In a reproductive‑age woman with a Nexplanon contraceptive implant who has recurrent urinary‑tract infections and a recent ureaplasma vaginal infection, is the implant causing urinary frequency and should I treat the UTI with ciprofloxacin?

Ciprofloxacin for Recurrent UTIs with Ureaplasma and Nexplanon

Ciprofloxacin is NOT the appropriate first-line antibiotic for your patient's recurrent UTIs, and the Nexplanon implant is unlikely to be causing her urinary frequency. 1, 2

Addressing the Nexplanon Question

The contraceptive implant is not a recognized cause of recurrent UTIs or urinary frequency. 1, 3 The established risk factors for recurrent UTIs in premenopausal women are sexual intercourse frequency and spermicide use—not hormonal contraceptive implants. 1, 3 Her urinary symptoms are more likely related to the recurrent infections themselves or the ureaplasma infection rather than the Nexplanon. 4

Why Not Ciprofloxacin?

The 2024 European Association of Urology guidelines explicitly recommend against using ciprofloxacin for recurrent UTIs unless local resistance rates are below 10% AND the patient has not used fluoroquinolones in the last 6 months. 1 This is a strong recommendation based on antimicrobial stewardship principles. 1

For recurrent UTIs in young women without structural abnormalities, first-line antibiotics should be:

• Nitrofurantoin 100 mg twice daily for 5 days 2
• Fosfomycin 3g single dose 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local E. coli resistance <20%) 2

The Ureaplasma Component

Ureaplasma urealyticum can cause chronic urinary symptoms that mimic recurrent UTIs and requires different antibiotic coverage than typical uropathogens. 1, 4 In one study, 48% of women with chronic voiding symptoms had positive ureaplasma cultures, and treatment resulted in significant symptom improvement. 4

For ureaplasma, the appropriate antibiotics are:

• Azithromycin 1g single dose as first-line 4
• Doxycycline, ofloxacin, or erythromycin for 7 days if azithromycin fails 4

Ciprofloxacin has activity against ureaplasma, but it is not the preferred agent. 4

Recommended Management Algorithm

Step 1: Obtain urine culture before starting any antibiotics 1, 2

• This confirms true bacterial UTI versus ureaplasma-related symptoms
• Guides appropriate antibiotic selection based on susceptibility patterns

Step 2: Treat the acute UTI episode with first-line agents 2

• Use nitrofurantoin, fosfomycin, or TMP-SMX based on prior culture data if available
• Avoid ciprofloxacin and other fluoroquinolones as first-line therapy 1, 2

Step 3: Address the ureaplasma infection separately 4

• If ureaplasma was documented on vaginal culture, treat with azithromycin 1g
• Confirm eradication with repeat culture if symptoms persist

Step 4: Implement prevention strategies 1, 2

• Behavioral modifications: Increase fluid intake, void after intercourse, avoid spermicide-containing contraceptives 2
• For post-coital UTIs: Consider low-dose antibiotic prophylaxis (nitrofurantoin 50mg, TMP-SMX 40/200mg, or trimethoprim 100mg) within 2 hours of sexual activity for 6-12 months 1, 2
• For non-coital recurrent UTIs: Consider daily low-dose prophylaxis with the same agents for 6-12 months 1, 2
• Non-antibiotic alternatives: D-mannose, cranberry products, methenamine hippurate, or lactobacillus probiotics 2

Critical Pitfalls to Avoid

Do not classify this patient as having "complicated" UTI simply because infections are recurrent. 1 Reserve the complicated UTI designation for structural/functional urinary tract abnormalities, immunosuppression, or pregnancy—this leads to unnecessary broad-spectrum antibiotic use. 1

Do not treat asymptomatic bacteriuria if found on follow-up cultures. 1 This promotes antimicrobial resistance and increases recurrence rates. 1

Do not perform extensive imaging or cystoscopy in this young woman without risk factors. 2 These invasive tests are not indicated for uncomplicated recurrent UTIs in women under 40. 2

Do not remove the Nexplanon based on urinary symptoms alone. 1, 3 There is no evidence linking hormonal contraceptive implants to recurrent UTIs or urinary frequency.