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Pharmacy Services
Pharmacy First: UTI in Women
How to assess and treat uncomplicated lower urinary tract infections under the NHS Pharmacy First service, covering age limits, upper UTI exclusion, the nitrofurantoin dose, and the many exclusions pharmacists commonly miss.
About this service
Urinary tract infection (UTI) is one of the most common reasons people visit community pharmacy. The NHS Pharmacy First service allows pharmacists to supply nitrofurantoin for uncomplicated lower UTI without a GP appointment. The pathway applies to non-pregnant women and eligible individuals aged 16 to 64.
The PGD (version 1.3, October 2025) uses inclusive language. It covers cisgender women, non-binary people assigned female at birth, and transgender men with no structural alteration to their urethra. The article uses the term 'women' for brevity but this should be understood to include all eligible individuals within those definitions.
The most important clinical distinction in this pathway is between lower UTI (cystitis) and upper UTI (pyelonephritis). Lower UTI presents with dysuria, frequency, and urgency without systemic features. Upper UTI presents with loin pain, fever (temperature 37.9 degrees Celsius or above), rigors, or nausea and vomiting, and requires urgent referral to GP or out-of-hours services. Any history of fever or chills within the past 48 hours is an exclusion from this pathway.
The exclusion list for this PGD is notably long. Diabetes (type 1 and type 2), catheter use, recent UTI antibiotic treatment, and care home residence are among the exclusions most commonly missed in practice.
Who to offer the service to
Include
- Cisgender women, non-binary people assigned female at birth, or transgender men with no structural urethral alteration
- Aged 16 to 64 years (under 16 or 65 and over: refer to GP)
- Signs and symptoms of lower UTI (dysuria, frequency, urgency, cloudy or offensive-smelling urine)
- No nitrofurantoin use in the past 3 months
- Not currently pregnant
- NHS eligibility requirements apply
Exclude
- Under 16 years or aged 65 and over: refer to GP
- Pregnancy or suspected pregnancy: refer urgently to GP or sexual health service
- Currently breastfeeding: excluded
- Any fever, raised temperature, or chills within the past 48 hours: suggests upper UTI. Refer to GP same day.
- Signs of upper UTI (pyelonephritis): loin pain or tenderness in back under ribs, new or different muscle pain, rigors, temperature 37.9 degrees Celsius or above, nausea or vomiting: refer to GP same day urgently
- Known diabetes mellitus (type 1 or type 2): excluded from this PGD. Refer to GP.
- Catheter use: indwelling urethral catheter, suprapubic catheter, or intermittent self-catheterisation. Refer to GP.
- Abnormal vaginal discharge: 80% of patients with vaginal discharge and urinary symptoms do not have a UTI. Refer to GP or sexual health service.
- Suspected sexually transmitted infection or urethritis: refer to sexual health service urgently
- Genitourinary symptoms of menopause (vulvovaginal atrophy): refer to GP
- Recurrent UTI (2 or more episodes in the past 6 months, or 3 or more in the past 12 months): needs urine culture. Refer to GP.
- Any UTI antibiotic treatment in the past 3 months: excluded
- Already on prophylactic antibiotics for UTI: excluded
- Failed previous antibiotic for this episode: refer to GP
- Known or suspected nitrofurantoin-resistant UTI: refer to GP
- Complicated UTI (structural or functional abnormality, under Urology care): refer to GP
- Care home resident: refer to GP
- UK hospitalisation for more than 7 days in the past 6 months: refer to GP
- Hospitalisation abroad in the past 3 months: refer to GP
- Known CKD stages 3b, 4, or 5 (eGFR below 45): excluded. Refer to GP.
- Known porphyria, G6PD deficiency, anaemia, folate deficiency, vitamin B deficiency, peripheral neuropathy, or electrolyte imbalance: excluded
- Severely immunocompromised or immunosuppressed: refer to GP urgently
- Sepsis suspected: call 999
How to deliver the service
- Confirm the diagnosis is lower UTI and exclude upper UTI Ask specifically about systemic features that would indicate upper UTI: fever or chills in the past 48 hours (even if resolved), temperature 37.9 degrees Celsius or above now, loin pain or tenderness in the back under the ribs, new or different muscle pain, rigors, nausea, or vomiting. If any of these are present, refer to GP or out-of-hours service same day. Do not supply nitrofurantoin.
- Confirm age and eligibility The PGD applies to individuals aged 16 to 64 only. Women aged 65 and over must be referred to their GP. Confirm the patient is not pregnant (pregnancy is an absolute exclusion). Confirm the patient is not breastfeeding.
- Work through the exclusion list The UTI PGD has an unusually long exclusion list. The most commonly missed exclusions in practice are: diabetes mellitus type 1 or type 2 (excluded entirely), catheter use of any type (refer to GP), vaginal discharge or suspected STI (refer), any UTI antibiotic use in the past 3 months (excluded), recurrent UTI (2 in 6 months or 3 in 12 months: refer for urine culture), care home residence (refer), UK hospitalisation for more than 7 days in past 6 months (refer), and renal function: excluded if eGFR below 45.
- Select the correct formulation and counsel on interactions Nitrofurantoin 100mg modified release capsules twice daily for 3 days is first line. Supply the 50mg immediate release formulation four times daily for 3 days only if modified release capsules are unavailable. Both must be taken with food or milk to reduce nausea. Advise specifically that OTC cystitis relief preparations (those containing potassium citrate, sodium bicarbonate, or sodium citrate) reduce the antibacterial action of nitrofurantoin and must not be taken during the course. Antacids such as magnesium trisilicate also decrease nitrofurantoin absorption and should be avoided during the course.
- Counsel on side effects and safety net Advise: complete the 3-day course, take with food or milk, drink plenty of fluids. Urine discolouration (dark yellow or brown) is expected and harmless. Symptoms should improve within 48 hours. Return if not improving within 48 hours, or if symptoms worsen or systemic features develop (fever, loin pain, rigors). Advise seeking urgent help if signs of sepsis develop. Counsel on rare but serious adverse effects: new breathing difficulties or cough (pulmonary reaction), jaundice or dark urine (hepatic reaction), or tingling or weakness in the limbs (peripheral neuropathy) all require the medicine to be stopped and medical advice sought urgently.
Assessment outcome: what to do
| Result | Action | Urgency |
|---|---|---|
| Upper UTI features or fever in past 48 hours | Refer to GP or out-of-hours service same day urgently. Do not supply nitrofurantoin. | Refer urgently |
| Pregnancy, suspected STI, or severely immunosuppressed | Pregnancy: refer to GP urgently. STI suspected: refer to sexual health urgently. Severely immunosuppressed: refer to GP urgently. | Refer urgently |
| Vaginal discharge, menopause symptoms, or urethritis | Refer to GP. Most patients with discharge and urinary symptoms do not have a UTI. | Refer to GP |
| Excluded (diabetes, catheter, recent antibiotic, care home, eGFR below 45, recurrent UTI, etc.) | Refer to GP. Record reason for exclusion. | Refer to GP |
| Lower UTI confirmed, no exclusions, aged 16-64, not pregnant | Supply nitrofurantoin 100mg MR twice daily for 3 days with food or milk. Counsel on OTC cystitis preparations, urine discolouration, and 48-hour improvement target. | Supply if PGD met |
Lower UTI vs Upper UTI: The Critical Distinction
Distinguishing lower from upper UTI determines whether treatment under this PGD is appropriate or urgent referral is needed. Any systemic feature excludes the patient from this pathway.
| Feature | Lower UTI (in pathway) | Upper UTI (refer urgently to GP) |
|---|---|---|
| Urinary symptoms | Dysuria, frequency, urgency, cloudy or offensive urine | Same urinary symptoms may be present |
| Systemic features | Absent: no fever, no rigors, no nausea/vomiting | Fever or chills in past 48 hours, temperature 37.9C or above, rigors, nausea or vomiting |
| Pain location | Suprapubic discomfort or dysuria | Loin pain or tenderness in the back under the ribs |
| Muscle symptoms | None | New or different muscle pain (myalgia) |
| Action | Assess against PGD criteria and supply if eligible | Refer to GP or out-of-hours service same day urgently |
Nitrofurantoin Doses (with food or milk, 3 days)
Modified release capsules are first line. Immediate release tablets are only if modified release are unavailable. Both are taken for 3 days.
| Formulation | Dose and frequency | Notes |
|---|---|---|
| Nitrofurantoin 100mg modified release capsules (first line) | 100mg twice daily for 3 days (every 12 hours) | Preferred. Take with food or milk. 6 capsules total. |
| Nitrofurantoin 50mg immediate release (if 100mg MR unavailable) | 50mg four times daily for 3 days (every 6 hours) | Second line only. Take with food or milk. 12 tablets total. |
Symptoms should start to improve within 48 hours. Urine may turn dark yellow or brown during treatment: this is expected and harmless. OTC cystitis preparations (potassium citrate, sodium bicarbonate, sodium citrate) reduce the antibacterial action of nitrofurantoin and must not be taken during the course.
Recording and submission
- Complete the consultation record contemporaneously on PharmOutcomes.
- Key information to record:
- Patient name, date of birth, NHS number
- Age confirmed (16 to 64)
- Symptoms and duration: dysuria, frequency, urgency, urine appearance
- Upper UTI features assessed and absent: no fever in past 48 hours, no loin pain, no rigors, no nausea/vomiting
- Pregnancy excluded
- Breastfeeding status
- Diabetes mellitus assessed and excluded
- Catheter use assessed and absent
- Vaginal discharge and STI assessed and absent
- Recent UTI antibiotic treatment in past 3 months: confirmed absent
- Recurrent UTI assessed (frequency of episodes in past 6 and 12 months)
- Renal function: eGFR or CKD status assessed
- Care home residence and recent hospitalisation assessed
- Nitrofurantoin formulation supplied, dose, frequency, duration, quantity, batch number, expiry date
- Counselling on OTC cystitis preparations, food/milk, urine colour, 48-hour review
- Safety netting provided
⚠ Common service pitfalls
- Treating a patient with diabetes. Both type 1 and type 2 diabetes mellitus are exclusion criteria under this PGD. Diabetes increases the risk of complicated UTI and altered urinary glucose can confound dipstick interpretation. Refer to GP.
- Treating a patient who uses a urinary catheter. Catheter-associated UTIs are managed differently from community-acquired lower UTIs and often require urine culture before treatment. Indwelling urethral, suprapubic, and intermittent self-catheterisation are all exclusions.
- Missing the recent antibiotic exclusion. Any UTI antibiotic treatment in the past 3 months is an exclusion. A patient who was recently treated for a UTI by their GP and has a second episode within 3 months needs GP referral for urine culture, not a second Pharmacy First supply.
- Not asking about vaginal discharge. Abnormal vaginal discharge as the presenting feature, or discharge alongside urinary symptoms, should prompt referral rather than treatment. Around 80% of such patients do not have a UTI.
- Treating a 65-year-old. The upper age limit is 64 years. Women aged 65 and over are excluded. UTI assessment and management in older women is more complex due to atypical presentations, greater risk of upper UTI, and higher baseline rates of asymptomatic bacteriuria.
- Supplying the wrong formulation. Nitrofurantoin 100mg modified release capsules twice daily for 3 days is first line. The 50mg immediate release formulation taken four times daily is second line only, for use when the modified release capsules are unavailable. Supplying the immediate release formulation without checking for modified release availability is a common dispensing error.
- Not warning about OTC cystitis preparations. Products containing potassium citrate, sodium bicarbonate, or sodium citrate (commonly sold as urinary alkalinisers) reduce the antibacterial activity of nitrofurantoin. Patients who have bought or are using these products should be advised to stop them during the course. This interaction is frequently missed.
- Missing the care home and hospitalisation exclusions. Care home residents and patients recently hospitalised in the UK for more than 7 days in the past 6 months, or abroad in the past 3 months, are at higher risk of resistant organisms and are excluded from this PGD.
- Not counselling on serious adverse effects. Nitrofurantoin can rarely cause pulmonary reactions, hepatotoxicity, and peripheral neuropathy. Patients should be advised to stop the medicine and seek urgent medical advice if they develop new breathing difficulties, jaundice, dark urine, or tingling in the limbs.
Key takeaways
- The pathway applies strictly to non-pregnant women aged 16 to 64. Exclude upper UTI by asking specifically about fever or chills in the past 48 hours, loin pain, rigors, and nausea or vomiting. Diabetes, catheter use, recent UTI antibiotic treatment, and care home residence are among the most commonly missed exclusions.
- Nitrofurantoin 100mg modified release capsules twice daily for 3 days is first line. Supply the 50mg immediate release formulation four times daily only if the modified release is unavailable.
- Advise patients specifically not to take OTC cystitis preparations (potassium citrate, sodium bicarbonate, sodium citrate) during the course, as these reduce the antibacterial action of nitrofurantoin. Urine discolouration is expected and harmless.
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Professional disclaimer: This article is for educational purposes
to support healthcare professionals' clinical decision-making. It does not replace
independent professional judgement, local pathways, NICE guidance, or standard
medical literature. Members of the public must not use this resource for
self-diagnosis and should seek prompt advice from a qualified healthcare
professional if experiencing chest pain, palpitations, fainting, or breathlessness.