What are the treatment options for recurrent Urinary Tract Infections (UTIs)?

Treatment Options for Recurrent Urinary Tract Infections

For recurrent UTIs, a stepwise approach beginning with non-antimicrobial interventions followed by prophylactic antimicrobials when necessary is strongly recommended, with treatment choices tailored based on culture results and local resistance patterns. 1

Diagnosis and Initial Assessment

• Recurrent UTIs are defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 1
• Diagnosis requires documented positive urine cultures with symptomatic episodes 1
• Obtain urine culture and sensitivity with each symptomatic episode before initiating treatment 1
• For women <40 years without risk factors, extensive workup (cystoscopy, ultrasound) is not recommended 1

Acute Episode Treatment

First-Line Antimicrobial Options:

• Nitrofurantoin 100 mg twice daily for 5 days
• Fosfomycin trometamol 3 g single dose
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance <20%)
• Pivmecillinam 400 mg three times daily for 3-5 days 1

Key Treatment Principles:

• Use shortest effective duration of antibiotics, generally ≤7 days 1
• For treatment failure, assume the organism is not susceptible to the original agent
• Retreatment should use a different agent for a 7-day course 1
• For resistant organisms, culture-directed parenteral antibiotics may be necessary 1

Prevention Strategies (in recommended order)

Non-Antimicrobial Measures:

1. For All Women:

   • Increased fluid intake (reduces rUTI risk in premenopausal women) 1
   • Immunoactive prophylaxis (strong recommendation) 1
   • Methenamine hippurate (strong recommendation for women without urinary tract abnormalities) 1

2. For Postmenopausal Women:

   • Vaginal estrogen replacement (strong recommendation) 1

3. Additional Options (Weaker Evidence):

   • Probiotics with proven efficacy for vaginal flora regeneration 1
   • Cranberry products (evidence is contradictory) 1
   • D-mannose (evidence is weak and contradictory) 1
   • Hyaluronic acid/chondroitin sulfate endovesical instillations (for patients who failed other approaches) 1

Antimicrobial Prophylaxis:

• Implement only when non-antimicrobial interventions have failed 1

• Options include:

  1. Continuous low-dose prophylaxis for 6-12 months
  2. Post-coital prophylaxis for infections related to sexual activity 1
  3. Self-administered short-term therapy for patients with good compliance 1

• Preferred agents: nitrofurantoin 50 mg, trimethoprim-sulfamethoxazole 40/200 mg, or trimethoprim 100 mg 1

• Avoid fluoroquinolones and cephalosporins for prophylaxis when possible 1

• Consider rotating antibiotics every 3 months to reduce resistance development 1

Special Considerations

Patient-Initiated Treatment

• Self-start treatment can be offered to reliable patients who can obtain urine specimens before starting therapy 1

Asymptomatic Bacteriuria

• Do not perform surveillance urine testing in asymptomatic patients 1
• Do not treat asymptomatic bacteriuria as this increases antimicrobial resistance and rUTI episodes 1

Antibiotic Stewardship

• Choose antibiotics based on prior culture results, local resistance patterns, and antibiotic stewardship principles 1
• Nitrofurantoin is preferred for retreatment as resistance is low and decays quickly 1
• Avoid classifying patients with rUTI as "complicated" as this often leads to unnecessary use of broad-spectrum antibiotics 1

Pitfalls to Avoid

• Using fluoroquinolones as first-line therapy (reserve for more invasive infections) 2
• Treating without obtaining cultures
• Prescribing prolonged antibiotic courses (>7 days) for acute episodes
• Treating asymptomatic bacteriuria
• Using broad-spectrum antibiotics when narrow-spectrum options are effective
• Neglecting non-antimicrobial preventive strategies before resorting to antibiotic prophylaxis

By following this evidence-based approach, clinicians can effectively manage recurrent UTIs while minimizing antibiotic resistance and optimizing patient outcomes.