What is the treatment for frequent Urinary Tract Infections (UTIs)?

Treatment of Frequent UTIs

For women with recurrent UTIs (≥3 UTIs/year or ≥2 UTIs in 6 months), begin with non-antibiotic preventive strategies, and reserve continuous antibiotic prophylaxis for 6-12 months only when non-antibiotic measures fail. 1, 2

Definition and Diagnosis

• Recurrent UTIs are defined as at least three UTIs per year or two UTIs in the last 6 months 1, 2
• Diagnose each recurrence via urine culture before initiating treatment 1, 2
• Do not perform extensive workup (cystoscopy, full abdominal ultrasound) in women younger than 40 years without risk factors 1, 2

First-Line: Non-Antibiotic Prevention Strategies

Start with these interventions before considering antibiotic prophylaxis:

For Premenopausal Women:

• Increase fluid intake as this may reduce recurrence risk 1, 2
• Immunoactive prophylaxis (strongly recommended) 2
• Methenamine hippurate for women without urinary tract abnormalities (RR 0.24 for preventing UTI) 1, 2
• Post-coital voiding and behavioral modifications 3

For Postmenopausal Women:

• Vaginal estrogen is strongly recommended and highly effective (RR 0.25-0.64 depending on formulation) 1, 2
• Oral estrogen is NOT effective (RR 1.08) and should not be used 1

Additional Options with Variable Evidence:

• Probiotics with proven efficacy for vaginal flora regeneration 2
• Cranberry products have weak and contradictory evidence 2
• D-mannose has weak evidence 2

Second-Line: Antibiotic Prophylaxis

When non-antibiotic measures fail, use continuous antibiotic prophylaxis for 6-12 months:

Preferred Prophylactic Regimens:

• Trimethoprim-sulfamethoxazole 40mg/200mg once daily 2, 4
• Trimethoprim 100mg once daily 2
• Nitrofurantoin macrocrystals 100mg once daily 2
• Fosfomycin 3g every 10 days (95% reduction in UTI episodes) 2
• Cephalexin for daily dosing 2

Important Considerations:

• Continuous antibiotic prophylaxis reduces recurrences by 79% (RR 0.21) with number needed to treat of 1.85 1
• The protective effect lasts only during active intake and does not persist after discontinuation 2
• Standard duration is 6-12 months with periodic assessment 2
• Long-term prophylaxis beyond 1 year is not evidence-based 2

Special Situation - Post-Coital Prophylaxis:

• For UTIs temporally related to sexual activity, use post-coital antibiotic prophylaxis (single dose within 2 hours after intercourse) 1, 2
• This approach is effective and associated with fewer adverse events than continuous prophylaxis 2
• Options include ciprofloxacin, norfloxacin, or nitrofurantoin 1

Treatment of Acute Episodes During Recurrence

When treating individual symptomatic episodes:

First-Line Acute Treatment Options:

• Fosfomycin trometamol 3g single dose 1, 5
• Nitrofurantoin 100mg twice daily for 5 days 1
• Pivmecillinam 400mg three times daily for 3-5 days 1

Alternative Options:

• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days (only if local E. coli resistance <20%) 1, 3
• Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) if local resistance <20% 1
• Reserve fluoroquinolones as last-line alternatives due to resistance concerns and FDA warnings about serious adverse effects 3, 6

Critical Pitfalls to Avoid

• Do NOT treat asymptomatic bacteriuria - this increases risk of symptomatic infection and bacterial resistance 1, 2
• Do NOT perform routine post-treatment urine cultures in asymptomatic patients 1, 2
• Do NOT use longer courses or more potent antibiotics for recurrent UTI - this may increase recurrences by disrupting protective vaginal microbiota 1
• Avoid fluoroquinolones and trimethoprim-sulfamethoxazole in areas with high resistance rates (>20%) or recent exposure 6, 7

Monitoring During Prophylaxis

• Confirm negative urine culture to document efficacy 2
• Do not perform surveillance urine testing in asymptomatic patients 2
• If symptoms persist despite appropriate therapy, repeat urine culture before prescribing additional antibiotics 3

Adverse Effects to Monitor

• Nitrofurantoin: rare pulmonary (0.001%) and hepatic toxicity (0.0003%), plus common GI disturbances 2
• Trimethoprim-sulfamethoxazole: GI disturbances and skin rash 2
• Nitrofurantoin showed more severe adverse events than other prophylactic antibiotics in comparative studies 1

Self-Management Option

• Self-administered short-term antimicrobial therapy may be considered for patients with good compliance and ability to recognize symptoms 2, 8
• This approach requires patient education on symptom recognition and when to seek medical attention 8