What are the management options for recurrent urinary tract infections (UTIs)?

Management of Recurrent Urinary Tract Infections

For recurrent urinary tract infections (defined as ≥2 culture-positive UTIs in 6 months or ≥3 in one year), a stepped approach beginning with non-antibiotic strategies should be implemented first, followed by antibiotic prophylaxis only when non-antimicrobial measures have failed. 1

Diagnosis and Definition

• Recurrent UTIs are defined as ≥2 culture-positive UTIs in 6 months or ≥3 in one year 1
• Diagnosis requires documentation of positive urine cultures associated with prior symptomatic episodes 1
• Obtain urine culture with each symptomatic episode prior to initiating treatment 1

Non-Antibiotic Prevention Strategies (First-Line)

Behavioral and Lifestyle Modifications

• Increase fluid intake to reduce risk of recurrent UTI 1
• Void after intercourse to flush bacteria from the urethra 1
• Avoid prolonged holding of urine 1
• Avoid disruption of normal vaginal flora with harsh cleansers or spermicides 1

Evidence-Based Non-Antibiotic Options

• Methenamine hippurate (1g twice daily) is strongly recommended as first-line non-antibiotic prophylaxis for women without urinary tract abnormalities 1, 2
• For postmenopausal women, vaginal estrogen replacement is strongly recommended 1, 2
• Immunoactive prophylaxis can reduce recurrent UTI episodes 1
• D-mannose (2g daily) may be considered, though evidence is weaker than for methenamine hippurate 2
• Cranberry products may reduce recurrent UTI episodes, though evidence is contradictory 1
• Probiotics containing strains with proven efficacy for vaginal flora regeneration may help prevent UTIs 1

Antibiotic Management Strategies (Second-Line)

For Acute Episodes

• Obtain urine culture before starting antibiotics for each episode 1
• Use prior culture data to guide antibiotic selection 1
• First-line options for uncomplicated cystitis:
  • Nitrofurantoin 100 mg twice daily for 5 days 1
  • Fosfomycin trometamol 3 g single dose 1
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance <20%) 1, 3

Antibiotic Prophylaxis (When Non-Antibiotic Measures Fail)

• For premenopausal women with infections related to sexual activity, consider low-dose post-coital antibiotics 1
• For premenopausal women with infections unrelated to sexual activity, consider low-dose daily antibiotic prophylaxis 1
• Continuous antibiotic prophylaxis for 6-12 months can reduce UTI recurrence by about 90% 4, 5
• Consider rotating antibiotics at 3-month intervals to avoid selection of antimicrobial resistance 1
• Postcoital antibiotic prophylaxis is as effective as daily prophylaxis for women whose UTIs are associated with sexual intercourse 6

Special Considerations

• Avoid classifying patients with recurrent UTIs as "complicated" as this leads to unnecessary use of broad-spectrum antibiotics 1
• Avoid treatment of asymptomatic bacteriuria as this increases antimicrobial resistance and recurrent UTI episodes 1
• If symptoms persist despite treatment, repeat urine culture before prescribing additional antibiotics 1
• Risk factors for recurrent UTI include diabetes mellitus, chronic renal disease, immunosuppression, renal transplant, urinary catheterization, immobilization, and neurogenic bladder 5, 7
• For patients with refractory recurrent UTIs, consider endovesical instillations of hyaluronic acid or combination of hyaluronic acid and chondroitin sulfate 1

Monitoring and Follow-up

• Document response to treatment and prophylactic strategies 1
• Reassess if symptoms persist or worsen despite appropriate therapy 1
• Monitor for efficacy of non-antibiotic prophylaxis by tracking UTI frequency 2
• Consider switching to options with stronger evidence if initial approaches are ineffective 2