Recurrent urinary tract infection
From IDWiki
Background
- At least 2 UTIs (with cultures) in 6 months or 3 in 12 months
- Most common in postmenopausal women
Management
- Acute treatment of urinary tract infection for each episode
- Assess for red flags that may warrant further assessment, including pelvic mass, vaginal prolapse beyond the hymen, rectal prolapse, nephrolithiasis, chronic catheterization, immunosuppression, atypical symptoms (eg, gross hematuria, pneumaturia following surgical procedure), or rapid progression to sepsis
Prevention
- Drinking 2 to 3 L of water daily
- Postcoital voiding
- Wiping front to back
- Low threshold for vaginal estrogen in post-menopausal women
- Can consider methenamine 1 g twice daily for 1 year
- Technically non-inferior to antibiotic prophylaxis, though likely not as effective1
- Limited evidence for vitamin C, oral probiotics, vaginal Lactobacillus capsules, garlic extract, cranberry juice or extract, L-arginine, and D-mannose
- However, it is probably quite safe to use cranberry extract, D-mannose, and probiotics
- Vaginal Lactobacillus capsules are promising in early studies
Considerations for Specific Risk Factors
| Risk Factor | Prevention | |
|---|---|---|
| Premenopausal woman | related to sex | postcoital voiding, avoid anal intercourse, postcoital antibiotic |
| Postmenopausal woman | genitourinary atrophy | vaginal estrogen (Estradiol 10mcg tablet inserted once daily 2 weeks then twice weekly forever) |
| related to sex | postcoital voiding, avoid anal intercourse, postcoital antibiotic | |
| Urinary catheterization | catheter care | |
| Poor bladder empyting | refer to specialist | |
| Diabetes mellitus | manage glucosuria, assess bladder emptying (especially if neuropathy) | |
| Advanced uterine prolapse | refer to specialist for surgery or pessary | |
| Enterovesical fistula | pneumaturia | consider suppressive antibiotics until resolved |
| Nephrolithiasis | recurrences with same organism | consider stone removal |
| Urethral diverticulum | postvoid dribbling, dyspareunia, vaginal bulge | consider suppressive antibiotics until diverticulum surgically corrected |
| Renal transplant | pyelonephritis | lower immunosuppression, consider suppressive antibiotic |
| asymptomatic bacteriuria | treat as infection for first 3 to 12 months | |
Prophylactic Dosing
- Reassess after 3 to 6 months after addressing underlying risk factors
| Antibiotic | Dosing |
|---|---|
| nitrofurantoin | 50 to 100 mg p.o. once daily |
| TMP-SMX | 0.5 to 1 SS tab p.o. once daily to 3 times weekly |
| cephalexin | 125 to 250 mg p.o. once daily |
| fosfomycin | 3 g p.o. once weekly |
Further Reading
- Recurrent Urinary Tract Infections in Adult Women. JAMA. 2020;323(7):658-659. doi: 10.1001/jama.2019.21377
References
- ^ Chris Harding, Helen Mossop, Tara Homer, Thomas Chadwick, William King, Sonya Carnell, Jan Lecouturier, Alaa Abouhajar, Luke Vale, Gillian Watson, Rebecca Forbes, Stephanie Currer, Robert Pickard, Ian Eardley, Ian Pearce, Nikesh Thiruchelvam, Karen Guerrero, Katherine Walton, Zahid Hussain, Henry Lazarowicz, Ased Ali. Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: multicentre, open label, randomised, non-inferiority trial. BMJ. 2022:e068229. doi:10.1136/bmj-2021-0068229.
