Specific measures including antibiotic treatment

Dependent on whether there is relapse (recurrent infection caused by original infecting organism) or reinfection (infection with different species or strain). Recurrent infection should be documented with culture.

The Canadian Urological Association (1) state that:

• definition of recurrent uncomplicated UTI
  • an uncomplicated UTI is one that occurs in a healthy host in the absence of structural or functional abnormalities of the urinary tract
  • recurrent uncomplicated UTI may be defined as 3 or more uncomplicated UTIs in 12 months
  • recurrent UTIs occur due to bacterial reinfection or bacterial persistence. Persistence involves the same bacteria not being eradicated in the urine 2 weeks after sensitivity-adjusted treatment. A reinfection is a recurrence with a different organism, the same organism in more than 2 weeks, or a sterile intervening culture

Note that "any woman who has recurrent, symptomatic and unexplained urinary infections should be referred for investigation using radiological imaging such as ultrasonography, to exclude anatomical abnormalities." (2)

Also consider the referral criteria in the linked item.

Recurrent UTI includes lower and upper UTI (3)

• recurrent UTI may be due to relapse (same strain of bacteria) or reinfection (different strain or species of bacteria)
  
  
• self-care
  • non-pregnant women may wish to try D-mannose
  • non-pregnant women may wish to try cranberry products (evidence uncertain)
  • advise people taking cranberry products or D-mannose about the sugar content of these products
• consider vaginal (not oral) oestrogen for postmenopausal women if behavioural and personal hygiene measures not effective or appropriate
  • consider vaginal (not oral) oestrogen for postmenopausal women if behavioural and personal hygiene measures not effective or appropriate
    
    
    • the lowest effective dose of vaginal oestrogen should be considered (for example, estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate
      
      
    • the following points should be discussed with the woman to ensure shared decision-making:
      • severity and frequency of previous symptoms
      • risk of developing complications from recurrent UTIs
      • possible benefits of treatment, including for other related symptoms, such as vaginal dryness
      • possible adverse effects such as breast tenderness and vaginal bleeding (which should be reported because it may require investigation)
      • uncertainty of endometrial safety with long-term or repeated use preferences of the woman for treatment with vaginal oestrogen.
      • review treatment within 12 months, or earlier if agreed with the woman
      • do not offer oral oestrogens (hormone replacement therapy) specifically to reduce the risk of recurrent UTI in postmenopausal women
        
        
  • review within 12 months (or earlier if agreed)
    
    
• if no improvement, consider single-dose antibiotic prophylaxis for exposure to an identifiable trigger
  
  
• if no improvement or no identifiable trigger, consider a trial of daily antibiotic prophylaxis
  
  refer or seek specialist advice if underlying cause unknown or cancer suspected
  
  

Choice of antibiotic: people aged 16 years and over

First choice antibiotic 1,2

• trimethoprim4
  • 200 mg single dose when exposed to a trigger, or 100 mg at night
• OR
  
  
• nitrofurantoin - if eGFR >=45 ml/minute5
  • 100 mg single dose when exposed to a trigger, or 50 to 100 mg at night

Second choice antibiotic

• amoxicillin 6 500 mg single dose when exposed to a trigger, or 250 mg at night
• cefalexin 500 mg single dose when exposed to a trigger, or 125 mg at night
• 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding.
• 2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI.
• 3 Doses given are by mouth using immediate-release medicines, unless otherwise stated.
• 4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNF, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics).
• 5 Avoid at term in pregnancy; may produce neonatal haemolysis (BNF, August 2018)
• 6 Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented.

Details if use single-dose or daily antibiotic prophylaxis:

• when single-dose antibiotic prophylaxis given, advise:
  • how to use
  • possible adverse effects of antibiotics, particularly diarrhoea and nausea
  • returning for review within 6 months
  • seeking medical help if symptoms of an acute UTI develop
    
    
• when a trial of daily antibiotic prophylaxis given, advise:
  • risk of resistance with long-term antibiotics
  • possible adverse effects of long-term antibiotics
  • returning for review within 6 months
  • seeking medical help if symptoms of an acute UTI develop
    
    
• review at least every 6 months should include:
  • assessing prophylaxis success
  • reminders about behavioural and personal hygiene measures, and self-care
  • discussing whether to continue, stop or change antibiotic prophylaxis

Notes:

• opinion varies on when a prophylactic antibiotic for a UTI should be started (3)
  • prophylaxis should not be initiated until eradication of active infection is confirmed by a negative culture at least one to two weeks after treatment is discontinued
    • after confirmation of a negative urine culture prophylaxis is usually initiated for a trial period of 6 months but has been safely and effectively continued for 2-5 years without the emergence of resistant organisms
      
      
  • infections occurring whilst the patient is taking prophylaxis are likely to be resistant to the agent being taken. Treatment of any acute relapse of UTI should therefore consist of an appropriate alternative drug. Urine culture should be carried out to ensure treatment is with a drug to which the organism is sensitive
    
    
  • antibiotics used in a prophylactic regime are generally alternated every 3-6 months
    
    
• a systematic review concluded that (4)
  • continuous antibiotic prophylaxis for 6-12 months reduced the rate of UTI during prophylaxis when compared to placebo; however there were more adverse events in the antibiotic group
  • one RCT compared postcoital versus continuous daily ciprofloxacin and found no significant difference in rates of UTIs, suggesting that postcoital treatment could be offered to woman who have UTI associated with sexual intercourse

Reference:

1. Dawson S et al. Guidelines for the diagnosis and management of recurrent urinary tract infection in women.Can Urol Assoc J. Oct 2011; 5(5): 316-322
2. Drug and Therapeutics Bulletin (1998), 36(4), 30-2.
3. NICE (October 2018). Urinary tract infection (recurrent): antimicrobial prescribing
4. Fihn SD. Acute uncomplicated urinary tract infection in women. New Eng J Med 2003; 349:259-66.
5. Huertas AX et el. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Huertas. Cochrane Database Syst Rev. 2004;(3):CD001209.