What treatment can be given to a patient who experiences recurrent Urinary Tract Infections (UTIs) after sexual intercourse?

Management of Post-Coital Recurrent UTIs in Women

For a woman experiencing recurrent UTIs after sexual intercourse, post-coital antibiotic prophylaxis is the most effective treatment option. 1, 2

Diagnosis Confirmation

• Confirm diagnosis of recurrent UTIs, defined as >2 culture-positive UTIs in 6 months or >3 in one year 1
• Ensure proper urine culture is obtained during symptomatic episodes to guide treatment 1

First-Line Treatment: Post-Coital Antibiotic Prophylaxis

• Post-coital antibiotic prophylaxis is specifically indicated for women with UTIs temporally related to sexual activity 1, 2
• Administer a single dose of antibiotic within 2 hours after sexual intercourse 1
• Recommended antibiotics for post-coital prophylaxis:
  • Trimethoprim-sulfamethoxazole 40/200 mg (single tablet) 1, 2
  • Trimethoprim 100 mg 1
  • Nitrofurantoin 50-100 mg 1

Duration of Treatment

• Initial prophylaxis should be continued for 6-12 months 1
• Reassess after this period; some women may require longer prophylaxis to maintain benefit 1

Antibiotic Selection Considerations

• Choose antibiotics based on previous urine culture results and susceptibility patterns 1, 3
• Avoid fluoroquinolones as first-line agents due to unfavorable risk-benefit ratio 1
• Nitrofurantoin and trimethoprim-sulfamethoxazole are preferred over fluoroquinolones or cephalosporins for antibiotic stewardship 1

Behavioral and Lifestyle Modifications

• These should be implemented alongside antibiotic prophylaxis:
  • Voiding immediately after sexual intercourse 1
  • Maintaining adequate hydration 1
  • Avoiding spermicides and harsh cleansers that disrupt vaginal flora 1
  • Avoiding prolonged urine retention 1
  • Avoiding sequential anal and vaginal intercourse 1

Non-Antibiotic Alternatives

For patients who prefer non-antibiotic options or have contraindications to antibiotics:

• Methenamine hippurate can be considered as an alternative 1
• Cranberry products (containing proanthocyanidins) may provide modest benefit in reducing recurrence rates 1, 4
• For postmenopausal women, vaginal estrogen therapy should be considered 1

Monitoring and Follow-up

• Reassess effectiveness after 6-12 months of prophylaxis 1
• Monitor for adverse effects of antibiotics, including gastrointestinal symptoms and yeast infections 1, 5
• Consider rotating antibiotics every 3 months if long-term prophylaxis is needed to reduce risk of resistance 1

Special Considerations

• Post-coital prophylaxis has been shown to be as effective as daily prophylaxis with significantly lower antibiotic exposure 5, 4
• The infection rate can be reduced from approximately 3.6 infections per patient-year to 0.3 per patient-year with post-coital prophylaxis 2
• Compliance is typically excellent with post-coital regimens compared to daily prophylaxis 2

Common Pitfalls to Avoid

• Treating without confirming diagnosis with urine culture 1
• Using fluoroquinolones as first-line agents despite FDA warnings 1
• Treating asymptomatic bacteriuria, which may increase risk of symptomatic infection and bacterial resistance 1
• Prolonged antibiotic courses (>5 days) for acute UTI episodes, which can disrupt normal vaginal flora 1