From the Guidelines
Recurrent urinary tract infections (UTIs) in females should be managed with a combination of preventive strategies, including increased fluid intake, urinating after sexual intercourse, and avoiding irritants, as well as low-dose antibiotic prophylaxis or non-antibiotic alternatives, such as vaginal estrogen therapy or cranberry products, to reduce the risk of recurrence and improve quality of life. The definition of recurrent UTIs is three or more episodes within 12 months or two episodes within 6 months 1. Preventive strategies are essential in managing recurrent UTIs, including:
- Increased fluid intake (2-3 liters daily) to promote frequent urination
- Urinating after sexual intercourse to reduce the risk of infection
- Avoiding irritants like spermicides
- Considering vaginal estrogen therapy for postmenopausal women to improve vaginal flora and reduce infection risk 1 Low-dose antibiotic prophylaxis may be prescribed, such as:
- Nitrofurantoin 50-100mg daily
- Trimethoprim-sulfamethoxazole 40/200mg daily
- Cephalexin 250mg daily, typically for 3-6 months 1 Non-antibiotic options include:
- Cranberry products (36mg proanthocyanidins daily)
- D-mannose (2g daily) These approaches are necessary because recurrent UTIs often result from bacterial persistence in vaginal or intestinal reservoirs, anatomical factors like shorter urethras in women, hormonal changes affecting vaginal pH, and sometimes genetic factors influencing bacterial adherence to urinary epithelium 1. It is essential to note that the management of recurrent UTIs should be individualized, taking into account the patient's medical history, lifestyle, and preferences, to improve clinical outcomes and quality of life 1.
From the Research
Definition and Risk Factors of Recurrent UTI in Women
- Recurrent urinary tract infections (UTIs) are common in women, including healthy women with normal genitourinary anatomy 2.
- Recurrent UTI is typically defined as three or more UTIs within 12 months, or two or more occurrences within six months 2.
- The same species that caused previous infections is typically responsible for recurrences 2.
- In premenopausal women, sexual intercourse three or more times per week, spermicide use, new or multiple sex partners, and having a UTI before 15 years of age are established risk factors 2.
- In postmenopausal women, risk is primarily increased by sequelae of lower estrogen levels 2.
Diagnosis and Treatment of Recurrent UTI
- Episodes of recurrent UTI are typically characterized by dysuria and urinary frequency or hesitancy 2.
- At least one symptomatic episode should be verified by urine culture to confirm the diagnosis and guide treatment 2.
- Short courses of antibiotics are as effective as longer courses 2.
- Patient-initiated treatment lowers the cost of diagnosis, number of physician visits, and number of symptomatic days compared with physician-initiated treatment 2.
- Antibiotic prophylaxis effectively limits UTI recurrence but increases the risk of antibiotic resistance and adverse effects 2, 3.
Prevention of Recurrent UTI
- Cranberry products may reduce recurrent UTIs in premenopausal women, but are less effective than antibiotic prophylaxis, and data are conflicting 2.
- Optimal dosing is unknown 2.
- Postmenopausal women with atrophic vaginitis may benefit from topical estrogen therapy 2.
- Nitrofurantoin can be considered as the most effective drug in the treatment of acute urinary infection, but due to the long-term side effects of this drug, especially in elderly patients, it is essential to introduce some criteria for prescribing NF in cases of chronic UTI 4.
- Daily prophylaxis for recurrent UTI with 50 mg instead of 100 mg nitrofurantoin was associated with an equivalent hazard on UTI or pyelonephritis, and a lower hazard on cough, dyspnoea and nausea 5.