Prophylactic Antibiotics for Recurrent Urinary Tract Infections

Definition and Diagnosis

The American Urological Association defines recurrent UTIs as ≥2 culture-positive UTIs in 6 months or ≥3 in one year 4
Confirm diagnosis with urine culture for each symptomatic episode before initiating treatment 4
Eradication of previous UTI should be confirmed by a negative urine culture 1-2 weeks after treatment before starting prophylaxis 1, 2

Implement behavioral modifications before considering antibiotics, including increasing fluid intake to promote frequent urination 4
Void after intercourse 3
Avoid prolonged holding of urine 3
Avoid spermicide-containing products 3, 4
Consider alternative contraception if using spermicide 1, 2
Cranberry products (minimum 36 mg/day proanthocyanidin A) may be effective in preventing UTIs 1, 2, 4
Intravaginal probiotics containing Lactobacillus rhamnosus GR-1 or Lactobacillus reuteri RC-14 once or twice weekly may be effective in preventing UTIs 1, 2

Consider antibiotic prophylaxis after non-antimicrobial measures have failed 1, 2, 3
Consider antibiotic prophylaxis when quality of life is significantly impacted by recurrent infections 2, 3

Continuous daily prophylaxis for 6-12 months with recommended antibiotics including trimethoprim-sulfamethoxazole, trimethoprim, nitrofurantoin, cefaclor, cephalexin 1, 2, 4
Post-coital prophylaxis with a single dose of antibiotics within 2 hours of intercourse may be effective for women with UTIs related to sexual activity 1, 2, 4
Self-initiated treatment with a short course of antibiotics at the first sign of symptoms may be effective for appropriately selected patients with good compliance 1, 2, 4

Base choice of antibiotics on identification and susceptibility pattern of organisms causing previous UTIs 1, 2
Consider patient's drug allergies and history when selecting antibiotics 1, 2

Do not use daily antibiotic prophylaxis in patients with indwelling catheters 5
Do not use daily antibiotic prophylaxis in patients with neurogenic bladder who manage with clean intermittent catheterization unless they have recurrent UTIs 5
Consider antibiotic resistance patterns in your community when selecting agents 4

UTIs in men are always considered complicated and require more extensive evaluation 6
Evaluate for urinary tract obstruction, foreign bodies, incomplete bladder emptying, vesicoureteral reflux in men with UTIs 6
Consider surgical management for men with recurrent UTIs due to BPH when refractory to other therapies 6