Diagnosing and managing lower urinary tract infections (UTIs) in women aged 65 years and over is important to ensure their health and wellbeing. This article explores how to diagnose lower UTI, considering alternative diagnoses especially in older adults, as their symptoms may mimic UTI but may indicate other underlying conditions. It also looks at how to manage and treat uncomplicated lower UTI and provides guidance on recurrent UTI, usually defines as three or more episodes in a year.  

Women are at increased risk of lower urinary tract infection (UTI), a risk which increases with age (Ahmed et al, 2018). Women who develop a lower UTI are likely to seek treatment in primary care or in NHS walk-in centres and most are prescribed antibiotics on presentation (Pujades-Rodriguez et al, 2019). Misdiagnosis is common and urine culture indicates that only 24–66% of women in the UK treated with an antibiotic have a confirmed UTI (Little et al, 2010; Butler et al, 2015). Misdiagnosis and inappropriate treatment with antibiotics has three consequences, namely:  
  • The woman who presented with lower urinary tract symptoms did not receive the correct diagnosis and treatment (Cortes-Penfield et al, 2017)  
  • She may also be exposed unnecessarily to adverse effects of antibiotic therapy. These range from fungal infection to life-threatening infections, such as Clostridium difficile (Mohsen et al, 2020)  
  • Inappropriate prescribing also increases the risk of antibiotic resistance (Mahmood et al, 2022).  
This article explains why women are at increased risk of lower UTI, why risks increase with age, how to diagnose and treat UTI and how to act when infection recurs.  
‘A lower urinary tract infection (UTI) is an infection of the bladder (also known as cystitis) usually caused by bacteria from the gastrointestinal tract.’  

(National Institute for Health and Care Excellence [NICE], 2023) 

FEMALE ANATOMY AND RISK OF LOWER URINARY TRACT INFECTION  


Women have an increased risk of UTI because the urethra, which provides a barrier to ascending bacteria, is only 5cm long; a man has a urethra of around 15cm in length.  

Ageing leads to normal and pathological changes in the urinary system, and can affect the kidneys, bladder and other components of the urinary system. It diminishes the body’s ability to maintain homeostasis, the normal balance within body systems and within the blood (Denic et al, 2016).  

The kidneys are important organs, which perform several crucial functions, including:  
  • Regulating fluid balance  
  • Maintaining the body’s acid-base balance (pH level)  
  • Regulating electrolyte balance (such as sodium, potassium calcium and phosphate in the blood) 
  • Excreting end products of metabolism and drugs  
  • Producing and releasing hormones (such as erythropoietin [EPO])  
  • Producing vitamin D (Andrade and Knight, 2017).  
Kidney mass decreases from 250 to 200 grams between the ages of 20 and 80. The majority of cells lost are in the renal cortex, which contains the largest number of nephrons. Glomerular cells in the nephrons filter blood and produce urine. In old age, 30–50% of these cells are lost, so the kidneys become less efficient (Andrade and Knight, 2017). These changes affect the blood flow through the nephrons and decrease the ability to concentrate urine and maintain pH balance (Andrade and Knight, 2017). In youth, the kidneys concentrate urine efficiently, so young adults rarely have to wake up in the night to pass urine. At the age of 85, an adult normally has to wake up twice a night to pass urine because the body produces more urine at night and the bladder is smaller than in youth. Antidiuretic hormone (ADH, also known as vasopressin) is produced effectively in youth and old age, with its main function being to regulate the balance of water in the body by controlling reabsorption in the kidneys. In younger people, ADH levels rise at night, this nocturnal rise does not occur in older people. The kidneys become less sensitive to ADH with ageing (El-Sharkawy et al, 2014).  

Ageing decreases bladder capacity and sensitivity to fullness. In youth, the bladder, like a balloon, is stretchy, enlarges well and empties fully. As adults age, the amount of fibrotic tissue increases, so the bladder becomes less stretchy and holds less urine. It no longer contracts down efficiently so the residual urine, the amount of urine left in the bladder after urinating, increases. These changes mean that the working capacity of the bladder is reduced (Smith and Kuchel, 2017).  

The bladder muscle contains sensors that alert adults to the fact that the bladder is filling up. However, these bladder sensors become less sensitive with age. Young adults are aware of the desire to void when the bladder is 50% full, while older adults become aware of the desire to void when the bladder is 90% full. Indeed, older people are more likely to urgently need to pass urine (Andrade and Knight, 2017).  

The urethra passes from the bladder to the outside of the body and allows urine to drain. As women age, oestrogen levels plummet (Robinson et al, 2013). Oestrogen deficiency can lead to female urethral tissues becoming thin and lacking the plumpness of youth. This can lead to decreased urethral closing pressures and increases the risk of urinary tract infection (UTI) (Pipitone et al, 2021).  

Age-related changes also heighten the risk of other non-infective lower urinary tract symptoms, such as increased urinary frequency, urgency and having to get up in the night to pass urine, which may mistakenly be thought to be an indication of infection.  

LOWER URINARY TRACT INFECTION — DIAGNOSIS  


The European Association of Urology (EAU, 2023) categorises urinary tract infections based on clinical presentation and anatomical level of the UTI. Table 1 shows the grade of severity of the infection and the categorisation of risk factors.  

It is recommended that when women present with lower urinary tract symptoms, clinicians: Take a complete medical history including symptoms and co-morbidity and perform a focused physical examination for evaluation of women with LUTS. (EAU, 2023)  

In busy GP practices with 10-minute consultation slots and walk-in centres with 15-minute slots, there is seldom time for such assessments. Urinary tract infection can be diagnosed via telephone consultations. If the older woman has a history of recurrent UTIs, the older woman, caregivers and relatives can and do telephone GPs and request antibiotic therapy, with prescriptions often being issued (Cooper et al, 2020).  

The number of older people diagnosed with UTIs is increasing (Ahmed et al, 2018). If misdiagnosis rates remain unaltered, increasing numbers of women will receive unnecessary antibiotic therapy (Little et al, 2010; Butler et al, 2015). Around 80% of antibiotics prescribed are done so in primary care (UK Health Security Agency, 2022), with UTI being the second most common cause of antibiotic prescribing, after respiratory tract infections (Dolk et al, 2018).  

Table 1: Classification of UTIs based on EAU, 2023 
Diagnosis of UTI in older women, i.e. those over the age of 65, differs from that of younger women. This is because of increases in bacterial colonisation of the bladder in older women. As said, as the bladder ages and becomes less stretchy, there is an increased amount of urine left in the bladder after voiding. This residual urine often becomes colonised with bacteria. This bacterial colonisation, known as asymptomatic bacteriuria, is generally harmless and women have no symptoms of infection. Asymptomatic bacteriuria is more prevalent in frail older women living in care homes (Biggel et al, 2019).  

The woman may, however, have non-infective lower UTI symptoms, such as frequency, urgency, dysuria, nocturia, stress incontinence, urge incontinence, voiding difficulties and the feeling of incomplete bladder emptying (Givler and Givler, 2023; Jarvis, 2023). Some older women may be fit and well at 65 and above and others may be frail, thus in the author’s clinical opinion, community nurses should exercise clinical judgement when treating older women. 

Guidance states that clinicians should determine diagnosis based on presenting problem, medical history and clinical features (EAU, 2023). Clinicians should exclude other causes of urinary symptoms, such as medication, obesity, age-related changes to the urinary system and undiagnosed disease, check for symptoms of UTI and prescribe appropriately.  
 

Excluding other possible diagnoses  


Clinicians should check for any new signs of pyelonephritis, systemic infection, or risk of suspected sepsis (NICE, 2016: Public Health England [PHE], 2018).  

In women who are menopausal, genito-urinary symptoms may be caused by atrophic vaginitis (Willacy, 2022). If the woman is sexually active, clinicians should consider the possibility of sexually transmitted infections (STIs), such as chlamydia and gonorrhoea (Michaels and Sands, 2015), which are on the rise in older people and is thought to be because of changing attitudes to sex and relationships and more casual sex (Evans, 2019). The clinician should also check for urethritis. The symptoms of urethritis are a more frequent urge to urinate, pain and burning on urination and irritation in the urethral area. While the primary cause is gonococcal infection, there are many other causes including trichomonas infection and non-infective causes (Young et al, 2022).  

Non-infective causes relevant to older women include vigorous sexual intercourse, vaginal dryness secondary to atrophic vaginitis, bubble baths and feminine hygiene sprays (Young et al, 2022). 

PRACTICE POINT 


Atrophic vaginitis is characterised by thinning, drying and inflammation of the vaginal walls and surrounding tissue, that occur when the body has less oestrogen, usually during or after the menopause. 

CLINICAL FEATURES OF LOWER URINARY TRACT INFECTION  


In older women, clinical features that are suggestive of urinary tract infection are:  
  • New onset of dysuria alone. Or, two or more of the following occurring:  
  • New frequency or urgency  
  • New incontinence  
  • Visible haematuria  
  • New suprapubic pain  
  • Temperature 1.5C above patients normal twice in 12 hours  
  • New or worsening delirium (PHE, 2018).  
If fever or delirium only, consider other causes before treating for UTI.  

DIPSTICK TESTING  


Urine dipsticks should not be performed in older women as they are unreliable due to the increasing prevalence of asymptomatic bacteriuria (ABU) (PHE, 2018). Around 80% of older women who have urinary incontinence and reside in care homes have ABU (Biggel et al, 2019). Women in care homes can have UTI diagnosed, ‘relying solely on vague symptoms such as changes in behaviour or changes in the appearance of urine rather than typical symptoms of a UTI such as dysuria, frequency or urgency’ (Sloane et al, 2017). 

Diagnostic failure can result in over use of antibiotics and expose the older woman to harm, such as the risk of adverse effect, and by not being treated appropriately, the problem, if not self-limiting, will persist (Cortes-Penfield et al, 2017).  
 

Urine cultures  


Guidance states that clinicians should, whenever possible, send a urine specimen for culture and sensitivity before starting antibiotics. This is because there are higher rates of resistance in older women (PHE, 2018). 

MANAGEMENT AND TREATMENT  


If the woman has new onset dysuria or two symptoms, as outlined above, UTI is likely. Although UTIs are normally self-limiting, most women who seek clinical advice are prescribed an antibiotic (Pujades-Rodriguez et al, 2019).  

Guidelines ask clinicians to consider if symptoms are mild, moderate or severe, and to advise and treat accordingly (PHE, 2018). Figure 1 provides details.  
 

Antibiotic prescribing  


A Cochrane review examined the efficacy of antibiotics in treating lower UTI. It found no significant difference in short or long-term symptomatic cure when comparing trimethoprim, fluoroquinolones, nitrofurantoin, and betalactams (amoxicillin, cefuroxime, pivmecillinam). It found co-amoxiclav to be less effective than fluoroquinolones (Zalmanovici Trestioreanu et al, 2010).  


Figure 1. UTI symptom severity and clinical management (NICE, 2018; 2023b)  
Fluoroquinolones, such as ciprofloxacin, are no longer widely used to treat UTIs because of increasing antimicrobial resistance and evidence of severe and irreversible toxicity associated with their use (Medicines and Healthcare products Regulatory Agency [MHRA], 2019a; 2019b).  

First-line treatment for UTIs are trimethoprim or nitrofurantoin, with three-day courses being recommended for treating uncomplicated UTIs (NICE, 2018; 2023b). There are no specific recommendations regarding duration of treatment for older women (NICE, 2018; 2023b). It is common practice for clinicians to prescribe longer courses of antibiotic for older people. A Cochrane review examined this issue and concluded that: Short-course treatment (three to six days) could be sufficient for treating uncomplicated UTIs in elderly women, although more studies on specific commonly prescribed antibiotics are needed. (Lutters and Vogt-Ferrier, 2008)  

Trimethoprim dosage is 200mg twice daily. A study carried out in London in 2008 found that resistance rates in the community were 39%, with the authors concluding that: Levels of resistance to trimethoprim and ampicillin render them unsuitable for empirical use. (Bean et al, 2008)  

Nitrofurantoin dosage is 100mg MR twice daily. It is excreted by the urinary tract and is not generally suitable for people with renal impairment and an estimated glomerular filtration rate (eGFR) of less than 45 (British National Formulary [BNF], 2023). Community resistance rates are around 5% (Bean et al, 2008).There are a range of other antibiotics that can be used, dependent on culture and sensitivity results.  

If there is no improvement in symptoms when first-choice antibiotic is taken for at least 48 hours (or if first choice is unsuitable), consider prescribing (NICE, 2018; 2023b):  
  • Nitrofurantoin 100mg modified-release twice a day for three days (if eGFR *45ml/minute and not used as first-choice)  
  • Pivmecillinam (a penicillin) 400mg initial dose, then 200mg three times a day for a total of three days  
  • Fosfomycin 3g single dose sachet.  
It is important that clinicians check urine cultures and if the cultured organism is not sensitive to the prescribed antibiotic that the antibiotic is changed.  
 

Single-dose and daily antibiotic prophylaxis  


These should only be considered if there has been an investigation of underlying causes, vaginal oestrogen has been prescribed, and the woman has been advised on drinking sufficient fluids and maintaining good hygiene, such as wiping from front to back after urination.  

NICE (2018) advises that if there is a known trigger that leads to infection, the woman may be prescribed a single-dose antibiotic to take prophylactically if exposed to this trigger. There should be a six-month review. 

Antibiotic prophylaxis, a daily dose of an antibiotic may be given.  
 

Non-compliance  


Obviously, prescribed medication that is not consumed is not effective. Non-compliance, a failure to take prescribed medication is common (Kleinsinger, 2018; Franklin et al, 2020). There are many reasons for this, including difficulty in:  
  • Collecting medication from the pharmacy  
  • Swallowing medication 
  • Remembering to take medication (Kleinsinger, 2018: Franklin et al, 2020). 
In the event of recurrence, it is important that clinicians gently ask if the person is managing to take the medication as it was prescribed.  

RECURRENCE  


The National Institute for Health and Care Excellence (NICE, 2018) defines recurrent urinary tract infection as: Recurrent urinary tract infection (UTI) is defined as two proven episodes within six months, or three within a year.  

Around 20–30% of older women who develop a UTI will have a recurrence (Beerepoot and Geerlings, 2016). There are normally three causes of recurrent UTI, namely:  
  • Diagnostic failure  
  • Treatment failure  
  • Non-compliance with treatment (Table 2).  
Recurrent UTI may be due to relapse (same strain of bacteria), or re-infection (different strain or species of bacteria). Any infection should be treated with an appropriate antibiotic, and vaginal oestrogen may be helpful.  

Table 2: Reducing risks of recurrent UTIs (author’s own work) 
The woman should be given information on self-care. Women may use remedies such as D-mannose, cranberry and probiotics. D-mannose and cranberry can be high in sugar. Currently, there is no evidence that probiotics are effective in preventing UTI (Schwenger et al, 2015). Most UTIs are caused by Escherichia coli (E. coli), and D-mannose, a type of sugar, is thought to work by preventing E.coli from adhering to the lower urinary tract. Indeed, a study of 308 women found that D-mannose was as effective as nitrofurantoin for preventing UTIs over a six-month period (Altarac and Papeš, 2014).  

Cranberry juice and cranberry products are also thought to prevent UTI by preventing bacteria from adhering to the urinary tract. There is some evidence that this is effective (Fu et al, 2017). A Cochrane review found that cranberry products may help reduce the risk of recurrent UTIs, however further research is required (Williams et al, 2023).  

There is some evidence that methenamine (Hiprex), a medication that can be bought in pharmacies, can prevent UTI. It acts as a urinary antiseptic, safely producing formaldehyde to prevent bacterial growth while avoiding bacterial resistance (Chwa et al, 2019).  

PATIENT STORY 


Rose Gallagher, a 72-year-old lady who was overweight, had had a number of UTIs over a six-month period. They were affecting her quality of life, and she was referred for specialist assessment. Mrs Gallagher complained of being very thirsty and was found to have type 2 diabetes. She was prescribed metformin and enrolled in the diabetes weight loss programme (NHS England, 2023). Mrs Gallaher was also found to have a hypotonic bladder and a large residual urine. She was taught how to carry out intermittent catheterisation to empty her bladder properly.  

Mrs Gallagher has now lost 15kg and her diabetes control is improving. She no longer feels terribly thirsty, is not passing excessive amounts of urine, and has not had a UTI for four months. 

Holistic care  


If a woman has repeated UTIs, it is important to carry out a thorough assessment to determine if there are any predisposing factors or bladder abnormalities.  

SAFETY NETTING  


Follow-up should be arranged within three to six months. The woman should be advised to seek urgent review if symptoms of acute UTI develop. Different antibiotics should be used for prophylaxis and treatment of acute UTI (NICE, 2018; 2023b). 

PRACTICE POINT 


A hypotonic bladder is when muscles of the bladder wall are weak, which can cause the bladder not to contract effectively during urination. As a result, the bladder may not be able to empty completely, leading to residual urine  

Residual urine refers to urine that remains in the bladder after urinating. In a healthy bladder, the volume should be minimal, typically less than 50 millilitres. However, in cases of a hypotonic bladder, the residual urine volume can be significantly larger. 

FUTURE THERAPIES  


Overuse of antibiotics contributes to antimicrobial resistance — an important and urgent public health threat. Systematic misuse and overuse of these drugs in human medicine and food production puts humanity at risk and there are few replacement products in the pipeline (World Health Organization [WHO], 2016). Currently, 20,000 unnecessary antibiotic prescriptions are written each day in primary care. At least one in five of around 100,000 antibiotic prescriptions issued by GPs in England every day are unnecessary (Smith, 2018; Palin et al, 2019).  

Antimicrobial resistance contributes to recurrent UTIs, which can have a huge effect on a woman’s quality of life. There is a new class of antibiotic, gepotidacin, that is awaiting approval. This works by damaging bacterial DNA (Gallagher, 2023).  

This new treatment may help women with recurrent UTIs, but in the author’s clinical opinion, it is important that diagnosis rates are improved, and antibiotics are prescribed prudently in order to improve quality of care.  

CONCLUSION  


Recurrent UTI can have a huge effect on a woman’s life. It is important that clinicians diagnose and treat UTIs effectively. If problems persist, specialist referral can address issues.  

RESOURCE 


TARGET stands for treat antibiotics responsibly, guidance, education and tools. It is a toolkit designed to support primary care clinicians to champion and implement antimicrobial stewardship activities (https://elearning.rcgp.org.uk/course/view.php?id=553).
 
Linda Nazarko is consultant nurse, physical health, West London NHS Trust
 
 
This piece was first published in the Journal of Community Nursing. To cite this article use: Nazarko L (2023) Recurrent lower urinary tract infection in older women. J Community Nurs 37(5): 46–52 

References

Ahmed H, Farewell D, Jones HM, et al (2018) Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004–2014. PloS One 13(1): e0190521  

Altarac S, Papeš D (2014) Comment. BJU Int 113: 9–10  

Andrade M, Knight J (2017) Anatomy and physiology of ageing 4: the renal system. Nurs Times 113(5): 46–9 

Bean DC, Krahe D, Wareham DW (2008) Antimicrobial resistance in community and nosocomial Escherichia coli urinary tract isolates, London 2005–2006. Ann Clin Microbiol Antimicrob 7: 13  

Beerepoot M, Geerlings S (2016) Non-Antibiotic prophylaxis for urinary tract infections. Pathogens (Basel, Switzerland) 5(2): 36  

Biggel M, Heytens S, Latour K, et al (2019) Asymptomatic bacteriuria in older adults: the most fragile women are prone to long-term colonization. BMC Geriatr 19: 170  

British National Formulary NF (2023) Urinary tract infections. Available online: https://bnf.nice.org.uk/treatment-summary/urinary-tract-infections.html   

Butler CC, Hawking MK, Quigley A, McNulty CA (2015) Incidence, severity, help seeking, and management of uncomplicated urinary tract infection: a population-based survey. Br J Gen Pract 65(639): e702–7  

Chwa A, Kavanagh K, Linnebur SA, Fixen DR (2019) Evaluation of methenamine for urinary tract infection prevention in older adults: a review of the evidence. Ther Adv Drug Saf 10: 2042098619876749  

Cooper E, Jones L, Joseph A, et al (2020) Diagnosis and management of UTI in primary care settings — a qualitative study to inform a diagnostic quick reference tool for women under 65 years. Antibiotics 9(9): 581  

Cortes-Penfield NW, Trautner BW, Jump RLP (2017) Urinary tract infection and asymptomatic bacteriuria in older adults. Infect Dis Clin N Am 31: 673–88  

Denic A, Glassock RJ, Rule AD (2016) Structural and functional changes with the aging kidney. Adv Chronic Kidney Dis 23(1): 19–28  

Dolk FCK, Pouwels KB, Smith DRM, Robotham JV, Smieszek T (2018) Antibiotics in primary care in England: which antibiotics are prescribed and for which conditions? J Antimicrob Chemother 73(suppl 2): ii2–ii10  

El-Sharkawy AM, Sahota O, Maughan RJ, Lobo DN (2014) The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr (Edinburgh, Scotland) 33(1): 6–13  

European Association of Urology (2023) Urological Infections guideline. Available online: https://uroweb.org/guideline/urological-infections/   

Evans M (2019) Why are STIs on the rise in older people? Patient info. Available online: https://patient.info/news-and-features/why-are-stis-on-the-rise-in-older-people   

Franklin BD, Abel G, Shojania KG (2020) Medication non-adherence: an overlooked target for quality improvement interventions. BMJ Quality Saf 29: 271–3  

Fu Z, Liska D, Talan D, Chung M (2017) Cranberry reduces the risk of urinary tract infection recurrence in otherwise healthy women: a systematic review and meta-analysis. J Nutr 147(12): 2282–88  

Gallagher A (2023) GSK’s Gepotidacin shows potential as first-in-class drug for uncomplicated UTIs. Pharmacy Times. Available online: www.pharmacytimes.com/view/gsk-s-gepotidacin-shows-potential-as-first-in-class-drug-for-uncomplicated-utis   

Givler DN, Givler A (2023) Asymptomatic bacteriuria. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available online: www.ncbi.nlm.nih.gov/books/NBK441848/  

Jarvis S (2023) Lower Urinary Tract Symptoms in Women. Patient Plus. Available online: https://patient.info/womens-health/lower-urinary-tract-symptoms-in-women-luts   

Kleinsinger F (2018) The unmet challenge of medication nonadherence. Permanente J 22: 18–033  

Little P, Moore MV, Turner S, et al (2010) Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ (clinical research edn) 340: c199  

Lutters M, Vogt-Ferrier NB (2008) Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women. Cochrane Database Syst Rev 3: CD001535  

Mahmood RK, Gillani SW, Alzaabi MJ, Gulam SM (2022) Evaluation of inappropriate antibiotic prescribing and management through pharmacist-led antimicrobial stewardship programmes: a meta-analysis of evidence. Eur J Hosp Pharm 29(1): 2–7  

Medicines and Healthcare Products Regulatory Agency (2019a) EMA’s final recommendation on quinolone and fluoroquinolone-containing medicinal products. Drug Safety Update 12(8): 1. Available online: www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-new-restrictions-and-precautions-for-use-due-to-very-rare-reports-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects   

Medicines and Healthcare products Regulatory Agency (2019b) Fluoroquinolone antibiotics (oxacins) what you need to know about side-effects of tendons, muscles, joints, and nerves. Available online: https://assets.publishing.service.gov.uk/media/5c9364c6e5274a48edb9a9fa/FQ-patient-sheet-final.pdf  

Michaels T, Sands J (2015) Dysuria: evaluation and differential diagnosis in adults. Am Fam Physician 92(9): 778–86  

Mohsen S, Dickinson JA, Somayaji R (2020) Update on the adverse effects of antimicrobial therapies in community practice. Can Fam Physician 66(9): 651–9  

NHS England (2023) NHS to expand soups and shakes for people with type 2 diabetes. Available online: www.england.nhs.uk/2023/04/nhs-to-expand-soups-and-shakes-for-people-with-type-2-diabetes/   

National Institute for Health and Care Excellence (2016) Sepsis: Recognition, diagnosis and early management. NICE, London. Available online: www.nice.org.uk/guidance/ng51/resources/sepsis-recognition-diagnosis-and-early-management-1837508256709   

National Institute for Health and Care Excellence (2018) Urinary tract infection (recurrent): antimicrobial prescribing. NICE guideline [NG112]. NICE, London. Available online: www.nice.org.uk/guidance/ng112  

National Institute for Health and Care Excellence (2023a) Urinary tract infections in adults. Quality standard [QS90] Published: 11 June 2015 Last updated: 15 February 2023. Available online: www.nice.org.uk/guidance/qs90/chapter/Quality-statement-4-Duration-of-antibiotic-treatment-for-urinary-tract-infection   

National Institute for Health and Care Excellence (2023b) Urinary tract infection (lower) — women. Clinical Knowledge Summary, NICE, London. Available online: https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/background-information/definition/   

Palin V, Molter A, Belmotne M, et al (2019) Antibiotic prescribing for common infections in UK general practice: variability and drivers. J Antimicrob Chemother 74(8): 2440–50  

Pipitone F, Sadeghi Z, DeLancey JOL (2021) Urethral function and failure: A review of current knowledge of urethral closure mechanisms, how they vary, and how they are affected by life events. Neurourol Urodyn 40(8): 1869–79  

Public Health England (2018) Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, London. Available online: www.gov.uk/government/publications/urinary-tract-infection-diagnosis   

Pujades-Rodriguez M, West RM, Wilcox MH, Sandoe J (2019) Lower urinary tract infections: management, outcomes and risk factors for antibiotic re-prescription in primary care. eClinicalMedicine, Lancet 14: 23–31. Available online: www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30120-8/fulltext    

Robinson D, Toozs-Hobson P, Cardozo L (2013) The effect of hormones on the lower urinary tract. Menopause Int 19(4): 155–62  

Schwenger EM, Tejani AM, Loewen PS (2015) Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev 12: CD008772  

Sloane PD, Kistler CE, Reed D, Weber D J, Ward K, Zimmerman S (2017) Urine culture testing in community nursing homes: gateway to antibiotic overprescribing. Infect Control Hosp Epidemiol 38(5): 524–31  

Smith DM, Dolk FCK, Pouwels KB, et al (2018) Defining the appropriateness and inappropriateness of antibiotic prescribing in primary care. J Antimicrob Chemother 73(suppl 2): ii11–ii18  

Smith PP, Kuchel GA (2017) Aging of the urinary tract. In: Fillit HM, Rockwood K, Young J, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 8th edn. Elsevier Philadelphia, PA: chap 22  

UK Health Security Agency (2022) English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) Report 2021 to 2022. Available online: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1118310/ESPAUR-report-2021-to-2022.pdf   

Willacy H (2022) Atrophic vaginitis: causes, symptoms, and treatment. Patient Plus. Available online: https://patient.info/doctor/atrophic-vaginitis   

Williams G, Hahn D, Stephens JH, Craig JC, Hodson EM (2023) Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 4(4): CD001321  

World Health Organization (2016) Global action plan on antimicrobial resistance. Available online: www.who.int/publications/i/item/9789241509763   

Young A, Toncar A, Wray AA (2022) Urethritis. [Updated 2022 Dec 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available online: www.ncbi.nlm.nih.gov/books/NBK537282/  

Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L (2010) Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 10: CD007182 


Back to journal