What is the best treatment and prevention strategy for recurrent Urinary Tract Infections (UTIs)?

Best Treatment and Prevention Strategies for Recurrent UTIs

Methenamine hippurate is strongly recommended as the first-line non-antibiotic prevention strategy for recurrent UTIs in women without urinary tract abnormalities. 1, 2, 3

Definition and Diagnosis

• 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
• Always obtain urine culture with each symptomatic episode prior to initiating treatment 1, 2

Prevention Strategies (Non-Antibiotic)

First-Line Options

• Methenamine hippurate (1g twice daily) has strong evidence supporting its efficacy and non-inferiority to antibiotic prophylaxis 2, 3
• For postmenopausal women, vaginal estrogen replacement is strongly recommended (contraindicated in women with breast cancer taking aromatase inhibitors) 1, 2
• Immunoactive prophylaxis is recommended to reduce recurrent UTI episodes 1, 2

Second-Line Options

• D-mannose (2g daily) can be used to reduce recurrent UTI episodes, though evidence is considered weak 1, 3
• Cranberry products may help reduce recurrent UTI episodes when used at sufficient doses (minimum 36 mg/day proanthrocyanindin A), though evidence is contradictory 2, 3
• Probiotics containing strains with proven efficacy for vaginal flora regeneration may help prevent UTIs 1, 2

Behavioral and Lifestyle Modifications

• Increase fluid intake throughout the day 1, 2
• Void after intercourse 1, 2
• Avoid prolonged holding of urine 1, 2
• Avoid disruption of normal vaginal flora with harsh cleansers or spermicides 1, 2
• Avoid sequential anal and vaginal intercourse 2

Antibiotic Management Strategies

Acute Treatment

• Obtain urine culture before starting antibiotics for each episode 1, 2
• First-line options for uncomplicated cystitis:
  • Nitrofurantoin 100 mg twice daily for 5 days 1, 4
  • Fosfomycin trometamol 3 g single dose 1, 4
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (if local resistance <20%) 1, 5

Prophylactic Strategies (When Non-Antibiotic Measures Fail)

• Continuous antibiotic prophylaxis with low-dose antibiotics (nitrofurantoin, trimethoprim-sulfamethoxazole, or trimethoprim) 1, 2
• Post-coital prophylaxis with low-dose antibiotics taken within 2 hours of sexual activity for infections related to sexual activity 1, 2
• Acute self-treatment for appropriately selected reliable patients 2, 6
• Consider rotating antibiotics at 3-month intervals to avoid selection of antimicrobial resistance 1

Special Considerations

• If symptoms persist despite treatment, repeat urine culture before prescribing additional antibiotics 1, 2
• Use nitrofurantoin when possible as first-line for re-treatment since resistance is low 1
• Avoid classifying patients with recurrent UTIs as "complicated" as this leads to unnecessary use of broad-spectrum antibiotics 1, 2
• Avoid treatment of asymptomatic bacteriuria as this increases antimicrobial resistance and recurrent UTI episodes 1, 2

Comparative Effectiveness

• Daily antibiotic prophylaxis is the most effective strategy for preventing recurrent UTIs but is also the most expensive to the payer 6
• Symptomatic self-treatment may be the most favorable strategy in terms of cost per quality-adjusted life-year gained 6
• For patients experiencing 3 UTIs/year, nitrofurantoin prophylaxis can reduce the rate to 0.4 UTIs/year 6

Follow-up

• Document response to treatment and prophylactic strategies 1
• Reassess if symptoms persist or worsen despite appropriate therapy 1
• If prophylactic measures fail, consider endovesical instillations of hyaluronic acid or combination of hyaluronic acid and chondroitin sulfate 1, 7