In focus: UTIs

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Reference: 2026 | Issue 7 | Vol 12 | Page 54

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After respiratory and intra-abdominal infections, urinary tract infections (UTIs) remain one of the most common bacterial infections encountered in clinical practice. They are generally classified based on the site of infection:

• Cystitis: Infection of the bladder (lower UTI).
• Urethritis: Infection of the urethra (lower UTI; may also require consideration of sexually-transmitted infections, particularly in younger patients).
• Pyelonephritis: Infection of the kidney (upper UTI).

UTIs are further categorised as complicated and uncomplicated. Complicated UTI includes infections in men, pregnant women, children, older adults, and those with structural or functional abnormalities, or upper UTIs. Uncomplicated infection typically occurs in otherwise healthy, non-pregnant adult women with lower urinary tract symptoms such as dysuria or urinary frequency.

Epidemiology

UTIs are significantly more common in women, with females estimated to be up to 30 times more likely than males to develop an infection. Approximately 50 per cent of women will experience at least one UTI in their lifetime, with many presenting before the age of 25. Although less common in men (lifetime risk ~10 to 12 per cent), UTIs in males are more likely to be complicated and may indicate an underlying condition such as prostate disease or urinary obstruction.

In children, UTIs are among the most common bacterial infections, particularly in those under two years of age. Around 8 per cent of girls and 2 per cent of boys will experience a UTI during childhood. Vesicoureteral reflux may be present in a proportion of cases and should be considered in recurrent infections. In older adults, diagnosis can be more challenging due to atypical presentation. Comorbidities such as incontinence or cognitive impairment may mask symptoms, and asymptomatic bacteriuria becomes more common with age.

Causes and risk factors

UTIs are mostly caused by bacteria, typically originating from the gastrointestinal tract, entering the urethra, and ascending the urinary tract. In many cases, normal urinary flow helps eliminate bacteria before infection develops. When host defences are overcome, bacteria may colonise and spread to the bladder or kidneys. Recognised risk factors include:

• Urinary tract obstruction (eg, kidney stones).
• Sexual activity.
• Diabetes or immunocompromised states.
• Previous history of UTIs.
• Pregnancy.
• Incomplete bladder emptying.
• Catheter use (current or recent).
• Structural abnormalities of the urinary tract.

Gender-specific considerations

Women: Women are more susceptible due to a shorter urethra and closer anatomical proximity to the rectum, facilitating bacterial entry into the urinary tract.

Pregnancy: Pregnancy increases UTI risk due to hormonal changes and mechanical pressure on the bladder, leading to incomplete emptying. Screening and treatment are particularly important due to potential complications.

Men: UTIs are uncommon in younger men but increase with age. Conditions such as benign prostatic hyperplasia can impair bladder emptying, increasing infection risk. Prostatitis may also present with UTI-like symptoms and should be considered. Men who have undergone prostate surgery may also have increased susceptibility due to anatomical changes affecting urinary flow.

Symptoms

Symptoms indicating a lower UTI (cystitis or urethritis) include:

• Increased urination frequency.
• Sudden need to urinate.
• Cloudy or smelly urine (may be indicative of dehydration and not a UTI).
• Burning feeling or pain when passing water.
• Feeling the bladder is not empty after urination.
• General sense of feeling unwell.
• Pain in lower abdomen.

Symptoms of an upper UTI (pyelonephritis) may include (in addition to the above):

• Temperature of 38°C or above.
• Chills and shivering or shaking.
• Pain in the lower back and/or sides.
• Confusion and agitation (especially in older people).
• Vomiting or nausea.
• Diarrhoea.

In addition to the above, children may also:

• Wet the bed – especially in the case of the very young, where they have been consecutively dry for the previous few months; could be a sign of UTI.
• Wet themselves or deliberately avoid urination because it burns or stings.
• With babies, they may be irritable and not feed properly.

Diagnosis

Urinalysis strips (dipsticks) are the most frequently used method to identify clinical evidence. For most women presenting with ‘typical’ symptoms of a lower UTI, eg, cystitis, urethritis, this test is usually sufficient to confirm a diagnosis and recommend a course of first-line treatment.

Samples may require laboratory testing if:

• Any case of UTI in men – this is to rule out other possible causes of symptoms, as UTIs in men are relatively rare by comparison.
• Any case where upper UTI is suspected.
• UTI in pregnancy.
• Where haematuria is present – again important to assess and rule out other causes, eg, bladder cancer.
• Where there is a higher risk factor present due to other conditions that may increase vulnerability to serious complication, eg, immunocompromised patients.

Treatment

Once a UTI diagnosis is confirmed, management should be individualised based on symptom severity, patient risk factors, and likelihood of complications. While antibiotics remain the mainstay of treatment, there is now a stronger emphasis on antimicrobial stewardship, including the option of delayed prescribing in selected patients. Additional focuses include:

• More cautious use of trimethoprim.
• Inclusion of methenamine hippurate for prevention.
• Reinforcement of short-course therapy.
• Increased emphasis on non-antibiotic management.

In recent years, both HSE and National Institute for Health and Care Excellence (NICE) guidance have evolved, with clearer recommendations on first-line choices, treatment duration, and appropriate use of non-antibiotic strategies. Importantly, there is now greater emphasis on avoiding unnecessary antibiotic use in mild cases.

Uncomplicated lower UTIs

• Consider delayed (back-up) antibiotic prescribing in mild cases.
• Advise use only if symptoms worsen or do not improve within 48 hours.
• Provide symptomatic relief advice:
  • Paracetamol or ibuprofen for pain.
  • Adequate hydration.

Exclude red flags (eg, fever, flank pain, pregnancy).

Key prescribing points:

• Nitrofurantoin remains the preferred first-line agent in Ireland due to low resistance rates.
• Avoid if estimated glomerular filtration rate (eGFR) <30mL/min.
• Increased awareness of rare pulmonary and hepatic adverse effects, particularly with prolonged use.
• Immediate vs prolonged release must be clearly specified on prescriptions. Nitrofurantoin is not suitable for suspected pyelonephritis or catheter-associated or complicated UTIs.

TABLE 1: First-line treatment of uncomplicated UTI

Extend to five days in females with recurrent UTIs or slower response.

Acute pyelonephritis (kidney infection)

Patients with suspected upper UTI require prompt antibiotic treatment and clinical assessment. (Table 3 and 4)

TABLE 2: Alternative first-line options (if nitrofurantoin unsuitable) uncomplicated UTI

Note: Trimethoprim should only be used where resistance risk is low (eg, no recent use, previous sensitivity confirmed). Resistance concerns have led to more cautious use than in previous years. Fosfomycin is an additional alternative for females only, given as a single 3g dose. It is increasingly recognised in NICE guidance as a useful option. Advise patients to take at night on an empty stomach with an empty bladder.

TABLE 3: First-line options acute pyelonephritis

TABLE 4: Second-line/penicillin allergy options acute pyelonephritis

Updated considerations:

• Fluoroquinolones (eg, ciprofloxacin) should be reserved for appropriate cases due to safety concerns.
• Co-amoxiclav should only be used where culture confirms susceptibility due to resistance concerns.

Prevention and recurrent UTI

There is now significantly greater emphasis on preventing recurrent UTIs and reducing antibiotic exposure. Non-antibiotic strategies include:

• Increased fluid intake.
• Post-coital voiding.
• Avoidance of spermicides where relevant.

For postmenopausal women, topical vaginal oestrogen is recommended where appropriate.

Methenamine hippurate is now recommended by NICE (2024 update) as a non-antibiotic prophylactic option. It is suitable for patients with recurrent UTIs where antibiotics are undesirable, and works by acidifying urine and preventing bacterial growth.

Key stewardship messages

• Avoid treating asymptomatic bacteriuria (except in pregnancy).
• Use shortest effective antibiotic course.
• Consider delayed prescribing where appropriate.
• Review recurrent cases carefully before initiating long-term antibiotics.
• Maintain a regular but gentle genital hygiene routine.

Do not

• Use perfumed soaps, bubble baths, and intimate hygiene products, which may irritate the urethra.
• Do not delay urination – regular bladder emptying is important.

Natural and non-antibiotic options

• Cranberry products: Evidence remains mixed; not routinely recommended.
• Probiotics and yoghurt: Insufficient evidence to support routine use.
• Methenamine hippurate: Recognised as a non-antibiotic preventive option for recurrent UTIs.
• Topical vaginal oestrogen: Recommended for postmenopausal women with recurrent UTIs.

Advice to patients

UTIs are very common, particularly in women, and in many cases are mild and self-limiting. There is now a greater emphasis on managing symptoms conservatively where appropriate. Symptoms can often be managed initially with paracetamol or ibuprofen for pain alongside adequate hydration. Some patients may be suitable for a delayed antibiotic approach, where treatment is only started if symptoms do not improve or worsen within 48 hours.

Self-care and prevention

When offering advice on how patients can help themselves to prevent UTIs, consider the following practical measures:

Do

• Toilet hygiene – wipe from front to back to reduce transfer of bacteria towards the urethra.
• Fully empty the bladder when urinating – reduces urinary stasis and infection risks.
• Maintain good fluid intake – helps flush bacteria from the urinary tract regularly.
• Shower instead of prolonged baths, particularly if prone to recurrent UTIs.
• Wear breathable underwear (eg, cotton) and avoid overly tight clothing.
• Urinate as soon as possible after sexual intercourse.
• Avoid spermicidal contraceptive products, which are associated with increased UTI risk.

Conclusion

In summary, effective management of UTIs involves early diagnosis, appropriate treatment based on clinical guidelines, and supportive measures such as adequate hydration and symptom relief. Patient education on areas like drug therapy, maintaining good personal hygiene, and recognising signs of recurrent or worsening infection is essential. Overall, prompt, evidence-based management helps relieve symptoms, prevents complications, and reduces the risk of antibiotic resistance and recurrent infections.

References on request