What is the recommended treatment approach for chronic Urinary Tract Infections (UTIs)?

Treatment of Chronic Urinary Tract Infections

For chronic UTIs, the cornerstone of management is addressing underlying urological abnormalities combined with culture-guided antimicrobial therapy for 7-14 days, while avoiding the common pitfall of treating asymptomatic bacteriuria which worsens resistance patterns. 1

Distinguishing Chronic from Recurrent UTIs

The term "chronic UTI" typically refers to complicated UTIs (cUTIs) - infections occurring in patients with structural or functional urinary tract abnormalities, foreign bodies, obstruction, or immunosuppression. 1 This differs fundamentally from recurrent UTIs in otherwise healthy individuals, which require a different management approach. 1, 2, 3

Critical distinction: Do not classify patients with frequent UTIs as having "complicated" infections solely based on recurrence, as this leads to unnecessary broad-spectrum antibiotic use. 1, 3 Reserve the "complicated" designation for patients with actual anatomical/functional abnormalities, pregnancy, immunosuppression, or multidrug-resistant organisms. 1

Management Algorithm for Complicated UTIs

Step 1: Identify and Address Underlying Factors

Mandatory first step: Optimal management of the urological abnormality or complicating factor is essential and takes priority. 1 Common factors include:

• Obstruction at any site in the urinary tract 1
• Foreign bodies (catheters, stents) 1
• Incomplete voiding or vesicoureteral reflux 1
• Recent instrumentation 1
• Diabetes mellitus or immunosuppression 1
• Multidrug-resistant organisms 1

Step 2: Obtain Urine Culture Before Treatment

Always obtain urine culture and susceptibility testing before initiating therapy. 1, 3 The microbial spectrum in cUTIs is broader than uncomplicated infections, with E. coli, Proteus, Klebsiella, Pseudomonas, Serratia, and Enterococcus species commonly isolated. 1 Antimicrobial resistance is significantly more likely. 1

Step 3: Empiric Antibiotic Selection

For cUTIs with systemic symptoms requiring hospitalization, the European Association of Urology strongly recommends: 1

• Amoxicillin plus an aminoglycoside, OR
• Second-generation cephalosporin plus an aminoglycoside, OR
• Intravenous third-generation cephalosporin

For oral outpatient treatment (when patient is stable and hospitalization not required): 1

• Ciprofloxacin - ONLY if local resistance rate is <10% AND patient has not used fluoroquinolones in the last 6 months 1
• Do NOT use fluoroquinolones for empirical treatment in urology department patients or those with recent fluoroquinolone exposure 1

Step 4: Tailor Therapy Based on Culture Results

Once susceptibility results are available, switch from empiric IV therapy to targeted oral therapy with an appropriate antimicrobial agent. 1

Step 5: Treatment Duration

Standard duration: 7-14 days 1

• 7 days: For patients who are hemodynamically stable and afebrile for ≥48 hours, particularly when shorter courses are desirable due to relative contraindications to the antibiotic 1
• 14 days: For men when prostatitis cannot be excluded 1
• Duration should be closely related to treatment of the underlying abnormality 1

Special Considerations for Multidrug-Resistant Organisms

For Carbapenem-Resistant Enterobacteriaceae (CRE):

First-line options: 1

• Ceftazidime-avibactam 2.5 g IV q8h (weak recommendation, very low quality evidence) 1
• Meropenem-vaborbactam 4 g IV q8h (weak recommendation, low quality evidence) 1
• Imipenem-cilastatin-relebactam 1.25 g IV q6h (weak recommendation, low quality evidence) 1
• Plazomicin 15 mg/kg IV q12h (weak recommendation, very low quality evidence) 1

For simple cystitis due to CRE: Single-dose aminoglycoside may be considered, as aminoglycosides achieve urinary concentrations 25-100 fold higher than plasma levels. 1

Management of Recurrent UTIs (Non-Complicated)

If the patient has recurrent UTIs without structural abnormalities (≥3 UTIs/year or ≥2 in 6 months), the approach differs significantly: 2, 3

Acute Episode Treatment:

First-line antibiotics: 2, 3

• Nitrofurantoin 100 mg twice daily for 5 days 2, 3
• Fosfomycin trometamol 3 g single dose 2, 3
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance <20%) 2, 4

Avoid fluoroquinolones due to high resistance rates and serious adverse effects. 2

Prevention Strategies (Hierarchical Approach):

1. Behavioral modifications first: 2, 3

• Increase fluid intake 2, 3
• Void after intercourse 3
• Avoid prolonged urine holding 3

2. Non-antibiotic prophylaxis (try before antibiotics): 1, 2, 3

For postmenopausal women:

• Vaginal estrogen replacement therapy (strongly recommended as first-line) 2, 3
• Consider adding methenamine hippurate 1 g twice daily 1, 2, 3
• Probiotics with proven vaginal flora regeneration strains 2, 3

For all women:

• Methenamine hippurate (strongly recommended for women without urinary tract abnormalities) 2, 3
• Immunoactive prophylaxis products 2, 3
• Cranberry products (weak evidence, contradictory findings) 2, 3
• D-mannose (limited evidence) 2, 3

3. Antimicrobial prophylaxis (when non-antimicrobial interventions fail): 2, 3

For premenopausal women with coital-related UTIs:

• Low-dose post-coital antibiotics 1, 3

For premenopausal women with non-coital UTIs:

• Low-dose daily antibiotic prophylaxis 1, 3
• Nitrofurantoin 50-100 mg daily preferred (resistance is low and decays quickly) 1, 2, 3

Critical Pitfalls to Avoid

1. Never treat asymptomatic bacteriuria - This increases antimicrobial resistance and paradoxically increases recurrent UTI episodes. 1, 2, 3

2. Do not perform extensive workup routinely - Cystoscopy and full abdominal ultrasound are not recommended for women <40 without risk factors. 2, 3

3. If symptoms persist despite treatment - Repeat urine culture to assess for ongoing bacteriuria before prescribing additional antibiotics. 1, 2, 3

4. Avoid misclassifying recurrent UTIs as complicated - This drives inappropriate broad-spectrum antibiotic use. 1, 3

5. Consider antibiotic rotation - Rotating antibiotics at 3-month intervals may help avoid selection of antimicrobial resistance. 3