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NICE Updates Quality Standards for UTI in Adults

The National Institute for Health and Care Excellence (NICE) published three new and two updated quality standards in urinary tract infections (UTIs). The latest guidance covered diagnosing and managing UTIs in people aged 16 and older, and described high-quality care in priority areas for improvement, with updated guidance on UTIs in adults and new guidance on antimicrobial prescribing for UTI.

Dr Paul Chrisp, director of Centre for Guidelines at NICE said that: "UTIs are a common occurrence, but they can cause people a great amount of discomfort and pain." He emphasised that for people with recurrent UTIs, this can lead to "a reduction in their quality of life".

Two Key Symptoms Sufficient for UTI Diagnosis

For its first new standard, NICE stated: "Women aged under 65 years are diagnosed with a UTI if they have two or more key urinary symptoms and no other excluding causes or warning signs." The regulator added that "women who present with two or more key symptoms should not require a dipstick test".

NICE explained the rationale for this new standard and highlighted that diagnosing UTI correctly supported "appropriate management", as well as reduced "unnecessary antibiotic prescribing" and the risk of antimicrobial resistance. It went on to caution that no single symptom or combination of symptoms was completely reliable in diagnosing UTI, and that before diagnosing a UTI, vaginal and urethral causes of urinary symptoms needed to be excluded as the "presence of vaginal discharge or vaginal irritation substantially reduces the probability of a UTI, and vaginal infections and some sexually transmitted diseases can mimic the symptoms of a UTI". 

"Professionals should exclude any other causes of urinary symptoms and consider warning signs of other conditions such as sepsis and cancer when diagnosing a UTI," said a NICE spokesperson.

Dr Chrisp highlighted that this standard would also help to "ensure that people are not misdiagnosed".

Short Course of Antibiotics Sufficient for Uncomplicated Lower UTI

The other new standards for 2023 are:

  • Non-pregnant women with an uncomplicated lower UTI should be prescribed a 3-day course of antibiotics, and men and pregnant women with an uncomplicated lower UTI should be prescribed a 7‐day course of antibiotics.
  • Men with a recurrent UTI, and women with a recurrent lower UTI where the cause is unknown, or a recurrent upper UTI should be referred for specialist advice.
NICE explained that a short (3-day) course of antimicrobials, which minimised the risk of adverse events and of antimicrobial resistance, was "sufficient" for treating uncomplicated lower UTI in non-pregnant women. However, a 7‐day course of antibiotics was needed to treat uncomplicated lower UTI in men and pregnant women, since men were more at risk of complications from UTIs than women due to anatomical differences and possible outflow obstruction, and pregnant women are at greater risk of harm from a UTI than non-pregnant women. 

The management of UTIs in trans people would need to take account of any gender reassignment surgery and whether there had been structural alteration of the person's urethra, NICE detailed.

"All people taking antibiotics are reassessed if symptoms worsen rapidly or significantly, or do not start to improve within 48 hours of taking the antibiotic," recommended NICE. 

Recurrent UTIs are common but referral for specialist advice is needed when there are "higher risks" or when it is "uncertain" if the UTI is the cause of urinary symptoms, said NICE. 

Useful and Useable Guidance

Two standards from the earlier 2015 published quality standards were updated by NICE:

  • Adults with indwelling urinary catheters do not need to have dipstick testing to diagnose UTIs.
  • Men and non-pregnant women are should not be prescribed antibiotics to treat asymptomatic bacteriuria.

"Dipstick testing is not an effective method for detecting UTIs in adults with indwelling urinary catheters," warned NICE, as catheters quickly become colonised with bacteria and give a positive dipstick result. However, this did "not indicate" that the bacteria are causing an infection in the bladder or kidneys, so "dipstick testing should not be used", insisted the regulator. Instead, the assessment of signs and symptoms, along with urine culture and sensitivity testing, should be used to support the diagnosis and, thereby, guide treatment.

"Asymptomatic bacteriuria should not routinely be treated with antibiotics in men and non-pregnant women because it is not a risk factor for harm," NICE pointed out. Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with increased risk of adverse events and is of "no clinical benefit", it said. It can also increase the resistance of bacteria that cause UTIs, making antibiotics less effective for future use. 

In older people – where asymptomatic bacteriuria is especially problematic – NICE recommended that symptoms should be assessed and identified before a urine sample is sent for culture, and that antibiotics should not be routinely prescribed when a urine culture identifies bacteriuria for a person without symptoms. 

"This quality standard sets out useful and usable guidance for health professionals to improve the diagnosis and management of UTIs in both women and men while also setting a clear treatment pathway for people with a recurrent UTI who are at higher risk of complications," Dr Chrisp emphasised.  

Asked to comment by Medscape News UK Dr Ranee Thakar, president of the Royal College of Obstetricians and Gynaecologists, welcomed the new NICE quality standard and highlighted how for women under 65 years of age who have two or more symptoms it will help them "access treatment quicker", and will improve "access to specialist support" for women with recurrent UTIs.

"Although antibiotics are the best way to treat UTIs, they are not needed in asymptomatic non-pregnant women," said Dr Thakar. He emphasised that the guidance will also help "minimise the risk of misdiagnosis and unnecessary antibiotic use".

The new quality standard also advise that the prevalence and frequency of UTI's should be measured, with the number of episodes of a suspected UTI, and recurrent UTIs, recorded in the patient's records.