Infection
How NZ, Australian, and international guidelines differ on first-line antibiotic selection for lower urinary tract infection in non-pregnant women - and what the absence of fosfomycin means for NZ practice.
Scope: acute, community-acquired lower UTI in non-pregnant women with no known structural or functional abnormality and no indwelling catheter.
Where they agree
Where they diverge
Comparison
| Domain | NZ - BPAC 2023 | AU - RACGP / Therapeutic Guidelines | International - NICE NG109 / EAU 2023 |
|---|---|---|---|
| When to treat empirically | Women with ≥2 typical symptoms (dysuria, frequency, urgency, haematuria, suprapubic pain). Clinical diagnosis without dipstick or culture required. | Similar. Clinical diagnosis acceptable with typical symptoms. No requirement for dipstick or culture before initiating treatment in uncomplicated cases. | NICE: ≥1 lower urinary tract symptom in women. EAU: ≥2 symptoms. Both allow empirical treatment without prior culture in uncomplicated presentations. |
| First-line antibiotic |
Trimethoprim 300mg once daily for 3 daysFunded OR nitrofurantoin MR 100mg twice daily for 5 days (preferred if trimethoprim resistance risk)Funded |
Nitrofurantoin MR 100mg twice daily for 5 days (often preferred)PBS OR trimethoprim 300mg once daily for 3 daysPBS OR fosfomycin 3g single dosePBS |
NICE: nitrofurantoin MR 100mg twice daily for 3 days (if eGFR ≥45) EAU: fosfomycin 3g single dose (preferred), or pivmecillinam, or nitrofurantoin MR 100mg twice daily for 5 days |
| Fosfomycin | Not registered in NZ. Cannot prescribe.Not available | PBS-listed. Useful where trimethoprim or nitrofurantoin resistance is likely, or for single-dose convenience and adherence.PBS | NICE: second-line if nitrofurantoin and trimethoprim not appropriate. EAU: preferred first-line due to single-dose convenience and resistance preservation. 3g single dose orally. |
| Pivmecillinam | Not available in NZ.Not available | Not routinely available in Australia.Not available | EAU: recommended first-line; 200mg three times daily for 5 days (or 400mg twice daily for 3 days). NICE: alternative option. Widely available in Scandinavia and UK. |
| Nitrofurantoin duration | MR formulation: 5 days (100mg twice daily). Standard formulation: 7 days (50mg four times daily). MR preferred for adherence. | MR formulation: 5 days (100mg twice daily). Aligned with NZ. | NICE: 3 days (MR 100mg twice daily) - shorter than NZ/AU. EAU: 5 days (MR) or 7 days (standard). NICE 3-day course has adequate evidence for uncomplicated cystitis. |
| Fluoroquinolones (ciprofloxacin) | Not recommended for uncomplicated cystitis. Reserve for pyelonephritis, complicated UTI, or where culture confirms susceptibility and other options are unavailable. | Not recommended first-line. Avoid for uncomplicated cystitis. Use only for complicated UTI or culture-directed treatment. | Explicitly not recommended by both NICE and EAU. Fluoroquinolones for uncomplicated UTI contribute to resistance selection and C. difficile risk. EAU: "should not be used" for uncomplicated cystitis. |
| Urine culture (MSU) | Recommended for: men, pregnancy, children, treatment failure, recurrent UTI (≥3/year), atypical or uncertain symptoms, recent urological procedure or catheter, immunocompromised. | Similar indications. Also consider if local trimethoprim resistance rates are high or patient has recent healthcare exposure. | Similar. EAU: consider culture if empirical choice may be inappropriate. NICE: offer dipstick to guide management; culture if dipstick negative but symptoms persist, or if atypical presentation. |
| Recurrent UTI (≥2-3 per year) | Patient-initiated self-start therapy (trimethoprim or nitrofurantoin); low-dose nocturnal prophylaxis; post-coital prophylaxis. Non-antibiotic options: D-mannose, cranberry. Review underlying risk factors. | Similar approach. Patient-initiated therapy or continuous low-dose prophylaxis. Consider specialist referral for ≥3 per year or if structural cause suspected. | Post-coital or continuous low-dose antibiotic prophylaxis. EAU strongly emphasises non-antibiotic strategies: D-mannose, immunostimulation (OM-89), intravaginal oestrogen in post-menopausal women. Vaginal probiotics under investigation. |
NZ clinical context
PHARMAC funding and population-specific considerations
Two agents dominate NZ primary care prescribing for uncomplicated UTI because they are the only fully funded first-line options:
Trimethoprim resistance in NZ E. coli isolates has been rising and varies by region and patient population. BPAC 2023 recommends avoiding trimethoprim as first-line if any of the following apply:1
If any of these apply, use nitrofurantoin as first-line and send an MSU.
Nitrofurantoin is contraindicated if eGFR is below 45 mL/min/1.73m² - it loses urinary efficacy and the risk of systemic accumulation increases. Check eGFR before prescribing, particularly in older patients and in Maori and Pacific peoples, who have a higher burden of chronic kidney disease. If eGFR <45 and trimethoprim is also contraindicated, cefalexin is the pragmatic alternative; send an MSU and tailor treatment to sensitivities.
UTI is not uncomplicated in men. Always send an MSU before treating, treat for at least 7 days, and consider prostatitis (which requires a longer course - typically 4 weeks of trimethoprim or a fluoroquinolone). Do not apply the above first-line regimens directly to men with urinary symptoms.
Bottom line for NZ practice
What this means in the consulting room
Sources