What is the management approach for a patient with recurrent Urinary Tract Infections (UTIs)?

Management of Recurrent Urinary Tract Infections (rUTIs)

For patients with recurrent UTIs, implement a stepwise approach starting with non-antimicrobial interventions before considering antimicrobial prophylaxis, as this strategy reduces morbidity, mortality, and improves quality of life while minimizing antimicrobial resistance. 1

Diagnosis and Definition

• Recurrent UTI is defined as ≥3 UTIs in 12 months or ≥2 UTIs in 6 months 1, 2
• Document positive urine cultures with each symptomatic episode before initiating treatment 1, 2
• Obtain repeat urine studies when contamination is suspected, considering catheterized specimens 1
• Routine cystoscopy and upper tract imaging are not recommended for uncomplicated rUTI in women <40 years without risk factors 1

Non-Antimicrobial Interventions (First-Line)

Lifestyle Modifications

• Increase fluid intake to reduce risk of recurrent UTIs 1, 3
• Encourage urge-initiated voiding and post-coital voiding 1, 3
• Avoid spermicide-containing contraceptives 1

Pharmacological Non-Antimicrobial Options

• For postmenopausal women: Use vaginal estrogen replacement (strong recommendation) 1, 3
• Use immunoactive prophylaxis to reduce recurrent UTIs (strong recommendation) 1, 3
• Use methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1, 3
• Consider cranberry products, though evidence is contradictory and of low quality 1, 3
• Consider D-mannose supplementation, though evidence is weak 1, 3
• Consider probiotics containing strains effective for vaginal flora regeneration 1
• For patients with unsuccessful less invasive approaches: Consider endovesical instillations of hyaluronic acid or combination with chondroitin sulfate 1, 3

Antimicrobial Management (When Non-Antimicrobial Measures Fail)

Acute Episode Treatment

• Use first-line antibiotics based on local antibiogram 1:
  • Fosfomycin trometamol: 3g single dose
  • Nitrofurantoin: 50-100mg four times daily for 5 days
  • Trimethoprim-sulfamethoxazole: 160/800mg twice daily for 3 days (avoid in last trimester of pregnancy)
• Treat for as short a duration as reasonable, generally no longer than 7 days 1
• Obtain urine culture before initiating antibiotics 1, 2

Antimicrobial Prophylaxis

• Implement continuous or postcoital antimicrobial prophylaxis when non-antimicrobial interventions have failed (strong recommendation) 1, 3
• For patients with good compliance, consider self-administered short-term antimicrobial therapy at symptom onset 1
• Base selection on previous culture results and local resistance patterns 4
• Common prophylactic options include nitrofurantoin (50-100mg daily) or trimethoprim-sulfamethoxazole at reduced doses 5

Special Considerations

Distinguishing Recurrence vs. Relapse

• Recurrence: New infection with different organism or same organism >2 weeks after treatment 2
• Relapse: Same organism within 2 weeks of completing treatment (suggests bacterial persistence) 2
• Relapse UTIs may require imaging to identify structural abnormalities 1, 2

Risk Factors for Recurrent UTIs

• Premenopausal women: Sexual activity, diaphragm/spermicide use 1
• Postmenopausal women: Atrophic vaginitis, urinary incontinence, cystocele, high postvoid residual 1
• General: Diabetes mellitus, chronic renal disease, immunosuppression, urinary catheterization, immobilization, neurogenic bladder 5

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria, which increases antimicrobial resistance 3, 2
• Using broad-spectrum antibiotics when narrower options are available 3, 6
• Failing to obtain cultures before initiating treatment in recurrent cases 1, 2
• Not considering structural abnormalities in patients with relapsing infections 2
• Continuing antibiotics beyond recommended duration 3
• Not recognizing increasing resistance patterns to first-line agents (e.g., 38% E. coli resistance to TMP-SMX, 28% to ciprofloxacin) 4

Monitoring and Follow-up

• Obtain periodic urine cultures during symptomatic episodes to guide antimicrobial selection 3
• Consider using prior culture results to guide empiric therapy, as they have good predictive value for future susceptibility (78-90% for common antibiotics) 4