NICE summary
The recommendations in this Best Practice topic are based on authoritative international guidelines, supplemented by recent practice-changing evidence and expert opinion. For your added benefit, we summarise below the key recommendations from relevant NICE guidelines.
Key NICE recommendations on management
Refer to the full NICE guideline and your local drug formulary for further information when prescribing - including dose, contraindications, cautions, safety issues, adverse effects, drug interactions, and monitoring requirements. Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is 'off-label').
This summary covers antimicrobial prescribing for lower urinary tract infection (UTI; where lower UTI refers to infection of the bladder) in men (aged 16 years and over).
Management of acute lower UTI
Refer to hospital if there are any symptoms or signs suggesting a more serious illness or condition (e.g., sepsis).[125]
Offer an immediate antibiotic prescription to men (who do not have a catheter) with lower UTI.[125] For guidance on catheter-associated UTI see Management of acute catheter-associated UTI (without upper UTI symptoms) section below.
Consider any previous urine culture and susceptibility results, and previous antibiotic use (which may have led to resistant bacteria), and choose antibiotics accordingly. Also take into account local antimicrobial resistance data.[125]
Obtain a midstream urine sample before antibiotics are taken, and send for culture and susceptibility testing.[125]
If there are symptoms of pyelonephritis (e.g., fever) or a complicated UTI, see the NICE guideline Pyelonephritis (acute): antimicrobial prescribing (NG111) for antibiotic choices.[125]
Prescribe a 7-day course of trimethoprim or nitrofurantoin (if estimated glomerular filtration rate [eGFR] is ≥45 ml/minute) as a first-choice antibiotic for lower UTI.[125]
Nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate.[125]
Nitrofurantoin may be used with caution if eGFR is 30 to 44 ml/minute to treat uncomplicated lower UTIs caused by suspected or proven multidrug-resistant bacteria and only if potential benefit outweighs risk.[125]
If there is no improvement in lower UTI symptoms on first-choice antibiotic taken for at least 48 hours, or when first-choice antibiotics are not suitable, consider alternative diagnoses and follow recommendations in the NICE guideline Pyelonephritis (acute): antimicrobial prescribing (NG111) or Prostatitis (acute): antimicrobial prescribing (NG110), choosing second-choice antibiotics based on recent culture and susceptibility results.[125]
Review choice of antibiotic when microbiological results are available. Change the antibiotic according to susceptibility results if the bacteria are resistant and symptoms are not already improving, using a narrow-spectrum antibiotic wherever possible.[125]
Advise about managing symptoms with self-care, including:[125]
Using paracetamol for pain (or, if preferred and suitable, ibuprofen)
Drinking enough fluids to avoid dehydration.
Be aware that no evidence was found on cranberry products or urine alkalinising agents to treat lower UTI.[125]
When an immediate antibiotic prescription is given, as well as the general advice on self-care, give advice about:[125]
Possible adverse effects of the antibiotic, particularly diarrhoea and nausea
Seeking medical help if symptoms worsen rapidly or significantly at any time, do not start to improve within 48 hours of taking the antibiotic, or the person becomes systemically very unwell.
Reassess if symptoms worsen rapidly or significantly at any time, or do not start to improve within 48 hours of taking the antibiotic, taking account of:[125]
Other possible diagnoses
Any symptoms or signs suggesting a more serious illness or condition (e.g., pyelonephritis)
Previous antibiotic use, which may have led to resistant bacteria.
Send a urine sample for culture and susceptibility testing if this has not already been done and review treatment when results are available.[125]
Asymptomatic bacteriuria (significant bacteria levels in the urine with no symptoms of UTI) is not routinely screened for, or treated, in men.[125]
Management of recurrent UTI in men
This section covers men, and trans women and non-binary people with a male genitourinary system, who have recurrent UTI, are aged 16 and over, and do not have a catheter.
Recurrent UTI in adults is defined as ≥2 UTIs in the last 6 months or ≥3 UTIs in the last 12 months.[126]
If acute UTI is present, manage appropriately.[126]
Give advice to people with recurrent UTI about behavioural and personal hygiene measures and self-care treatments that may help to reduce the risk of UTI.[126]
Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI.[126]
Refer or seek specialist advice on further investigation and management for:[126]
Men, and trans women and non-binary people with a male genitourinary system
People with suspected cancer, in line with the NICE guideline Suspected cancer: recognition and referral (NG12)
Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained UTI.[127]
See the NICE guideline for information on treatments for preventing recurrent UTI that can be used with specialist advice (e.g., daily antibiotic prophylaxis, methenamine hippurate).[126]
Management of acute catheter-associated UTI (without upper UTI symptoms)
Refer to hospital if there are any symptoms or signs suggesting a more serious illness or condition (e.g., sepsis).[128]
Consider removing or, if this cannot be done, changing the catheter as soon as possible if it has been in place for >7 days.[128]
Do not allow catheter removal or change to delay antibiotic treatment.[128]
Obtain a urine sample (before antibiotics are taken) and send it for culture and susceptibility testing (noting suspected catheter-associated UTI and any antibiotic prescribed).[128]
Offer an antibiotic to people with catheter-associated UTI. Consider:[128]
The severity of symptoms
The risk of developing complications, which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression
Previous urine culture and susceptibility results
Previous antibiotic use, which may have led to resistant bacteria
Local antimicrobial resistance data.
Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.[128]
If intravenous antibiotics are required, review these by 48 hours and consider stepping down to oral antibiotics where possible.[128]
For men without upper UTI symptoms, prescribe a 7-day course of oral nitrofurantoin (if eGFR is ≥45 ml/minute) or trimethoprim (if low risk of resistance) or amoxicillin (only if culture results available and susceptible) as a first-choice oral antibiotic.[128]
Prescribe a 7-day course of oral pivmecillinam (a penicillin) as a second-choice oral antibiotic when first-choice antibiotics are not suitable.[128]
Nitrofurantoin and pivmecillinam are not suitable for people with a blocked catheter.[128]
Nitrofurantoin may be used with caution if eGFR is 30 to 44 ml/minute to treat uncomplicated lower UTIs caused by suspected or proven multidrug-resistant bacteria and only if potential benefit outweighs risk.[128]
Lower risk of resistance to trimethoprim is likely if it was not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where local epidemiology data suggests resistance is low. A higher risk of resistance is likely with recent use and in older people in care homes.[128]
For men who are vomiting, unable to take oral antibiotics or severely unwell, prescribe intravenous co-amoxiclav (amoxicillin/clavulanate; co-amoxiclav should only be used in combination, unless culture results confirm susceptibility) or cefuroxime or ceftriaxone or gentamicin or amikacin as a first-choice intravenous antibiotic.[128]
Ciprofloxacin can be used as a first-choice intravenous antibiotic only if other first-choice antibiotics are unsuitable.[128]
Fluoroquinolone antibiotics (e.g., ciprofloxacin) must only be prescribed when other commonly recommended antibiotics are inappropriate.[128]
Antibiotics may be combined if susceptibility or sepsis is a concern.[128]
For second-choice intravenous antibiotics, consult a local microbiologist.[128]
When urine culture and susceptibility results are available, review the choice of antibiotic and change the antibiotic according to susceptibility results if the bacteria are resistant, using narrow-spectrum antibiotics wherever possible.[128]
Advise about managing symptoms with self-care, including:[128]
Using paracetamol for pain
Drinking enough fluids to avoid dehydration.
When an antibiotic is given, as well as general self-care advice, give advice about:[128]
Possible adverse effects of antibiotics, particularly diarrhoea and nausea
Seeking medical help if symptoms worsen at any time, do not start to improve within 48 hours of taking the antibiotic, or the person becomes systemically very unwell.
Reassess if symptoms worsen at any time, or do not start to improve within 48 hours of taking the antibiotic, taking account of:[128]
Other possible diagnoses
Any symptoms or signs suggesting a more serious illness or condition (e.g., sepsis)
Previous antibiotic use, which may have led to resistant bacteria.
Consider referring or seeking specialist advice for men who:[128]
Are significantly dehydrated or unable to take oral fluids and medicines or
Have a higher risk of developing complications (e.g., people with known or suspected structural or functional abnormality of the genitourinary tract, or underlying disease [e.g., diabetes or immunosuppression]) or
Have recurrent catheter-associated UTIs or
Have bacteria that are resistant to oral antibiotics.
Antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter (after 1 month, nearly all people with a catheter have bacteriuria).[128]
Do not routinely offer antibiotic prophylaxis to prevent catheter-associated UTIs in people with a short-term or a long-term (indwelling or intermittent) catheter.[128]
Advise about seeking medical help if symptoms of an acute UTI develop.[128]
© NICE (2018) (2024) (2025) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Links to NICE guidance
Urinary tract infection (lower): antimicrobial prescribing (NG109) October 2018. https://www.nice.org.uk/guidance/ng109
Urinary tract infection (recurrent): antimicrobial prescribing (NG112) December 2024. https://www.nice.org.uk/guidance/ng112
Urinary tract infection (catheter-associated): antimicrobial prescribing (NG113) November 2018. https://www.nice.org.uk/guidance/ng113
Suspected cancer: recognition and referral (NG12) May 2025. https://www.nice.org.uk/guidance/ng12
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