What are the treatment options for recurrent urinary tract infections (UTIs) in women?

Treatment Options for Recurrent Urinary Tract Infections in Women

For women with recurrent urinary tract infections (defined as ≥3 UTIs/year or 2 UTIs in the last 6 months), a combination of non-antimicrobial interventions should be tried first, with antimicrobial prophylaxis reserved for cases where these interventions fail. 1, 2

Diagnosis and Initial Assessment

• Confirm recurrent UTI with urine culture for each symptomatic episode before initiating treatment
• Document frequency of UTIs, antimicrobial usage history, and cultured microorganisms
• Assess for risk factors:
  • Diabetes mellitus
  • Chronic renal disease
  • Immunosuppression
  • Urinary catheterization
  • Immobilization
  • Neurogenic bladder
  • Postmenopausal status with vaginal atrophy

Treatment Algorithm for Acute UTI Episodes

1. First-line antibiotics for acute symptomatic episodes 1, 2:

   • Nitrofurantoin 100mg twice daily for 5 days
   • Fosfomycin trometamol 3g single dose
   • Pivmecillinam 400mg three times daily for 3-5 days

2. Alternative options (based on local resistance patterns):

   • Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days)
   • Trimethoprim 200mg twice daily for 5 days
   • Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days

3. Treatment duration:

   • Keep antibiotic courses as short as reasonable, generally no longer than 7 days 1
   • Single-dose therapy (except for fosfomycin) is not recommended due to lower cure rates

Non-Antimicrobial Prevention Strategies

1. Behavioral modifications:

   • Increased fluid intake (strong evidence for prevention) 1, 2
   • Post-coital voiding
   • Urge-initiated voiding

2. For postmenopausal women:

   • Vaginal estrogen replacement therapy (strong recommendation) 1, 2

3. Other non-antimicrobial options (in order of evidence strength):

   • Methenamine hippurate 1g twice daily (strong recommendation) 1, 2
   • Immunoactive prophylaxis (strong recommendation) 1
   • Probiotics containing strains with proven efficacy for vaginal flora regeneration (weak recommendation) 1
   • Cranberry products (weak recommendation with contradictory evidence) 1, 2
   • D-mannose (weak recommendation with contradictory evidence) 1
   • Endovesical instillations of hyaluronic acid or combination with chondroitin sulfate (weak recommendation) 1

Antimicrobial Prophylaxis

When non-antimicrobial interventions fail, consider antimicrobial prophylaxis 1, 2:

1. Continuous daily prophylaxis (6-12 months):

   • Nitrofurantoin (most common)
   • Trimethoprim-sulfamethoxazole
   • Cephalexin

2. Post-coital prophylaxis (for UTIs related to sexual activity):

   • Single dose within 2 hours of intercourse

3. Self-initiated treatment (for patients with good compliance):

   • Patient starts short course of antibiotics at first sign of UTI symptoms
   • Should submit urine culture before starting antibiotics

Important Considerations and Pitfalls

• Do not test or treat asymptomatic bacteriuria in non-pregnant women 1, 2
• Do not perform extensive workup (cystoscopy, abdominal ultrasound) in women <40 years with no risk factors 1
• Avoid surveillance urine testing in asymptomatic patients 1
• Beware of antibiotic resistance development with long-term prophylaxis
• Monitor for adverse effects of antibiotics:
  • Nitrofurantoin: rare but serious pulmonary/hepatic toxicity (0.001% and 0.0003% respectively) 1
  • Common side effects: gastrointestinal disturbances and skin rash 1

Special Populations

• For complicated UTIs (structural/functional abnormalities):

  • More extensive imaging (CT urography recommended)
  • Longer treatment courses
  • Consider urological referral

• For pregnant women:

  • Screen and treat asymptomatic bacteriuria to prevent progression to pyelonephritis
  • Periodic screening throughout pregnancy due to high recurrence risk

By implementing this comprehensive approach to recurrent UTIs in women, clinicians can effectively manage acute episodes while reducing the frequency of recurrences and minimizing antibiotic use.