Treatment Plan for Recurrent UTI
For women with recurrent UTIs, treat acute episodes with short-course nitrofurantoin (5 days), trimethoprim-sulfamethoxazole (3 days), or fosfomycin (single dose) as first-line therapy, and implement prevention strategies including vaginal estrogen for postmenopausal women, increased fluid intake, and consider continuous antibiotic prophylaxis only after non-antimicrobial options have been exhausted. 1, 2
Acute Episode Management
Diagnosis
- Obtain urine culture and antimicrobial susceptibility testing before initiating treatment for each symptomatic episode 2
- Diagnosis requires both laboratory confirmation of significant bacteriuria AND acute-onset urinary symptoms (frequency, urgency, dysuria, suprapubic pain) 1, 3
- Do NOT treat asymptomatic bacteriuria - this increases risk of symptomatic infection, bacterial resistance, and healthcare costs 1, 2
First-Line Antibiotic Therapy
Select based on local antibiogram patterns 2:
Trimethoprim-sulfamethoxazole: 160/800 mg BID for 3 days 1, 2, 5
Fosfomycin trometamol: 3 g single dose 2, 3
- 95.5% susceptibility for E. coli in recurrent UTI populations 4
Antibiotics to AVOID
Fluoroquinolones should NOT be used for uncomplicated UTI - the FDA issued an advisory warning in July 2016 that disabling and serious adverse effects result in an unfavorable risk-benefit ratio 1. Despite this:
- E. coli shows 83.8% persistent resistance to ciprofloxacin 1
- 39.9% resistance to fluoroquinolones in recurrent UTI populations 4
Beta-lactam antibiotics are not first-line due to collateral damage effects and propensity to promote more rapid UTI recurrence 1
Treatment Duration
- Use short-duration therapy - generally no longer than 7 days 2
- Longer courses or greater potency antibiotics are NOT needed in rUTI and may increase recurrences due to loss of protective periurethral and vaginal microbiota 1
Prevention Strategies
Non-Antimicrobial Options (Try FIRST)
Postmenopausal Women:
- Vaginal estrogen replacement (strong recommendation) 2
All Women:
- Increase fluid intake to reduce recurrence risk 2
- Immunoactive prophylaxis (e.g., OM-89/Uro-Vaxom where available) - safe and effective for 6-12 months 1
- Methenamine hippurate for women without urinary tract abnormalities 2
- Cranberry products may help prevent recurrence 3
Antimicrobial Prophylaxis Options
Only consider after non-antimicrobial strategies 2:
Continuous prophylaxis for 6-12 months significantly reduces UTI rate (RR 0.15-0.21, NNT 1.85) 1
Post-coital prophylaxis: Use nitrofurantoin or quinolone within 2 hours after sexual intercourse 1
Patient-initiated self-treatment: Short-term antimicrobial therapy for patients with good compliance 2
Critical Pitfalls to Avoid
Never treat asymptomatic bacteriuria - increases symptomatic infection risk and resistance 1, 2
Do NOT perform surveillance urine testing in patients with rUTI 2
Avoid classifying rUTI patients as "complicated" - this leads to unnecessary broad-spectrum antibiotic use 2
Do NOT use longer antibiotic courses - no evidence they help and may worsen recurrences 1
Avoid fluoroquinolones and cephalosporins - more likely to alter fecal microbiota and cause C. difficile infection 1
Antibiotic Stewardship Principles
- Treat all acute UTIs according to guidelines using short-duration first-line therapy 1
- Base empiric therapy on local susceptibility patterns 2, 3
- Obtain culture and susceptibility for treatment failures, resistant isolates, or atypical presentations 3
- Recognize that rUTI tends to occur in clusters with periods of asymptomatic bacteriuria between symptomatic episodes 1