Urology · EAU

Urinary tract infection

EAU

Source:EAU Guidelines on Urological Infections (Limited Update April 2024)IDSA Guideline on Uncomplicated UTI (2024)NICE NG109 Pyelonephritis (2024)

Verified Apr 2026

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Red Flags

Suspected sepsis (qSOFA ≥2, NEWS2 ≥5, hypotension, lactate >2) — sepsis pathway with IV antibiotic within 1 h, fluids, lactate, blood cultures^[1]
Obstructed pyelonephritis with stone or anatomic abnormality — emergency urology, urgent decompression (ureteric stent / percutaneous nephrostomy)^[1]
Complicated UTI in pregnancy, transplant recipient, or with indwelling urinary catheter — broader cover, longer duration; senior input^[1]
Recurrent UTI (≥2 in 6 months or ≥3 in 12 months) — investigate underlying cause; antibiotic stewardship^[1]

First-line treatment

Interventions

Distinguish uncomplicated cystitis from pyelonephritis and complicated UTI^[1]
Uncomplicated cystitis: short-course oral antibiotic. Pyelonephritis: 7–14 day course, oral or IV. Complicated UTI (CKD, transplant, anatomic abnormality, immunosuppression, men, pregnancy): broader cover and longer course
Antibiotic stewardship^[1]
Use narrow-spectrum agents per local resistance data; avoid fluoroquinolones for uncomplicated cystitis; reserve carbapenems for known ESBL or critical illness; review at 48 h with culture sensitivities
Asymptomatic bacteriuria — selective treatment^[1]
Treat in pregnancy, before urological intervention with mucosal trauma, after kidney transplant first 1 month. Do NOT treat in healthy non-pregnant women, men, elderly, diabetics, catheterised patients
Recurrent UTI prevention^[1]
Behavioural: hydration, post-coital voiding, no spermicide; topical vaginal estrogen postmenopausal; cranberry products (modest); methenamine hippurate; antimicrobial prophylaxis for refractory cases (continuous low-dose, post-coital, or self-start)

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Nitrofurantoin (uncomplicated cystitis)^[1]	Furan antimicrobial	100 mg PO BD × 5 days	≥3 months: 5–7 mg/kg/day	First-line for uncomplicated cystitis; effective concentration only in urine; avoid eGFR <30 (insufficient excretion); pulmonary fibrosis with prolonged use; safe in pregnancy except at term
Fosfomycin (uncomplicated cystitis)^[1]	Phosphonic acid antimicrobial	3 g PO single dose (sachet dissolved in water)	—	Single-dose convenience for uncomplicated cystitis; resistance increasing; useful in suspected ESBL pathogen
Co-trimoxazole (uncomplicated cystitis)^[1]	Sulfonamide + trimethoprim	160/800 mg PO BD × 3 days	8/40 mg/kg/day in 2 divided doses	Use only where local E. coli resistance <20%; avoid in pregnancy near term, G6PD, severe renal impairment
Co-amoxiclav (alternative cystitis)^[1]	Aminopenicillin + beta-lactamase inhibitor	625 mg PO TDS × 5 days	20–40 mg/kg/day amoxicillin component	Useful in penicillin-tolerant; rising resistance; check local antibiogram
Ceftriaxone (pyelonephritis or complicated UTI)^[1]	Third-generation cephalosporin	1–2 g IV daily; switch to oral cefuroxime 500 mg BD or per culture × total 10–14 days	50–80 mg/kg/day IV	First-line for pyelonephritis or complicated UTI requiring IV; switch to oral by culture sensitivity at 48–72 h
Piperacillin-tazobactam or meropenem (severe complicated UTI)^[1]	Beta-lactam ± beta-lactamase inhibitor / carbapenem	Piperacillin-tazobactam 4.5 g IV every 6–8 h; meropenem 1 g IV every 8 h	Per local protocol	Severe complicated UTI, sepsis, ESBL or AmpC concern; renal dose adjustment; reassess at 48 h with cultures
Vaginal estrogen (postmenopausal recurrent UTI)^[1]	Local estrogen	Estradiol 25 µg pessary or 0.1 mg cream nightly × 2 weeks then 2× weekly	—	First-line non-antibiotic prevention in postmenopausal women; minimal systemic absorption; safe with most contraindications to systemic HRT

Nitrofurantoin (uncomplicated cystitis)^[1]

Furan antimicrobial

Adult: 100 mg PO BD × 5 days
Paediatric: ≥3 months: 5–7 mg/kg/day

First-line for uncomplicated cystitis; effective concentration only in urine; avoid eGFR <30 (insufficient excretion); pulmonary fibrosis with prolonged use; safe in pregnancy except at term

Fosfomycin (uncomplicated cystitis)^[1]

Phosphonic acid antimicrobial

Adult: 3 g PO single dose (sachet dissolved in water)
Paediatric: —

Single-dose convenience for uncomplicated cystitis; resistance increasing; useful in suspected ESBL pathogen

Co-trimoxazole (uncomplicated cystitis)^[1]

Sulfonamide + trimethoprim

Adult: 160/800 mg PO BD × 3 days
Paediatric: 8/40 mg/kg/day in 2 divided doses

Use only where local E. coli resistance <20%; avoid in pregnancy near term, G6PD, severe renal impairment

Co-amoxiclav (alternative cystitis)^[1]

Aminopenicillin + beta-lactamase inhibitor

Adult: 625 mg PO TDS × 5 days
Paediatric: 20–40 mg/kg/day amoxicillin component

Useful in penicillin-tolerant; rising resistance; check local antibiogram

Ceftriaxone (pyelonephritis or complicated UTI)^[1]

Third-generation cephalosporin

Adult: 1–2 g IV daily; switch to oral cefuroxime 500 mg BD or per culture × total 10–14 days
Paediatric: 50–80 mg/kg/day IV

First-line for pyelonephritis or complicated UTI requiring IV; switch to oral by culture sensitivity at 48–72 h

Piperacillin-tazobactam or meropenem (severe complicated UTI)^[1]

Beta-lactam ± beta-lactamase inhibitor / carbapenem

Adult: Piperacillin-tazobactam 4.5 g IV every 6–8 h; meropenem 1 g IV every 8 h
Paediatric: Per local protocol

Severe complicated UTI, sepsis, ESBL or AmpC concern; renal dose adjustment; reassess at 48 h with cultures

Vaginal estrogen (postmenopausal recurrent UTI)^[1]

Local estrogen

Adult: Estradiol 25 µg pessary or 0.1 mg cream nightly × 2 weeks then 2× weekly
Paediatric: —

First-line non-antibiotic prevention in postmenopausal women; minimal systemic absorption; safe with most contraindications to systemic HRT

Safety-net

Drink plenty of water and complete your antibiotic course; symptoms should improve within 48 h — return if worsening, fever, vomiting, or back pain^[1]
If you develop high fever, severe back pain, or systemic features — same-day medical review (pyelonephritis or sepsis)^[1]
Frequent UTIs warrant investigation; do not just take repeat antibiotics — see your clinician for cause and prevention^[1]

Referral criteria

Sepsis or pyelonephritis with deterioration despite IV antibiotic at 48–72 hSenior medical team and urology^[1]
Obstructed pyelonephritis or renal abscessUrology for urgent decompression^[1]
Recurrent UTI requiring underlying-cause workupUrology with imaging and cystoscopy^[1]
Pregnancy with UTI / pyelonephritisJoint obstetric and infection review; pregnancy-safe antibiotic^[1]

Clinical summary

Diagnosis and stewardship-focused antimicrobial management of uncomplicated and complicated UTI in adults.

References

1.EAU Guidelines on Urological Infections (Limited Update April 2024); IDSA Guideline on Uncomplicated UTI; NICE NG109 Pyelonephritis (2024)

Drug

Class

Adult

Paediatric

Notes

Nitrofurantoin (uncomplicated cystitis)^[1]

Furan antimicrobial

100 mg PO BD × 5 days

≥3 months: 5–7 mg/kg/day

First-line for uncomplicated cystitis; effective concentration only in urine; avoid eGFR <30 (insufficient excretion); pulmonary fibrosis with prolonged use; safe in pregnancy except at term

Fosfomycin (uncomplicated cystitis)^[1]

Phosphonic acid antimicrobial

3 g PO single dose (sachet dissolved in water)

—

Single-dose convenience for uncomplicated cystitis; resistance increasing; useful in suspected ESBL pathogen

Co-trimoxazole (uncomplicated cystitis)^[1]

Sulfonamide + trimethoprim

160/800 mg PO BD × 3 days

8/40 mg/kg/day in 2 divided doses

Use only where local E. coli resistance <20%; avoid in pregnancy near term, G6PD, severe renal impairment

Co-amoxiclav (alternative cystitis)^[1]

Aminopenicillin + beta-lactamase inhibitor

625 mg PO TDS × 5 days

20–40 mg/kg/day amoxicillin component

Useful in penicillin-tolerant; rising resistance; check local antibiogram

Ceftriaxone (pyelonephritis or complicated UTI)^[1]

Third-generation cephalosporin

1–2 g IV daily; switch to oral cefuroxime 500 mg BD or per culture × total 10–14 days

50–80 mg/kg/day IV