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

Treatment Options for Recurrent Urinary Tract Infections

The most effective treatment approach for recurrent UTIs includes both non-antimicrobial interventions as first-line options and antimicrobial prophylaxis when necessary, with treatment decisions guided by urine culture results and patient-specific factors. 1

Definition and Impact

• Recurrent UTIs (rUTIs) are defined as at least three UTIs per year or two UTIs in the last 6 months, including both lower tract (cystitis) and upper tract (pyelonephritis) infections 1
• rUTIs significantly impact quality of life, affecting social and sexual relationships, self-esteem, and work capacity 1

Diagnostic Approach

• Diagnose recurrent UTI via urine culture (strong recommendation) 1
• Obtain urine culture and antimicrobial susceptibility testing for each symptomatic episode prior to initiating treatment 1
• Extensive workup (cystoscopy, abdominal ultrasound) is not recommended for women under 40 years without risk factors 1

Treatment Algorithm for Acute Episodes

First-Line Antimicrobial Options for Acute Episodes

• Use first-line therapy based on local antibiogram patterns 1:
  • Nitrofurantoin (50-100 mg QID or 100 mg BID for 5 days)
  • Trimethoprim-sulfamethoxazole (160/800 mg BID for 3 days)
  • Fosfomycin trometamol (3 g single dose)

Duration and Approach for Acute Episodes

• Treat acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than 7 days 1
• For symptoms that don't resolve by the end of treatment or recur within 2 weeks, perform urine culture and susceptibility testing 1
• For retreatment, assume the infecting organism is not susceptible to the original agent and use a different antibiotic for a 7-day regimen 1
• For cultures showing resistance to oral antibiotics, consider culture-directed parenteral antibiotics for as short a course as reasonable (≤7 days) 1

Prevention Strategies (in Recommended Order)

1. Non-Antimicrobial Preventive Measures

• For premenopausal women:

  • Increase fluid intake to reduce risk of recurrent UTI (weak recommendation) 1
  • Use immunoactive prophylaxis (strong recommendation) 1

• For postmenopausal women:

  • Use vaginal estrogen replacement (strong recommendation) 1

• For all patients, consider:

  • Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1
  • Probiotics with strains proven effective for vaginal flora regeneration (weak recommendation) 1
  • Cranberry products, though evidence is low quality with contradictory findings (weak recommendation) 1
  • D-mannose, though evidence is weak and contradictory (weak recommendation) 1
  • For patients where less invasive approaches have failed, consider endovesical instillations of hyaluronic acid or combination of hyaluronic acid and chondroitin sulfate (weak recommendation) 1

2. Antimicrobial Prophylaxis (When Non-Antimicrobial Interventions Fail)

• Continuous or post-coital antimicrobial prophylaxis (strong recommendation) 1

  • Options include nitrofurantoin 50 mg, trimethoprim-sulfamethoxazole 40/200 mg, or trimethoprim 100 mg 1
  • Duration typically ranges from 6-12 months 1
  • Prefer these agents over fluoroquinolones and cephalosporins 1
  • Consider rotating antibiotics at 3-month intervals to avoid resistance 1

• Self-administered short-term antimicrobial therapy for patients with good compliance (strong recommendation) 1

  • Patient obtains urine specimen before starting therapy and communicates with provider 1

Special Considerations

• Do not perform surveillance urine testing or treat asymptomatic bacteriuria in patients with rUTI 1
• Avoid classifying patients with rUTI as "complicated" as this often leads to unnecessary use of broad-spectrum antibiotics 1
• Adverse events: All antibiotics carry risks that should be discussed with patients 1
  • Nitrofurantoin: Potential pulmonary and hepatic toxicity (though rates are extremely low at 0.001% and 0.0003% respectively) 1
  • Common adverse effects include gastrointestinal disturbances and skin rash 1

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria, which fosters antimicrobial resistance and increases rUTI episodes 1
• Using broad-spectrum antibiotics when narrower options are available 1
• Continuing antibiotics beyond recommended duration 1
• Failing to obtain urine culture before initiating treatment in recurrent cases 1
• Not considering non-antimicrobial options before antimicrobial prophylaxis 1