Treatment Options for Recurrent Urinary Tract Infections

Definition and Diagnosis

Recurrent UTIs (rUTIs) are defined as at least three UTIs per year or two UTIs in the last 6 months, including both lower tract (cystitis) and upper tract (pyelonephritis) infections 1
rUTIs significantly impact quality of life, affecting social and sexual relationships, self-esteem, and work capacity 1
Diagnose recurrent UTI via urine culture (strong recommendation) 1, 4
Obtain urine culture and antimicrobial susceptibility testing for each symptomatic episode prior to initiating treatment 4

Use first-line therapy based on local antibiogram patterns 4, 5
First-line antimicrobial options for acute episodes include Nitrofurantoin (50-100 mg QID or 100 mg BID for 5 days) 3, Trimethoprim-sulfamethoxazole (160/800 mg BID for 3 days) 2, and Fosfomycin trometamol (3 g single dose) 1
Treat acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than 7 days 4, 5

Increase fluid intake to reduce risk of recurrent UTI (weak recommendation) 1
Use immunoactive prophylaxis (strong recommendation) 1
Use vaginal estrogen replacement for postmenopausal women (strong recommendation) 1, 6
Consider methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1, 6
Continuous or post-coital antimicrobial prophylaxis (strong recommendation) 1, 7
Self-administered short-term antimicrobial therapy for patients with good compliance (strong recommendation) 1, 4

Do not perform surveillance urine testing or treat asymptomatic bacteriuria in patients with rUTI 5, 6
Avoid classifying patients with rUTI as "complicated" as this often leads to unnecessary use of broad-spectrum antibiotics 6
Discuss adverse events of antibiotics with patients, including potential pulmonary and hepatic toxicity with Nitrofurantoin 7

Treating asymptomatic bacteriuria, which fosters antimicrobial resistance and increases rUTI episodes 6
Using broad-spectrum antibiotics when narrower options are available 6
Continuing antibiotics beyond recommended duration 6
Failing to obtain urine culture before initiating treatment in recurrent cases 4
Not considering non-antimicrobial options before antimicrobial prophylaxis 1, 6