Diagnostic and Management Approach to Recurrent Infections
The approach to recurrent infections must be tailored to the infection site: for recurrent skin abscesses, drain and culture early with consideration of S. aureus decolonization; for recurrent UTIs in women, confirm each episode with culture and implement non-antimicrobial prevention strategies first; and for recurrent UTIs in men, perform comprehensive urological evaluation since all male UTIs are considered complicated. 1, 2, 3
Recurrent Skin and Soft Tissue Infections
Initial Diagnostic Steps
- Search for local anatomic causes when abscesses recur at the same site, including pilonidal cysts, hidradenitis suppurativa, or retained foreign material 1
- Drain and culture recurrent abscesses early in the infection course to guide targeted antibiotic therapy 1
Treatment Protocol
- Administer a 5-10 day course of antibiotics active against the cultured pathogen 1
- For recurrent S. aureus infections specifically, implement a 5-day decolonization regimen consisting of:
- Intranasal mupirocin twice daily
- Daily chlorhexidine body washes
- Daily decontamination of personal items (towels, sheets, clothing) 1
When to Evaluate for Immunodeficiency
- Evaluate adult patients for neutrophil disorders only if recurrent abscesses began in early childhood 1
- Adults who develop abscesses for the first time in adulthood do not require neutrophil function testing 1
Recurrent Urinary Tract Infections in Women
Diagnostic Confirmation
- Define recurrence as ≥3 culture-positive UTIs within 12 months or ≥2 within 6 months 3
- Obtain urine culture with sensitivity testing for each symptomatic episode before initiating treatment 2, 3
- Avoid treating asymptomatic bacteriuria, as this promotes antibiotic resistance 3
Acute Episode Management
- First-line treatment options include:
Prevention Strategy (Stepwise Approach)
- Start with non-antimicrobial interventions before considering antibiotic prophylaxis 3
- For postmenopausal women, vaginal estrogen therapy is the cornerstone intervention with strong evidence for reducing recurrence 3
- Methenamine hippurate 1g twice daily has strong evidence for prevention in women without urinary tract abnormalities 3
- Behavioral modifications include adequate hydration, post-coital voiding, and avoiding spermicidal contraceptives 1
Imaging Considerations
- Routine imaging is not indicated for women with uncomplicated recurrent UTIs who respond promptly to therapy and have <2 episodes per year 1
- Consider imaging for patients with rapid recurrence (within 2 weeks), bacterial persistence, or suspected anatomic abnormalities 1
Recurrent Urinary Tract Infections in Men
Critical Distinction
- All UTIs in men are considered complicated and require more extensive evaluation than in women 2
- Confirm diagnosis with urine culture for each symptomatic episode 2
Comprehensive Urological Workup
- Evaluate for urinary tract obstruction at any site 2
- Assess for foreign bodies (catheters, stents) 2
- Measure post-void residual to check for incomplete bladder emptying 2
- Evaluate for vesicoureteral reflux 2
- Review recent urinary tract instrumentation history 2
- Screen for diabetes mellitus and immunosuppression 2
Treatment Approach
- Trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days is first-line treatment for men (note the longer duration compared to women) 2
- Address underlying anatomical or functional abnormalities when identified 2
- Consider surgical intervention for men with recurrent UTIs due to benign prostatic hyperplasia refractory to other therapies 2
Common Pitfalls to Avoid
- Never classify patients with recurrent uncomplicated UTIs as "complicated" - this leads to unnecessary broad-spectrum antibiotics with prolonged durations 3
- Do not routinely obtain blood cultures or imaging for community-acquired skin infections without systemic signs 1
- Avoid empiric treatment without culture confirmation in recurrent infections, as this prevents identification of resistance patterns 2, 3
- Do not evaluate adults for primary immunodeficiency unless infections began in childhood 1
Antimicrobial Stewardship Principles
- Base antibiotic selection on prior culture data and local antibiograms 2, 3
- Tailor treatment to the shortest effective duration to mitigate antibiotic resistance 2
- Consider patient-specific factors including allergies, renal function, drug interactions, and cost 3
- Reserve continuous antibiotic prophylaxis only when non-antimicrobial interventions have failed 2, 3