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

Treatment Parameters for Recurrent Urinary Tract Infections (rUTIs)

Recurrent UTIs should be managed with a stepwise approach starting with non-antimicrobial interventions before progressing to antimicrobial prophylaxis, with treatment decisions guided by urine culture results and local antibiogram patterns. 1

Definition and Diagnosis

• rUTIs are defined as at least three UTIs per year or two UTIs in the last 6 months 1, 2
• Diagnose recurrent UTI via urine culture (strong recommendation) 1
• Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment 1, 2
• Do not perform surveillance urine testing in asymptomatic patients with rUTIs 1

Risk Factors to Assess

• Sexual activity (post-coital cystitis accounts for 60% of recurrent cases) 3
• Use of spermicides 4
• Vaginal atrophy in postmenopausal women 1
• History of UTIs before menopause or during childhood 1, 4
• Inadequate fluid intake 1, 4
• Delayed urination habits 4
• Functional or anatomical abnormalities of the urinary tract 5

Treatment of Acute Episodes

• Use first-line antimicrobials based on local antibiogram patterns: 1, 2
  • Nitrofurantoin 50-100 mg QID or 100 mg BID for 5 days 1
  • Fosfomycin trometamol 3 g single dose 1
  • Trimethoprim-sulfamethoxazole 160/800 mg BID for 3 days (not in first or last trimester of pregnancy) 1, 6
  • Pivmecillinam 400 mg TID for 3-5 days 1
• Treat acute episodes with as short a duration of antibiotics as reasonable, generally no longer than 7 days 1
• For patients with good compliance, self-administered short-term antimicrobial therapy can be considered 1

Prevention Strategies (Non-antimicrobial)

• Increase fluid intake in premenopausal women (weak recommendation) 1, 2
• Use vaginal estrogen replacement in postmenopausal women (strong recommendation) 1, 2
• Use immunoactive prophylaxis to reduce recurrent UTI in all age groups (strong recommendation) 1, 2
• Use methenamine hippurate to reduce recurrent UTI episodes in women without abnormalities of the urinary tract (strong recommendation) 1, 2
• Consider probiotics containing strains with proven efficacy for vaginal flora regeneration (weak recommendation) 1, 2
• Cranberry products may be used, though evidence is low quality with contradictory findings (weak recommendation) 1, 2
• D-mannose may be used, though evidence is weak and contradictory (weak recommendation) 1, 2

Antimicrobial Prophylaxis

• Use continuous or post-coital antimicrobial prophylaxis when non-antimicrobial interventions have failed (strong recommendation) 1, 2
• For post-coital prophylaxis in premenopausal women with infections related to sexual activity, use low-dose antibiotics 1, 5
• For continuous prophylaxis in premenopausal women with infections unrelated to sexual activity, use low-dose daily antibiotics 1, 5
• Counsel patients regarding possible side effects of long-term antibiotic use 1, 7

Special Considerations

• Do not treat asymptomatic bacteriuria in patients with rUTI as this fosters antimicrobial resistance and increases rUTI episodes 1
• Avoid classifying patients with rUTI as "complicated" as this often leads to unnecessary use of broad-spectrum antibiotics 1
• For patients with persistent symptoms despite treatment, repeat urine culture before prescribing additional antibiotics 1
• Consider endovesical instillations of hyaluronic acid or combination of hyaluronic acid and chondroitin sulfate for patients where less invasive approaches have failed (weak recommendation) 1, 5

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria 1
• Using broad-spectrum antibiotics when narrower options are available 1, 7
• Continuing antibiotics beyond recommended duration 1, 7
• Failing to obtain urine culture before initiating treatment in recurrent cases 1, 2
• Not considering non-antimicrobial options before antimicrobial prophylaxis 1