Treatment of Recurrent Urinary Tract Infections
For recurrent UTIs, prioritize non-antimicrobial preventive strategies first, escalating to antimicrobial prophylaxis only when these fail, while treating acute episodes with short-course, culture-guided antibiotics (≤7 days). 1
Acute Episode Management
Diagnostic Approach
- Obtain urine culture and susceptibility testing before initiating treatment for every symptomatic acute episode 1
- This establishes baseline patterns, guides therapy based on bacterial sensitivities, and helps identify alternative diagnoses if cultures don't correlate with symptoms 1
- Patient-initiated treatment (self-start) may be offered to select patients while awaiting culture results 1
Antibiotic Selection for Acute Episodes
First-line agents (choose based on local antibiogram): 1
- 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 E. coli resistance <20%) 1
Key principle: Treat for ≤7 days maximum 1. Shorter courses balance symptom resolution against resistance risk and recurrence 1.
For treatment failures or resistant organisms: Use culture-directed parenteral antibiotics for ≤7 days if oral options are exhausted 1
Prevention Strategy Algorithm
Step 1: Non-Antimicrobial Interventions (Try First)
Postmenopausal women:
- Vaginal estrogen replacement (strong recommendation) 1
All age groups:
- Immunoactive prophylaxis (strong recommendation) 1
- Methenamine hippurate (strong recommendation for women without urinary tract abnormalities) 1
Premenopausal women:
- Increase fluid intake 1
Weaker evidence options (counsel patients about limited/contradictory evidence):
- Probiotics with proven vaginal flora efficacy 1
- Cranberry products (low quality evidence with contradictory findings) 1
- D-mannose (weak and contradictory evidence) 1
For refractory cases:
- Endovesical instillations of hyaluronic acid or hyaluronic acid/chondroitin sulfate combination when less invasive approaches fail 1
Step 2: Antimicrobial Prophylaxis (When Non-Antimicrobial Interventions Fail)
Use continuous or postcoital antimicrobial prophylaxis only after non-antimicrobial interventions have been unsuccessful 1. This is a strong recommendation but must be balanced against:
- Risk of adverse effects 1
- Development of antimicrobial resistance 1
- Collateral damage to normal flora 1
Alternative for compliant patients: Self-administered short-term antimicrobial therapy at symptom onset (strong recommendation) 1
Critical Pitfalls to Avoid
Do NOT treat asymptomatic bacteriuria 1. This is a strong recommendation—surveillance urine testing in asymptomatic patients should be omitted 1.
Do NOT perform extensive workup (cystoscopy, full abdominal ultrasound) in women <40 years with recurrent UTI and no risk factors 1
Do NOT use fluoroquinolones or trimethoprim-sulfamethoxazole empirically in areas with high resistance rates (>20% for E. coli) or in patients recently exposed to these agents 1, 2, 3. Resistance rates to these agents now approach 40-47% in many populations 3.
Do NOT continue antibiotics beyond 7 days for acute cystitis episodes—longer courses increase resistance without improving outcomes 1
Special Considerations
If symptoms recur within 2 weeks of treatment completion: Assume the organism is not susceptible to the original agent and retreat with a 7-day regimen using a different antibiotic 1
Repeated pyelonephritis: Should prompt consideration of a complicated etiology requiring further investigation 1
Men with recurrent UTI: Treat for 7 days with trimethoprim-sulfamethoxazole 160/800 mg twice daily (or fluoroquinolones based on local susceptibility) 1