What are the treatment recommendations for recurrent Urinary Tract Infections (UTIs)?

Treatment Recommendations for Recurrent Urinary Tract Infections

Acute Episode Management

For acute symptomatic episodes, treat with short-course, culture-guided antibiotics for ≤7 days maximum, using nitrofurantoin (100 mg twice daily for 5 days), fosfomycin (3 g single dose), or trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) as first-line agents. 1

Diagnostic Requirements

• Obtain urine culture and susceptibility testing before initiating treatment for every symptomatic acute episode to establish baseline patterns and guide therapy based on bacterial sensitivities 1, 2
• Document positive cultures and types of microorganisms to establish patterns 2
• Patient-initiated treatment (self-start) may be offered to select compliant patients while awaiting culture results 1, 2

First-Line Antibiotic Selection

• Nitrofurantoin 100 mg twice daily for 5 days is the preferred first-line agent due to low resistance rates (85.5% susceptibility) and minimal resistance development even with repeated use 1, 3
• Fosfomycin trometamol 3 g single dose provides excellent convenience and maintains 95.5% susceptibility rates 1, 3
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days only if local E. coli resistance is <20% 1, 4
• Avoid fluoroquinolones empirically due to high resistance rates (39.9% for E. coli) and significant adverse effect profiles 1, 3

Critical Treatment Duration

• Treat for ≤7 days maximum for acute cystitis episodes, as longer courses increase resistance without improving outcomes 1, 2
• If symptoms recur within 2 weeks of treatment completion, assume organism resistance to the original agent and retreat with a 7-day regimen using a different antibiotic 1

Prevention Strategy Algorithm

Begin with non-antimicrobial interventions as first-line prevention before considering antibiotic prophylaxis. 1

First-Line Non-Antimicrobial Prevention

• Vaginal estrogen replacement for postmenopausal women has strong evidence for prevention 1
• Increase fluid intake for premenopausal women 1, 2
• Methenamine hippurate for women without urinary tract abnormalities 1
• Immunoactive prophylaxis 1

Second-Line Options (Weaker Evidence)

• Probiotics with proven vaginal flora efficacy 1
• Cranberry products 1, 5
• D-mannose 1
• Counsel patients about limited or contradictory evidence for these options 1

Third-Line: Endovesical Therapy

• Consider endovesical instillations of hyaluronic acid or hyaluronic acid/chondroitin sulfate combination when less invasive approaches fail 1

Antimicrobial Prophylaxis (Last Resort)

Use continuous or postcoital antimicrobial prophylaxis only after non-antimicrobial interventions have been unsuccessful, due to risk of adverse effects, antimicrobial resistance development, and collateral damage to normal flora. 1

When to Consider Prophylaxis

• After failure of all non-antimicrobial interventions 1
• For patients experiencing ≥3 UTIs per year or ≥2 UTIs in 6 months 2, 6
• Prophylaxis reduces UTI rate from 3-8 episodes/year to 0.4 episodes/year with nitrofurantoin 5

Prophylactic Antibiotic Options

• Nitrofurantoin 50-100 mg daily at bedtime for 6-12 months is most effective, reducing UTI episodes, emergency room visits, and hospital admissions 1, 6, 5
• Trimethoprim-sulfamethoxazole (single strength daily or three times weekly) is an alternative if local resistance patterns are favorable 6
• Postcoital dosing with either agent for sexually-related recurrences 1
• Continuous prophylaxis significantly reduces UTI rates (RR 0.21,95% CI 0.13-0.34) 2

Self-Administered Short-Term Therapy

• Consider self-administered short-term antimicrobial therapy at symptom onset for compliant patients as an alternative to continuous prophylaxis 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria - surveillance urine testing in asymptomatic patients should be omitted as it increases antimicrobial resistance and risk of symptomatic infections 1, 2
• 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
• Do not continue antibiotics beyond 7 days for acute cystitis episodes 1, 2
• Do not use broad-spectrum antibiotics when narrower options are available 2
• Do not fail to obtain cultures before initiating treatment in recurrent cases 2

Special Populations

Men with Recurrent UTI

• Treat for 7 days with trimethoprim-sulfamethoxazole 160/800 mg twice daily or fluoroquinolones based on local susceptibility 1, 4

Relapse UTI (Same Organism Within 2 Weeks)

• Extended antibiotic course (7-14 days) based on culture and sensitivity 2
• Consider parenteral antibiotics for cultures resistant to oral options 2
• Imaging studies to identify structural abnormalities (calculi, foreign bodies, diverticula) may be necessary 2
• Reclassify as complicated UTI requiring further investigation 2

Repeated Pyelonephritis

• Prompt consideration of complicated etiology requiring further investigation 1