What are the current guidelines for the management of urinary tract infections in women of childbearing age?

For women of childbearing age (from 16 years onwards), the management of urinary tract infections (UTIs) varies depending on whether the woman is pregnant, the nature of the infection (acute or recurrent), and symptom severity ¹.

Acute Uncomplicated UTI in Non-Pregnant Women

• Assessment and Treatment Initiation: If a woman presents with suspected acute UTI, urgent hospital admission should be arranged if there are severe systemic symptoms (e.g., pyelonephritis, sepsis) or if she is unable to tolerate or adhere to primary care treatment ¹. For mild-to-moderate symptoms of uncomplicated UTI, self-care measures may be considered instead of immediate antibiotics, based on clinical judgement ¹.
• Antibiotic Prescribing: If immediate antibiotics are prescribed, treatment should be guided by recent urine culture susceptibilities if available, or empirically based on local antimicrobial resistance patterns ¹. First-line options include Nitrofurantoin 100 mg modified-release twice a day for 3 days, or Trimethoprim 200 mg twice a day for 3 days (if there is a low risk of antimicrobial resistance) ¹. Second-line options, if first-line treatment is ineffective after 48 hours or contraindicated, include Nitrofurantoin (if not used first-line), Pivmecillinam (400 mg initial dose, then 200 mg three times a day for 3 days), or Fosfomycin (3 g single dose sachet) ¹. A delayed antibiotic prescription can be considered for mild symptoms without risk factors for complicated UTI, advising the woman to start treatment if symptoms do not improve within 48 hours or worsen ¹.
• Asymptomatic Bacteriuria: Antibiotic treatment is not routinely prescribed for asymptomatic bacteriuria in non-pregnant women ¹.
• Self-Care Measures: Advise on short-term over-the-counter simple analgesia (e.g., paracetamol or ibuprofen) and maintaining adequate hydration (aiming for 1.5 L of water a day) ¹. Do not recommend over-the-counter cranberry products or urine alkalinising agents ¹.

Acute UTI in Pregnant Women

• Urgent Admission and Referral: Urgent hospital admission is required for severe systemic symptoms or inability to tolerate/adhere to primary care treatment ¹. Specialist advice or referral should be sought for recurrent UTI during pregnancy (refer to an obstetrician), catheter-associated UTI, atypical or resistant organisms, underlying structural/functional urinary tract abnormalities, or suspected serious underlying causes like renal disease or urogynaecological malignancy ¹.
• Antibiotic Prescribing: An immediate antibiotic should be prescribed, ensuring a mid-stream urine (MSU) sample for culture and sensitivities is sent before starting treatment ¹. First choice is Nitrofurantoin 100 mg modified-release twice daily for 7 days (avoid in the third trimester) ¹. Second choice options are Cefalexin 500 mg twice a day for 7 days or Amoxicillin 500 mg three times a day for 7 days ¹. Advise urgent medical review if symptoms worsen rapidly or do not improve within 48 hours of starting antibiotics ¹.
• Self-Care Measures: For a first presentation of uncomplicated UTI, advise on simple analgesia (e.g., paracetamol) and maintaining fluid balance ¹. Do not recommend over-the-counter cranberry products or urine alkalinising agents ¹.

Recurrent UTI in Women

• Assessment and Treatment: For recurrent UTI, an MSU sample for culture and sensitivities should be sent before starting antibiotic treatment ¹. Self-initiated immediate short-course antibiotic treatment can be considered if the woman is able to self-diagnose and self-treat appropriately ¹.
• Referral: Refer or seek specialist advice for recurrent upper UTI, recurrent lower UTI when the underlying cause is unknown, or if there is a suspected underlying cause needing specialist assessment (e.g., renal stones, interstitial cystitis) ¹. Consider a non-urgent urological referral for bladder cancer in women aged 60 years and over with unexplained recurrent or persistent UTI ¹.
• Preventative Self-Care: Advise on measures such as maintaining adequate hydration (1.5 L of water a day), avoiding douching and occlusive underwear, wiping from front to back after defecation, and avoiding delay of habitual and post-coital urination ¹. Do not recommend over-the-counter cranberry products, urine alkalinising agents, or D-mannose preparations ¹.