What advice should be given to a 45-year-old woman with recurrent acute bacterial Urinary Tract Infections (UTIs) typically after vaginal intercourse?

Management of Recurrent UTIs in Women with Post-Coital Infections

For a 45-year-old woman with recurrent bacterial UTIs typically occurring after vaginal intercourse, post-coital low-dose antibiotic prophylaxis should be initiated within 2 hours of sexual activity for 6-12 months.1, 2

Diagnostic Confirmation and Initial Assessment

• Recurrent UTIs are defined as ≥2 culture-positive UTIs in 6 months or ≥3 in one year 1, 2
• A thorough history and physical exam should assess for complicating factors that may warrant additional testing 1
• Confirm eradication of previous UTI with a negative urine culture 1-2 weeks after treatment before starting any prophylactic regimen 1

Behavioral and Lifestyle Modifications (First-Line)

• Maintain adequate hydration to promote frequent urination 1
• Void immediately after sexual intercourse 1
• Avoid prolonged holding of urine 1
• Avoid sequential anal and vaginal intercourse 1
• Avoid spermicide-containing contraceptives and consider alternative contraception methods 1, 3
• Avoid disruption of normal vaginal flora with harsh cleansers 1
• Control blood glucose if diabetic 1

Post-Coital Antibiotic Prophylaxis

• For women with UTIs clearly linked to sexual activity, post-coital antibiotic prophylaxis is highly effective 1, 2
• Take a single dose of antibiotic within 2 hours after sexual intercourse 1, 2
• Recommended antibiotics include:
  • Nitrofurantoin 50 mg 1, 2
  • Trimethoprim-sulfamethoxazole 40/200 mg 1, 2
  • Trimethoprim 100 mg 1, 2
• Duration of prophylaxis should be 6-12 months 1, 2
• Antibiotic choice should be based on previous culture results, susceptibility patterns, and patient allergies 1

Alternative Non-Antibiotic Options

• If patient prefers non-antibiotic alternatives or has contraindications to antibiotics, consider:
  • Methenamine hippurate 1
  • Lactobacillus-containing probiotics 1
• Cranberry products have limited evidence for efficacy in preventing recurrent UTIs 1

Monitoring and Follow-Up

• Urine culture should be obtained with each symptomatic episode before initiating treatment 2
• Do not repeat urine cultures after successful treatment if symptoms have resolved 2
• If prophylaxis fails, consider rotating antibiotics every 3 months to reduce development of resistance 1

Important Caveats

• Avoid treating asymptomatic bacteriuria as this promotes antimicrobial resistance 2
• Fluoroquinolones and cephalosporins should be restricted to specific indications due to concerns about resistance 1, 2
• Extensive workup (cystoscopy, imaging) is not routinely recommended unless specific risk factors are present 2
• If UTIs persist despite prophylaxis, reassess for anatomical abnormalities or other complicating factors 1
• Continuous daily antibiotic prophylaxis may be considered if post-coital prophylaxis is ineffective 1, 4

Special Considerations

• If the patient is approaching menopause, consider that vaginal estrogen therapy may be beneficial in the future for postmenopausal women with recurrent UTIs 1, 3
• The risk of developing antibiotic resistance must be balanced against the morbidity of recurrent infections 5, 4