Treatment of Chronic UTI
For recurrent uncomplicated UTIs in women, use first-line antibiotics (nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin) for acute episodes with treatment duration of 5-7 days maximum, and address the underlying cause with culture-proven documentation before initiating any therapy. 1
Defining Chronic/Recurrent UTI
Chronic UTI is defined as ≥2 culture-positive UTIs within 6 months or ≥3 within one year 1. Every episode must be documented with positive urine cultures obtained before starting antibiotics to confirm true infection versus asymptomatic bacteriuria 1.
Critical First Step: Distinguish Complicated from Uncomplicated
Do not classify recurrent UTIs as "complicated" unless specific risk factors exist, as this leads to unnecessary broad-spectrum antibiotic use 1. Complicated UTIs require different management and occur with:
- Urinary tract obstruction, foreign bodies, incomplete voiding, or vesicoureteral reflux 1
- Male sex, pregnancy, diabetes, or immunosuppression 1
- Recent instrumentation or catheterization 1
- Healthcare-associated infections or multidrug-resistant organisms 1
Acute Episode Treatment (Uncomplicated)
First-Line Antibiotics
Use nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin based on local resistance patterns 1. These agents cause minimal collateral damage to normal flora and have lower resistance rates 1.
Specific dosing:
- Nitrofurantoin: Preferred when possible due to low resistance 1
- TMP-SMX: 1 double-strength tablet every 12 hours for 10-14 days (standard UTI) 2, though shorter 5-7 day courses are recommended for recurrent UTI 1
- Fosfomycin: Single 3-gram dose option 3
Treatment Duration
Treat for 5-7 days maximum—no longer 1. Single-dose therapy increases bacteriological persistence risk 1. Avoid prolonged courses as they increase resistance and adverse effects without improving outcomes 1.
Culture Requirements
Obtain urine culture and sensitivity before every treatment 1. This allows:
- Confirmation of true infection versus asymptomatic bacteriuria
- Tailoring therapy to specific organism sensitivities
- Tracking patterns to guide future empiric choices 1
Complicated UTI Treatment
For patients with complicating factors, management of the underlying urological abnormality is mandatory 1.
Empiric therapy for complicated UTI with systemic symptoms:
- Amoxicillin plus aminoglycoside, OR
- Second-generation cephalosporin plus aminoglycoside, OR
- Intravenous third-generation cephalosporin 1
Treatment duration: 7-14 days (14 days for men when prostatitis cannot be excluded) 1. May shorten to 7 days if hemodynamically stable and afebrile ≥48 hours 1.
Fluoroquinolone restrictions:
- Only use ciprofloxacin if local resistance <10% AND patient doesn't require hospitalization AND no β-lactam allergy 1
- Never use fluoroquinolones if patient used them in last 6 months or in urology department patients 1
Critical Pitfall: Asymptomatic Bacteriuria
Do not treat asymptomatic bacteriuria 1. This is a strong recommendation because:
- Treatment fosters antimicrobial resistance 1
- Increases number of recurrent UTI episodes 1
- Provides no clinical benefit in non-pregnant patients 1
Do not perform surveillance urine cultures in asymptomatic patients 1.
Prevention Strategies (After Acute Treatment)
Postmenopausal Women
Vaginal estrogen with or without lactobacillus-containing probiotics 1
Premenopausal Women with Coitus-Related UTIs
Low-dose post-coital antibiotics 1
Premenopausal Women with Non-Coitus-Related UTIs
Low-dose daily antibiotic prophylaxis 1. Choice should be based on:
- Prior organism identification and susceptibility
- Drug allergies
- Antibiotic stewardship principles 1
Non-Antibiotic Alternatives
Methenamine hippurate and/or lactobacillus-containing probiotics as alternatives to daily antibiotics 1
Patient-Initiated Treatment Option
May offer self-start treatment to reliable patients who can obtain urine specimens before starting therapy and communicate effectively with providers 1. This requires prior discussion and established protocol.
Catheter-Associated UTI
Treat symptomatic catheter-associated UTI according to complicated UTI recommendations 1. Catheter-associated bacteremia carries approximately 10% mortality 1. Always obtain urine culture before initiating therapy in catheterized patients 1.
Antimicrobial Stewardship Principles
The microbial spectrum in complicated UTIs includes E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp., with higher antimicrobial resistance rates 1. Tailor initial empiric therapy based on culture results and local antibiograms 1. This approach reduces fluoroquinolone and cephalosporin resistance development 1.