Recommendations:TREATMENT TO PREVENT URINARY TRACT INFECTION
51.

Do not routinely use antibiotic prophylaxis for urinary tract infections in people with neurogenic lower urinary tract dysfunction.

52.

Consider antibiotic prophylaxis for people who have a recent history of frequent or severe urinary tract infections.

53.

Before prescribing antibiotic prophylaxis for urinary tract infection:

  • investigate the urinary tract for an underlying treatable cause (such as urinary tract stones or incomplete bladder emptying)
  • take into account and discuss with the person the risks and benefits of prophylaxis
  • refer to local protocols approved by a microbiologist or discuss suitable regimens with a microbiologist.
54.

Ensure that the need for ongoing prophylaxis in all people who are receiving antibiotic prophylaxis is regularly reviewed.

55.

When changing catheters in patients with a long-term indwelling urinary catheter:

  • do not offer antibiotic prophylaxis routinely
  • consider antibiotic prophylaxisn for patients who:
    -

    have a history of symptomatic urinary tract infection after catheter change or

    -

    experience traumao during catheterisation.

    [This recommendation is from ‘Infection: prevention and control of healthcare-associated infections in primary and community care’ (NICE clinical guideline 139).]
Relative value placed on the outcomes consideredSymptomatic urinary tract infections are a major clinical problem both in terms of the impact of symptoms on the patient and, in some cases, the risk of progression to severe sepsis
The GDG recognised the world-wide concerns that exist in relation to the increasing problem of bacterial antibiotic resistance. This issue necessitates the need for balancing the potential for benefit from antibiotic use in the individual patient with the requirement for adherence with the public health strategy to control the spread of antibiotic-resistant organisms.
Quality of evidenceThe evidence was assessed to be moderate, low or very low quality. The studies that addressed the question were carried out before antibiotic resistance became a critical issue. The lack of recent high quality studies on this issue was felt to be a major concern.
There was a notable absence of studies looking at the use of prophylaxis in high-risk patient groups, such as those with frequent urinary tract infections.
In children, the four studies that were included in the evidence review all involved patients with congenital neurological conditions. Three studies were prone to bias due to limitations in their design but Zegers was of higher quality206.
The nine studies that were included in the review and looked at an adult population were graded between moderate and very low in quality. They found that, for adults with new spinal cord injuries, prophylactic antibiotics led to a reduction in the incidence of symptomatic UTIs. This conclusion was based on a meta-analysis graded as moderate in quality for these outcomes, but it was noted that some studies which were not included in the meta-analysis did not reach a similar conclusion.
Trade-off between clinical benefits and harmsFor individual patients the reduction in the frequency of symptomatic urinary tract infections can be a major benefit. In some cases urinary tract infection can be life threatening and any reduction in such episodes will be of major importance.
For the large majority of patients the use of antibiotic prophylaxis is a benign intervention that is not associated with troublesome complications. However, the widespread use of antibiotics is known to be associated with the development of antibiotic resistance which is a risk both to individual patients and to the wider population.
It is also recognised that the use of prophylactic antibiotics can be associated with serious complications. For example Nitrofurantoin use can be associated with the development of pulmonary, neurological and hepatic disease.
The GDG agreed from the limited evidence presented, and their own clinical experience, prophylactic antibiotics should not be routinely prescribed. They also agreed that frequent urinary tract infections could have a significant impact on the quality of life for a patient, and acknowledged the associated risks of serious complications, such as renal damage, that may warrant the use of this treatment in some circumstances.
Economic considerationsThe GDG was of the opinion that there is currently an over use in the frequency of the prescription of antibiotics for the prophylaxis of UTIs in patients with neurogenic LUT dysfunction. The clinical evidence shows that there is no benefit to prescribing prophylactic antibiotics routinely. However, this evidence is highly uncertain. If antibiotics were indeed effective, perhaps in the longer term, then the low cost of prophylactic antibiotics compared with the relatively high cost of a hospital admitted UTI is probably favourable. The cost of a normal course of antibiotics and the cost of a doctor’s appointment for the treatment of a UTI is also similar to the price of prophylactic antibiotics. This means that if effective, they will be cost saving or at least cost neutral. If they are currently over prescribed then, any reduction in use will be cost saving.
Other considerationsThe GDG recognised that many patients with NLUTD will have permanent urinary tract colonisation with bacteria and that asymptomatic bacteriuria should not, in general, be treated. Furthermore, in some cases, it can be difficult to determine whether an active infection is present because symptoms are not always directly attributable to the urinary tract; a judgement may have to be made as to whether non-specific symptoms are present as a result of UTI.
The difficulty in diagnosing UTI is compounded by the problems that are associated with the laboratory interpretation of urine samples in some patients with NLUTD. For example, the use of intermittent or indwelling catheters can lead to the presence of bacteruria and pyuria which might be of no clinical significance. These difficulties not only create problems in clinical practice but present challenges to those who are conducting research in this field. The importance of providing the microbiology department with correctly taken samples and appropriate clinical information was emphasised by the GDG.
The GDG recognised the importance of avoiding inappropriately prolonged antibiotic prophylaxis. There was low quality evidence in children to suggest that discontinuing treatment may be beneficial rather than harmful. Long term prophylactic antibiotics may promote antibiotic resistance.
n

At the time of publication (August 2012), no antibiotics had a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the GMC’s ‘Good practice in prescribing medicines – guidance for doctors’ for further information.

o

The GDG for ‘Infection: prevention and control of healthcare-associated infections in primary and community care’ defined trauma as frank haematuria after catheterisation or two or more attempts of catheterisation.

From: 13, Treatment to prevent urinary tract infection

Cover of Urinary Incontinence in Neurological Disease
Urinary Incontinence in Neurological Disease: Management of Lower Urinary Tract Dysfunction in Neurological Disease.
NICE Clinical Guidelines, No. 148.
National Clinical Guideline Centre (UK).
Copyright © 2012, National Clinical Guideline Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Clinical Guideline Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.