National Institute for Health and Care Excellence APG Urinary tract infection (lower): draft for consultation Urinary tract infection (lower): antimicrobial prescribing guideline Evidence review April 2018 Draft for Consultation Commissioned by the National Institute for Health and Care Excellence DRAFT FOR CONSULTATION Contents Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: DRAFT FOR CONSULTATION Contents Contents Contents .............................................................................................................................. 4 1 Context .......................................................................................................................... 7 1.1 Background ........................................................................................................... 7 1.2 Managing infections that require antibiotics ........................................................... 9 1.2.1 Self-care .................................................................................................... 9 1.2.2 Back-up prescribing strategies ................................................................... 9 1.2.3 Antibiotic prescribing strategies .................................................................. 9 1.3 Safety netting advice ........................................................................................... 10 1.4 Symptoms and signs of a more serious illness or condition (red flags) ................ 11 2 Evidence selection ..................................................................................................... 12 2.1 Literature search ................................................................................................. 12 2.2 Summary of included studies............................................................................... 12 3 Clinical effectiveness ................................................................................................. 20 3.1 Non-pharmacological interventions in adults ....................................................... 20 3.1.1 Cranberry products .................................................................................. 20 3.1.2 Other non-pharmacological interventions ................................................. 20 3.2 Non-antimicrobial pharmacological interventions in adults ................................... 21 3.2.1 Oral analgesia .......................................................................................... 21 3.3 Antimicrobials in non-pregnant women ................................................................ 22 3.3.1 Natural history of lower urinary tract infections ......................................... 22 3.3.2 Antibiotic prescribing strategies ................................................................ 23 3.3.3 Antibiotics compared with placebo ........................................................... 24 3.3.4 Choice of antibiotic ................................................................................... 25 3.3.5 Antibiotic dosing and course length .......................................................... 28 3.4 Antimicrobials in pregnant women ....................................................................... 29 3.4.1 Antibiotic prescribing strategies ................................................................ 29 3.4.2 Antibiotics compared with placebo or no treatment .................................. 29 3.4.3 Choice of antibiotics ................................................................................. 30 3.4.4 Antibiotic dosing and course length .......................................................... 31 Direct comparisons of different antibiotic course lengths ..................................... 32 3.5 Antimicrobials in older people .............................................................................. 33 3.5.1 Antibiotic prescribing strategies ................................................................ 33 Antibiotics compared with placebo or no treatment .................................. 33 3.5.2 33 3.5.3 Choice of antibiotic ................................................................................... 33 3.5.4 Antibiotic dosing and course length .......................................................... 33 3.6 Antimicrobials in men .......................................................................................... 34 3.7 Antimicrobials in children ..................................................................................... 35 3.7.1 Antibiotic prescribing strategies ................................................................ 35 4 DRAFT FOR CONSULTATION Contents 3.7.2 Antibiotics compared with placebo ........................................................... 35 3.7.3 Choice of antibiotic ................................................................................... 35 3.7.4 Antibiotic dosing and course length .......................................................... 35 4 Safety and tolerability ................................................................................................ 37 4.1 Non-pharmacological interventions ..................................................................... 37 4.1.1 Cranberry products .................................................................................. 37 4.1.2 Other non-pharmacological interventions ................................................. 37 4.2 Non-antimicrobial pharmacological interventions ................................................. 37 4.2.1 Oral analgesia .......................................................................................... 37 4.3 Antimicrobials ...................................................................................................... 38 4.3.1 Antibiotics in non-pregnant women .......................................................... 38 4.3.2 Antibiotics in pregnant women ................................................................. 40 4.3.3 Antibiotics in older people ........................................................................ 41 4.3.4 Antibiotics in children ............................................................................... 41 5 Antimicrobial resistance ............................................................................................ 42 6 Other considerations ................................................................................................. 43 6.1 Resource impact ................................................................................................. 43 6.1.1 Antibiotics ................................................................................................ 43 6.2 Medicines adherence .......................................................................................... 43 7 Terms used in the guideline ...................................................................................... 44 7.1.1 Apgar score ............................................................................................. 44 Appendices ........................................................................................................................ 45 Appendix A: Evidence sources .................................................................................. 45 Appendix B: Review protocol ..................................................................................... 49 Appendix C: Literature search strategy ..................................................................... 56 Appendix D: Study flow diagram ................................................................................ 68 Appendix E: Evidence prioritisation .......................................................................... 69 Appendix F: Included studies ..................................................................................... 71 Appendix G: Quality assessment of included studies .............................................. 73 G.1 Cranberry products ...................................................................................................