Suspected UTI in an adult
Dysuria, frequency or urgency. Not for children or patients with a urinary catheter.
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Family MedicineManagement
Uncomplicated UTI (Cystitis) in Adults
Uncomplicated UTI (Cystitis) in Adults: Suspected UTI in an adult → Signs of infection beyond the bladder? → Yes: check for sepsis first → Yes: pyelonep...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Decision Signs of infection beyond the bladder?
Fever 38 °C or more, rigors, flank pain or renal angle tenderness, nausea or vomiting, or signs of sepsis.
- Fever 38 °C or more or rigors
- Flank pain or renal angle tenderness
- Nausea or vomiting
- Signs of sepsis: low BP, confusion, fast breathing
- If Yes
03Warning Yes: check for sepsis first
Sepsis or suspected obstruction is an emergency. Do not delay antibiotics.
- Sepsis signs: follow the local sepsis pathway; IV antibiotics within 60 minutes
- Take blood and urine cultures first if this causes no delay
- Infection with suspected obstruction: urgent imaging and urology review
04Action Yes: pyelonephritis or complicated UTI
Infection beyond the bladder (IDSA 2025). Always send urine for culture before antibiotics.
- Admit if septic, vomiting or unable to take oral drugs, pregnant, obstruction suspected, or no improvement
- Choose the empirical agent by severity, resistance risk and local antibiogram (IDSA 2025; Australia: eTG acute pyelonephritis)
- Outpatient oral options (IDSA 2025): fluoroquinolone; TMP-SMX or an oral beta-lactam only if the organism is likely susceptible (less evidence; higher doses)
- Duration for most: 7 days (5 to 7 days with a fluoroquinolone)
- Pregnancy: admit; avoid fluoroquinolones
- Men with fever and perineal or pelvic pain: think of acute prostatitis (longer course)
- Imaging if obstruction suspected or no improvement in 48 to 72 h
05Outcome Review at 48 to 72 h with culture results
Narrow therapy to the organism. Switch IV to oral when stable. Not improving: image for obstruction or abscess and get specialist advice.
If No06Decision No: pregnant, male or another risk group?
Pregnancy, male sex, immunocompromise, urinary tract abnormality, stones or recent urological procedure, recent antibiotics or a resistant organism.
- Pregnancy
- Male sex
- Immunocompromise
- Known urinary tract abnormality or stones, or recent urological procedure
- Recent antibiotics or a known resistant organism
- If Yes
07Warning Yes: if pregnant, avoid trimethoprim and fluoroquinolones
Pregnant women with cystitis: culture before treatment. Pyelonephritis in pregnancy: admit.
- Pregnancy (eTG): cefalexin 500 mg 12-hourly for 5 days, or nitrofurantoin 100 mg 6-hourly for 5 days
- No nitrofurantoin from 37 weeks, in labour or when birth is imminent
- Repeat urine culture after treatment to confirm cure
08Action Yes: cystitis in a risk group
Send urine for culture before the first dose. Adjust to susceptibilities.
- Pregnancy: see the warning above
- Drug cautions: no nitrofurantoin if eGFR under 45 mL/min or G6PD deficiency; trimethoprim raises potassium (ACE inhibitor, ARB, spironolactone) and INR (warfarin)
- Men: treat for 7 days; empirical nitrofurantoin 100 mg 6-hourly (eTG 2025 first-line) or trimethoprim 300 mg once daily if low resistance risk; adjust to culture
- Men with persistent symptoms after treatment: refer to urology (eTG)
- Men with fever or perineal or pelvic pain: treat as prostatitis or complicated UTI
- Other risk groups: culture-guided agent; seek advice if resistant organism
09Decision Symptoms resolved?
Review if not better in 48 h, if symptoms worsen, or if they return within 2 weeks.
- If Yes
10Outcome Yes: resolved
No test of cure is needed for non-pregnant women. Return if symptoms recur.
11Action If recurrent UTI (2 or more in 6 months, or 3 or more in 12 months): prevention
Confirm each episode with culture before prevention.
- Men, haematuria, stones or suspected obstruction: imaging and urology referral
- Non-antibiotic options: vaginal oestrogen after menopause; methenamine hippurate; cranberry products may help
- Antibiotic prophylaxis (post-coital or low-dose nightly): dose, see eTG or local guideline
- Long-term nitrofurantoin: lung and liver toxicity can occur; monitor
- Self-start treatment for reliable patients, with a urine culture first
12Outcome Review the prevention plan and adverse effects regularly
Stop or change prophylaxis if breakthrough infection or adverse effects occur; culture any breakthrough episode.
If No13Action No: persistent symptoms after treatment
Culture-directed therapy and reassessment.
- Send urine for culture and susceptibility
- Reassess for pyelonephritis, STI, vaginitis or another diagnosis
- Treat by susceptibilities
- Men: refer to urology (eTG)
- Path rejoins step 11Shared downstream outcome
If No14Action No: uncomplicated cystitis in a non-pregnant woman
Infection confined to the bladder, no risk group, no urinary catheter. Empirical treatment is appropriate.
- Dysuria and frequency without vaginal discharge or irritation: UTI is highly likely
- Urine culture not needed for a typical first episode
- Send culture if symptoms are atypical, recur, or follow recent antibiotics
- Vaginal discharge or irritation: consider STI or vaginitis
15Decision Mild symptoms, under 65, not immunocompromised, and prefers no antibiotic?
eTG 2025: a trial of ibuprofen without antibiotics may be offered to these women after a shared decision.
- If Yes
16Action Yes: ibuprofen trial without antibiotics
Not with kidney disease, peptic ulcer, heart failure, an anticoagulant or NSAID-sensitive asthma. Pyelonephritis was more common than with antibiotics in trials: give safety-net advice.
- Adult: ibuprofen 400 mg 8-hourly with food for up to 3 days (Brufen PI: max 1,600 mg a day)
- Start an antibiotic if no better in 48 h or if symptoms worsen
- Seek care at once for fever, rigors, flank pain or vomiting
- Path rejoins step 09Shared downstream outcome
If No17Warning No (or she prefers an antibiotic): check drug cautions first
Check kidney function, allergy history and current medicines.
- Nitrofurantoin: not if eGFR under 45 mL/min (short course at 30 to 44 only for a resistant organism; TGA PI), G6PD deficiency, or from 37 weeks of pregnancy
- Trimethoprim or TMP-SMX: high potassium with ACE inhibitor, ARB, spironolactone or potassium; raises INR with warfarin; avoid with methotrexate
- Beta-lactam allergy: check the reaction type before cefalexin or amoxicillin-clavulanate
18Action Non-pregnant adult women: first-line antibiotic
Choose by allergy, kidney function, local resistance and recent antibiotic use. Australia: nitrofurantoin first (eTG 2025).
- Australia (eTG 2025) first: nitrofurantoin 100 mg 6-hourly with food for 5 days (AU capsules are macrocrystals, 4 times daily)
- Second: fosfomycin 3 g sachet as a single dose
- If these are unsuitable: trimethoprim 300 mg once daily for 3 days (not if trimethoprim in the last 3 months or a resistant isolate)
- or cefalexin 500 mg 12-hourly for 5 days
- US (IDSA 2011): nitrofurantoin monohydrate/macrocrystals (twice-daily product) 100 mg twice daily for 5 days
- US (IDSA 2011): TMP-SMX 160/800 mg twice daily for 3 days if local resistance is 20% or less
- Do not use fluoroquinolones for uncomplicated cystitis when other options exist
- Do not use amoxicillin alone empirically (high resistance)
19Action If first-line agents are unsuitable: alternatives
Allergy, intolerance or resistance to the first-line agents.
- Beta-lactams (e.g. amoxicillin-clavulanate) for 3 to 7 days: less effective than first-line (IDSA 2011)
- Cefpodoxime, cefdinir and pivmecillinam: not registered in Australia
- Fluoroquinolone only if no other option; send culture first
- Resistant organism on culture: use susceptibilities; get microbiology or ID advice
20Action Symptom relief with any treatment
Pain relief and advice. Symptoms usually improve within 48 h.
- Paracetamol, or ibuprofen if no NSAID caution
- Phenazopyridine: US only, for no more than 2 days; not registered in Australia
- Finish the antibiotic course even if symptoms improve
- Path rejoins step 09Shared downstream outcome
Guideline Source
IDSA/ESCMID International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women (2010 update, CID 2011)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- For non-pregnant adults with bladder-only infection; fever, flank pain or sepsis needs the pyelonephritis or complicated UTI pathway (IDSA 2025).
- Antibiotic choice must follow local resistance; Australian doses follow eTG Antibiotic, US doses follow IDSA 2011.
- IDSA 2011 cystitis guidance is under update; pyelonephritis guidance is replaced by the IDSA 2025 complicated UTI guideline.
- Not for children, catheter-associated UTI or asymptomatic bacteriuria.
- Pregnancy guidance here is brief; use the local antenatal UTI guideline.
Contraindicated Populations
childrenurinary catheter (catheter-associated UTI)asymptomatic bacteriuria
Applicable Regions
USAUUKEU
AU: eTG Antibiotic (2025): nitrofurantoin first-line for acute cystitis in adults (AU capsules are macrocrystals, 100 mg 6-hourly); fosfomycin 3 g second-line in non-pregnant women; trimethoprim or cefalexin if these are unsuitable. Ibuprofen-only trial may be offered for mild symptoms in non-pregnant women under 65. Twice-daily nitrofurantoin (Macrobid) is not marketed; cefpodoxime, cefdinir, pivmecillinam and phenazopyridine are not on the ARTG.
UK: NICE NG109 applies (nitrofurantoin first choice if eGFR 45 or more; trimethoprim if low resistance risk); see NICE for doses.
US: IDSA 2011 regimens; FDA 2016 safety warning: do not use fluoroquinolones for uncomplicated cystitis when other options exist.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Uncomplicated UTI (Cystitis) in Adults?
The Uncomplicated UTI (Cystitis) in Adults is a management clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on IDSA/ESCMID International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women (2010 update, CID 2011).
What guideline is the Uncomplicated UTI (Cystitis) in Adults based on?
This algorithm is based on IDSA/ESCMID International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women (2010 update, CID 2011) (DOI: 10.1093/cid/ciq257).
What are the limitations of the Uncomplicated UTI (Cystitis) in Adults?
Known limitations include: For non-pregnant adults with bladder-only infection; fever, flank pain or sepsis needs the pyelonephritis or complicated UTI pathway (IDSA 2025).; Antibiotic choice must follow local resistance; Australian doses follow eTG Antibiotic, US doses follow IDSA 2011.; IDSA 2011 cystitis guidance is under update; pyelonephritis guidance is replaced by the IDSA 2025 complicated UTI guideline.; Not for children, catheter-associated UTI or asymptomatic bacteriuria.; Pregnancy guidance here is brief; use the local antenatal UTI guideline.. Individual patient factors may require deviation from these recommendations.
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