Pharmacy First: UTI in Women

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 (NHS England, 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. This article uses the term 'women' for brevity but this should be understood to include all eligible individuals within those definitions.

Diagnosis should follow the UKHSA diagnostic tool and Pharmacy First clinical pathway.¹² The three key diagnostic features are: new dysuria, new nocturia, and cloudy urine visible to the naked eye. Two or more of these three features makes lower UTI likely and supports empirical treatment under this PGD, provided all exclusion criteria are excluded. Frequency, urgency, visible haematuria, and suprapubic tenderness may support the diagnosis but are not the core diagnostic triad and should not replace it. Offensive-smelling urine was not identified as a reliable predictive feature in the key diagnostic study and should not be used as a main diagnostic criterion.

Where only one key diagnostic feature is present, or where urinary symptoms such as frequency, urgency, visible haematuria, or suprapubic tenderness are present without two of the triad, UKHSA recommends considering dipstick testing to increase diagnostic certainty. A result showing both nitrite positive and leucocyte positive increases the likelihood of UTI. Where dipstick testing is not possible or not conclusive and only one key feature is present, shared decision-making, self-care advice with safety-netting, or referral to GP should be considered depending on the patient's symptoms, risk, and preference. Do not supply nitrofurantoin empirically with fewer than two of the three key features unless dipstick supports the diagnosis.

The most important clinical distinction in this pathway remains lower UTI versus upper UTI (pyelonephritis). Lower UTI presents with the triad above 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. 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
• Signs or symptoms of lower UTI assessed using the UKHSA diagnostic tool: new dysuria, new nocturia, and/or cloudy urine visible to the naked eye. Two or more of these three features makes lower UTI likely. Frequency, urgency, visible haematuria, and suprapubic tenderness may support the diagnosis but should not replace the three key features.
• No nitrofurantoin use in the past 3 months
• Not currently pregnant
• Able to absorb oral medicines and swallow oral dosage forms (tablets or capsules)
• Informed consent obtained and documented
• 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: the majority 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
• Known hypersensitivity to nitrofurantoin or any component of the formulation: excluded
• Complicated UTI (structural or functional abnormality, under Urology care): refer to GP
• Inability to absorb oral medicines or inability to swallow oral dosage forms (tablets or capsules): excluded
• Oral typhoid vaccine received within the past 3 days, or due within the next 3 days: excluded
• 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 chronic kidney disease 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
• Informed consent refused: do not supply. Document reason.

How to deliver the service

1. Confirm the diagnosis using the UKHSA diagnostic triad and exclude upper UTI Apply the UKHSA diagnostic tool. Ask about the three key features: new dysuria, new nocturia, and cloudy urine visible to the naked eye.² Two or more of these features makes lower UTI likely and supports treatment under this PGD. One feature only: consider dipstick testing to increase diagnostic certainty. If both nitrites and leucocytes are positive, treatment may still be appropriate if all exclusions are excluded. If dipstick is negative or not available and only one feature is present, use shared decision-making: self-care with safety-netting, or referral to GP. Do not supply nitrofurantoin with zero features. Frequency, urgency, visible haematuria, and suprapubic tenderness may support the diagnosis but do not replace the triad. Do not use offensive-smelling urine as a diagnostic criterion. Also ask specifically about systemic features that would indicate upper UTI: fever or chills in the past 48 hours (even if now resolved), temperature 37.9 degrees Celsius or above currently, 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.
2. Confirm age, pregnancy, breastfeeding, and consent The PGD applies to individuals aged 16 to 64 only. Women aged 65 and over must be referred to GP. Confirm the patient is not pregnant (pregnancy is an absolute exclusion: refer urgently). Confirm the patient is not breastfeeding. Obtain and document informed consent to supply under this PGD.
3. Work through the exclusion list The UTI PGD has an unusually long exclusion list. Commonly missed exclusions in practice include: diabetes mellitus type 1 or type 2 (excluded entirely), catheter use of any type (refer to GP), vaginal discharge or suspected sexually transmitted infection (refer), any UTI antibiotic use in the past 3 months (excluded), recurrent UTI (2 or more in 6 months or 3 or more in 12 months: refer for urine culture), care home residence (refer), UK hospitalisation for more than 7 days in past 6 months (refer), known chronic kidney disease stages 3b to 5 (eGFR below 45: excluded). Also check: known hypersensitivity to nitrofurantoin or any formulation component (excluded), inability to absorb oral medicines or swallow capsules or tablets (excluded), and oral typhoid vaccine timing: excluded if oral typhoid vaccine received within the past 3 days or due within the next 3 days.
4. 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. Check excipients where relevant before supply (capsules contain lactose; some formulations contain sucrose, fructose, sorbitol, or aspartame). Advise specifically that OTC cystitis relief preparations containing potassium citrate, sodium bicarbonate, or sodium citrate reduce the antibacterial action of nitrofurantoin and must not be taken during the course. Antacids containing magnesium trisilicate decrease nitrofurantoin absorption. Oral typhoid vaccine must not be taken within 3 days either side of the nitrofurantoin course.
5. Counsel on side effects, safety-netting, and driving 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, symptoms worsen, or systemic features develop (fever, loin pain, rigors). If visible haematuria is present before or during treatment, advise the patient to seek medical attention if it continues after the course is completed. 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), and tingling or weakness in the limbs (peripheral neuropathy) all require the medicine to be stopped and urgent medical advice to be sought. Warn patients that nitrofurantoin can cause dizziness or drowsiness: do not drive or operate machinery if affected.

Assessment outcome: what to do

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.

Nitrofurantoin Doses (with food or milk, 3 days)

Modified release capsules are first line. Immediate release tablets are used only if modified release capsules are unavailable. Both are taken for 3 days.

Symptoms should start to improve within 48 hours. Urine may turn dark yellow or brown during treatment: this is expected and harmless. Check excipients where relevant (lactose, sucrose, fructose, sorbitol, and aspartame content for patients with phenylketonuria). OTC cystitis preparations containing potassium citrate, sodium bicarbonate, or sodium citrate reduce the antibacterial action of nitrofurantoin and must not be taken during the course. Antacids containing magnesium trisilicate also decrease nitrofurantoin absorption and should be avoided.

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)
  • Informed consent obtained and documented
  • Symptoms and duration: dysuria, new nocturia, urine appearance
  • UKHSA diagnostic triad assessed: number of key features present (0, 1, 2, or 3)
  • If 1 feature only: dipstick result recorded or shared decision-making documented
  • Upper UTI features assessed and absent: no fever in past 48 hours, no loin pain, no rigors, no nausea or vomiting
  • Pregnancy excluded
  • Breastfeeding status
  • Diabetes mellitus assessed and excluded
  • Catheter use assessed and absent
  • Vaginal discharge and sexually transmitted infection assessed and absent
  • Known hypersensitivity to nitrofurantoin or formulation components: confirmed absent
  • Ability to absorb oral medicines and swallow capsules or tablets: confirmed
  • Oral typhoid vaccine timing checked: not within 3 days either side of course
  • 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 chronic kidney disease status assessed
  • Care home residence and recent hospitalisation assessed
  • Excipient check completed where relevant (lactose, sorbitol, aspartame)
  • Nitrofurantoin formulation supplied, dose, frequency, duration, quantity, batch number, expiry date
  • Counselling on OTC cystitis preparations, food or milk, urine colour, haematuria, driving, and 48-hour review
  • Safety-netting provided

Key takeaways

• Use the UKHSA diagnostic triad: new dysuria, new nocturia, and cloudy urine visible to the naked eye. Two or more of these three features makes lower UTI likely and supports treatment under this PGD. With only one feature, consider dipstick testing before supplying. Exclude upper UTI by asking specifically about fever or chills in the past 48 hours, loin pain, rigors, and nausea or vomiting.
• The pathway applies strictly to eligible non-pregnant individuals aged 16 to 64 within the PGD population who give informed consent. Commonly missed exclusions include: diabetes (both types), catheter use, known hypersensitivity to nitrofurantoin, inability to swallow oral dosage forms, recent UTI antibiotic treatment, recurrent UTI, care home residence, and eGFR below 45.
• Nitrofurantoin 100mg modified release capsules twice daily for 3 days is first line. Advise patients not to take OTC cystitis preparations during the course, warn about urine discolouration (harmless), and advise seeking medical attention if visible haematuria persists after treatment or systemic features develop.

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