fr recurrent cystitis such as stnes, papillary necrsis, and vesicureteric reflux this assessment may require imaging and urlgical referral. Relieve symptms with paracetaml r ibuprfen. If symptms are mderate r severe, ffer an antibitic immediately. If symptms are mild, suggest delaying antibitic treatment until culture results are available t guide chice f antibitic. Advise n lifestyle measures such as high-strength cranberry capsules t reduce the risk f recurrent episdes. If trublesme cystitis recurs frequently: Cnsider ffering a prescriptin fr a 'stand-by' antibitic t be used fr future episdes. Cnsider preventive treatments. Refer r seek specialist advice if these measures are nt successful. Basis fr recmmendatin Cnfirming urinary tract infectin and excluding ther causes 29
The recmmendatin t cnfirm infectin with urine culture, and exclude ther causes, is pragmatic. The recmmendatin t refer urgently if cancer is suspected is based n guidelines frm the Natinal Institute fr Health and Clinical Excellence [NICE, 2005b]. Treatments The basis fr recmmending symptmatic relief with paracetaml r ibuprfen is discussed in Managing suspected cystitis. The basis fr ffering empirical antibitic treatment if symptms are mderate r severe, r delaying treatment if symptms are mild, is discussed in Managing suspected cystitis. The recmmendatin t cnsider 'stand-by' antibitics is based n expert pinin [Harris et al, 2008]. Lifestyle measures and preventive treatment The basis fr lifestyle measures and prphylactic treatments is discussed in the sectins n Lifestyle measures and Preventive treatments. Referral The basis fr the recmmendatin t refer the wman if prphylactic measures are unsuccessful is pragmatic. Which antibitic shuld I prescribe fr a wman with recurrent cystitis? Fllw lcal guidelines when available. Otherwise: Fr empirical treatment, prescribe either: Trimethprim 200 mg twice daily, fr 3 days, r Nitrfurantin 50 mg fur times daily, r 100 mg (mdified-release) twice daily, fr 3 days. If the wman has been treated with trimethprim recently (up t a year previusly), cnsider prescribing nitrfurantin instead f trimethprim. Basis fr recmmendatin Chice f antibitic 30
The reasns fr preferring trimethprim and nitrfurantin as first-line ptins fr treating cystitis are discussed in Chice f antibitic. Cnsidering nitrfurantin when trimethprim has been used recently Nitrfurantin may be preferable fr empirical prescribing when the wman has recently used trimethprim because there is evidence that urpathgens are mre likely t be resistant t trimethprim if it has been used recently (up t the past year). The evidence is nt clear enugh t recmmend precise threshlds f expsure. Trimethprim is nt preferred when nitrfurantin has previusly been used because there is n evidence that previus treatment with nitrfurantin increases the chance that future infectins will be resistant rganisms. Furthermre, labratry studies find that nitrfurantin-resistant Escherichia cli reprduce substantially less effectively than nitrfurantin-sensitive E. cli (in ther wrds, nitrfurantin resistance impses a high fitness cst n the rganism) [Sandegren et al, 2008]. What lifestyle measures shuld I advise fr preventing cystitis? Advise wmen with recurrent cystitis that: Cranberry prducts reduce the recurrence rate f cystitis, and are available frm shps (but nt n the NHS). Cranberry prducts shuld nt be taken if warfarin is being used. High strength capsules (cntaining at least 200 mg f cranberry extract) are recmmended because: They may be mre effective than cranberry drinks, which require a large vlume t be drunk t prvide the same amunt f cranberry extract: 200 mg f cranberry extract is equivalent t abut 5000 mg f fresh cranberries. Cranberry capsules may be mre acceptable than cranberry juice, which sme wmen find difficult t take regularly because f the bitter taste r the large amunt f sugar added t mask the bitterness. If cystitis is related t sexual intercurse, ptins t be cnsidered include: A different cntraceptive methd, if a diaphragm is being used. Viding sn after intercurse. Using a lubricant if symptms culd be due t mild trauma rather than infectin. Basis fr recmmendatin 31
Cranberry extract fr preventing cystitis There is gd evidence that cranberry prducts effectively prevent cystitis. A Cchrane systematic review f randmized cntrlled trials fund that cranberry prducts significantly reduced the incidence f urinary tract infectins (UTIs) ver 12 mnths, cmpared with placeb r cntrl treatments. Hwever, withdrawal rates in the trials were high, which may indicate that many wmen find taking cranberry prducts unacceptable in the lng term. Als, the benefits f cranberry may be less in elderly wmen and wmen with a urinary catheter. The ptimal dse and frm f administratin f cranberry prducts is nt established. Hwever, higher dses may be mre effective than lwer dses [SIGN, 2006]. Cranberry prducts shuld be avided by peple taking warfarin, as they can ptentiate its effects [CSM, 2003; CSM, 2004]. Recurrent cystitis related t sexual intercurse These recmmendatins are based n expert pinin [Harris et al, 2008]. The Scttish Intercllegiate Guidelines Netwrk (SIGN) guidelines explain that because 'there is n cnclusive assciatin between lifestyle factrs, such as diet, hydratin, clthing, tileting activity, and sexual activity, and susceptibility t bacterial UTI in adult, nn-pregnant wmen, there is n evidence t supprt healthcare prfessinals giving rutine advice abut lifestyle factrs' [SIGN, 2006]. The incidence f UTI may be increased in wmen wh use diaphragms this may relate t the fit and size f the diaphragm putting pressure n the urethra. The incidence f UTI may als be increased in wmen wh use spermicides, but the use f spermicides with cndms is n lnger recmmended. Fr further infrmatin, see the sectins n Diaphragm and cap, and Male cndm in the CKS tpic n Cntraceptin. When shuld I ffer preventive treatments fr recurrent cystitis? Cnsider ffering a prescriptin fr a 'stand-by' antibitic t be used fr future episdes f cystitis befre prescribing prphylactic drug treatment. When deciding t ffer prphylactic drug treatment, cnsider the frequency, severity, and impact f recurrent cystitis, and whether referral fr urlgical investigatin wuld be apprpriate. Fr recurrent cystitis assciated with sexual intercurse: Offer trimethprim 100 mg t be taken within 2 hurs f intercurse (ff-label use). 32