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

Treatment for Recurrent Urinary Tract Infections

For women with recurrent UTIs, the most effective treatment approach includes non-antimicrobial interventions as first-line therapy, followed by antimicrobial prophylaxis only when non-antimicrobial measures have failed. 1

Diagnosis and Definition

• Recurrent UTIs are defined as at least three UTI episodes within the preceding 12 months or two UTIs in the last 6 months 1
• Diagnosis requires confirmation via urine culture 1
• Most recurrent UTIs (approximately 75%) are caused by Escherichia coli 1

Treatment Algorithm

Step 1: Non-Antimicrobial Preventive Measures

1. Lifestyle modifications:

   • Increased fluid intake (reduces risk of recurrence) 1
   • Urination after sexual intercourse 1
   • Avoidance of spermicide-containing contraceptives 1

2. For postmenopausal women:

   • Vaginal estrogen replacement therapy (strong recommendation) 1

3. Other non-antimicrobial options:

   • Immunoactive prophylaxis (strong recommendation) 1
   • Methenamine hippurate (strong recommendation) 1
   • Cranberry products (weak recommendation due to contradictory evidence) 1
   • D-mannose (weak recommendation) 1
   • Probiotics containing Lactobacillus strains for vaginal flora regeneration (weak recommendation) 1
   • Hyaluronic acid or combination with chondroitin sulfate endovesical instillations for patients where other approaches have failed (weak recommendation) 1

Step 2: Antimicrobial Prophylaxis (when non-antimicrobial interventions fail)

1. Continuous prophylaxis options:

   • Trimethoprim-sulfamethoxazole: 160/800 mg (one tablet) daily 2
   • Nitrofurantoin: 50-100 mg daily 3
   • Cephalexin: 250 mg daily 1
   • Fosfomycin: 3g every 10 days 4, 5

2. Post-coital prophylaxis (single dose taken after intercourse) 1

   • Same antibiotics as continuous prophylaxis but taken only after sexual activity

3. Self-administered short-term therapy (for patients with good compliance) 1

   • Patient-initiated treatment at first signs of UTI
   • Requires proper patient education and reliable follow-up

Special Considerations

Antibiotic Selection

• Base selection on local resistance patterns and previous culture results 4, 5
• E. coli resistance rates to commonly used antibiotics:
  • Fosfomycin: 4.5% resistance (95.5% susceptibility) 4
  • Nitrofurantoin: 14.5% resistance (85.5% susceptibility) 4
  • Trimethoprim-sulfamethoxazole: 46.6% resistance 4
  • Fluoroquinolones: 39.9% resistance 4

Treatment Duration

• Prophylactic antibiotics: typically prescribed for 6-12 months 1
• Acute treatment of UTI episodes:
  • 3-5 days for uncomplicated cystitis 1
  • 7 days for complicated UTIs 2

Pitfalls and Caveats

• Do not perform extensive workup (cystoscopy, full abdominal ultrasound) in women younger than 40 years with no risk factors 1
• Avoid fluoroquinolones as first-line empiric therapy due to high resistance rates and risk of adverse effects 4, 5
• Consider urological evaluation for patients with multiple recurrences despite appropriate prophylaxis 6
• Monitor for antibiotic resistance development with long-term prophylaxis 3, 7
• Ensure complete eradication of previous UTI (confirmed by negative urine culture) before starting prophylaxis 1

Emerging Evidence

Recent studies suggest fosfomycin, nitrofurantoin, and cefuroxime may be better first-choice options for treatment of acute episodes due to lower resistance rates compared to traditional first-line agents like trimethoprim-sulfamethoxazole and fluoroquinolones 4, 5.

Continuous antibiotic prophylaxis has been shown to significantly reduce UTI episodes, emergency room visits, and hospital admissions in patients with recurrent UTIs, yet it is underutilized, being prescribed in only about 55% of eligible patients 3.