What is the recommended treatment for a non-pregnant, otherwise healthy adult with recurrent urinary tract infections (UTIs)?

Treatment of Recurrent Uncomplicated UTIs in Non-Pregnant, Healthy Adult Women

For recurrent uncomplicated UTIs in otherwise healthy adult women, start with behavioral modifications and non-antimicrobial prevention strategies before considering antibiotic prophylaxis, reserving antibiotics for acute treatment episodes guided by urine culture. 1

Acute Episode Management

Diagnosis Requirements

• Obtain urine culture with sensitivity testing for every symptomatic episode before initiating treatment to confirm diagnosis and guide therapy 1
• Recurrent UTI is defined as ≥3 culture-proven infections within 12 months or ≥2 within 6 months 1, 2
• Acute-onset dysuria combined with urgency, frequency, or hematuria indicates cystitis; dysuria has >90% accuracy for UTI diagnosis 1

First-Line Antibiotic Treatment for Acute Episodes

When culture is pending and empiric treatment is needed, use prior culture data and local resistance patterns to select from: 3, 4

• Nitrofurantoin 100 mg twice daily for 5 days (preferred due to low resistance rates) 3, 4
• Fosfomycin 3 g single dose 3, 4
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance <20%) 5, 4

Critical Treatment Pitfalls to Avoid

• Do NOT treat asymptomatic bacteriuria - this fosters antimicrobial resistance and increases recurrence frequency 1
• Do NOT classify these patients as "complicated UTI" unless structural/functional abnormalities or immunosuppression exist, as this leads to unnecessary broad-spectrum antibiotic use 1
• Avoid fluoroquinolones and cephalosporins as first-line agents due to increasing resistance and antimicrobial stewardship concerns 1

Prevention Strategy Algorithm

Step 1: Behavioral and Lifestyle Modifications (All Patients)

Implement these measures before considering antimicrobial prophylaxis: 1

• Increase fluid intake to promote frequent urination 6
• Void when urge occurs and practice post-coital voiding 1
• Discontinue spermicide-containing contraceptives if used 1
• Wipe front to back after defecation 7
• Avoid habitual delayed urination 7

Step 2: Population-Specific Non-Antimicrobial Interventions

For Postmenopausal Women:

First-line prevention (strongly recommended): 1, 6

• Vaginal estrogen therapy (topical application) for those with atrophic vaginitis 1, 6
• Lactobacillus-containing probiotics (can be combined with vaginal estrogen) 1, 6
• Methenamine hippurate 1, 6
• Oral immunostimulant OM-89 (appears most promising among immunostimulants) 1

For Premenopausal Women with Coitus-Related UTIs:

• Post-coital antibiotic prophylaxis using single-dose trimethoprim-sulfamethoxazole 40/200 mg or nitrofurantoin 50-100 mg after intercourse 1

For Premenopausal Women with Non-Coital Pattern:

• Lactobacillus-containing probiotics as first-line non-antimicrobial option 1
• Methenamine hippurate as alternative 1

Step 3: Antimicrobial Prophylaxis (Only When Non-Antimicrobial Measures Fail)

Continuous daily prophylaxis options: 1, 6

• Nitrofurantoin 50-100 mg daily (preferred due to low resistance) 1
• Trimethoprim-sulfamethoxazole 40/200 mg daily (if susceptibility confirmed) 1, 5
• Fosfomycin 3 g every 10 days 1

Important considerations for prophylaxis: 1

• Base antibiotic selection on patient's prior organism identification and susceptibility profile 1
• Consider patient drug allergies and local antibiogram patterns 1
• Avoid Augmentin (amoxicillin-clavulanate) as first-line prophylaxis due to resistance concerns 6

Step 4: Self-Start Therapy Option

For reliable patients who communicate effectively: 1

• Provide prescription for patient-initiated treatment at symptom onset 1
• Patient must obtain urine specimen before starting antibiotics and communicate with provider 1
• Use same first-line agents as acute treatment (nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole) 1

When to Consider Further Evaluation

Refer for urologic evaluation if: 1, 8

• Persistent symptoms despite appropriate treatment 1
• Repeated pyelonephritis episodes 1
• Gross hematuria after infection resolution 1
• History of urinary tract stones, surgery, or trauma 1
• Symptoms suggesting fistula (pneumaturia, fecaluria) 1

Imaging or cystoscopy may be warranted to evaluate for anatomic abnormalities (cystocele, bladder diverticula, obstruction, vesicoureteral reflux) or functional problems (voiding dysfunction, incomplete emptying) 1, 8

Antimicrobial Stewardship Principles

• Tailor treatment to shortest effective duration to mitigate fluoroquinolone and cephalosporin resistance 1
• Select antimicrobials with least impact on normal vaginal and fecal flora 1
• Combine knowledge of local antibiogram with individual patient susceptibility data 1
• If persistent symptoms occur despite treatment, repeat urine culture before prescribing additional antibiotics 1