What is the treatment for a woman with intercourse-associated urinary tract infections (UTIs)?

Treatment for Women with Intercourse-Associated UTIs

For women with intercourse-associated urinary tract infections (UTIs), postcoital antimicrobial prophylaxis is strongly recommended as the most effective treatment strategy when non-antimicrobial interventions have failed. 1

Diagnosis and Initial Management

• Confirm diagnosis of recurrent UTIs (defined as ≥3 UTIs per year or ≥2 UTIs in 6 months) via urine culture 1
• Obtain urine culture and antimicrobial susceptibility testing with each symptomatic episode before initiating treatment 1, 2
• For acute episodes, treat with first-line antibiotics based on local antibiogram patterns 1:
  • Nitrofurantoin 50-100 mg QID or 100 mg BID for 5 days 1, 2
  • Trimethoprim-sulfamethoxazole 160/800 mg BID for 3 days (if local resistance <20%) 1, 3
  • Fosfomycin trometamol 3 g single dose 1, 2
• Treat acute episodes with as short a duration of antibiotics as reasonable, generally no longer than 7 days 1, 2

Prevention Strategies for Intercourse-Associated UTIs

Non-Antimicrobial Interventions (First-Line)

• Increase fluid intake to reduce risk of recurrent UTI 1, 2
• Void after sexual intercourse 1, 4
• Avoid spermicides and harsh cleansers that disrupt normal vaginal flora 1, 4
• For postmenopausal women, use vaginal estrogen replacement 1

Antimicrobial Prophylaxis (When Non-Antimicrobial Measures Fail)

• Postcoital antimicrobial prophylaxis is highly effective for intercourse-associated UTIs 1, 5:
  • Trimethoprim-sulfamethoxazole 40/200 mg or 80/400 mg taken within 2 hours after intercourse 1, 5
  • Nitrofurantoin 50-100 mg taken within 2 hours after intercourse 1, 2
• Postcoital prophylaxis is effective regardless of intercourse frequency (low: ≤2 times/week or high: ≥3 times/week) 5
• Continue prophylaxis for 6-12 months, then reassess 1, 2

Alternative Approaches

• Self-administered short-term antimicrobial therapy for patients with good compliance 1, 4
• Consider methenamine hippurate for women without urinary tract abnormalities 1
• Consider immunoactive prophylaxis 1, 2

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria, which can increase antimicrobial resistance 1, 2
• Using fluoroquinolones as first-line agents due to safety concerns and resistance issues 2, 6
• Continuing antibiotics beyond recommended duration 1, 7
• Failing to obtain urine culture before initiating treatment in recurrent cases 1, 2
• Not considering local resistance patterns when selecting empiric therapy 1, 7

Monitoring and Follow-Up

• Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients 1
• For symptoms that don't resolve by end of treatment or recur within 2 weeks, perform urine culture and susceptibility testing 1
• For treatment failure, assume the organism is not susceptible to the original agent and retreat with a 7-day regimen using another agent 1