Heterogeneity between studies did not allow a comparison of vaginal estrogens to antibiotics. The role of excretory urography and cystoscopy in the evaluation and management of women with recurrent urinary tract infection. In general, patients who are hemodynamically stable and able to tolerate and absorb oral medications can be treated with oral agents such as fluoroquinolones. For young women with catheter-acquired UTIs, treatment of bacteriuria persisting 48 hours after catheter removal may beconsidered. Click on the thumbnail to expand the algorithm. Dominoni M, Scatigno AL, La Verde M, Bogliolo S, Melito C, Gritti A, Pasquali MF, Torella M, Gardella B. Healthcare (Basel). Disclaimer. Positive culture, regardless of definition, is predicted by symptoms of dysuria, frequency, urgency, hematuria, back pain, self-diagnosis of UTI, nocturia, costovertebral angle tenderness and the absence of vaginal discharge or irritation.11,12 Factors that predispose to recurrent uncomplicated UTI include menopause, family history, sexual activity, use of spermicides and recent antimicrobial use.13,14 A physical examination, including pelvic examination, should also be performed. Stapleton A, Latham RH, Johnson C, et al. If the patient reports incontinence, overactive bladder, or incomplete bladder emptying, postvoid residual urinary volume and urodynamic testing may be helpful in guiding treatment.14,23, Patients who are candidates for prophylactic or self-initiated treatment should have at least one positive urine culture (at least 102 bacterial colonies per mL of a known urinary pathogen) while symptomatic to confirm concordance of symptoms with a true infection.3,5,11,15,17,22 Thereafter, repeat testing during recurrence of typical symptoms may increase cost and inconvenience for the patient, and subsequent benefit is unclear.11,12,17,2325 However, repeat cultures should be obtained to establish resistance patterns in patients who have breakthrough UTIs while receiving prophylactic therapy.11,16 Cultures are warranted in patients with persistent UTI symptoms after 48 hours of antibiotic therapy, or with persistent symptomatic bacteriuria after two weeks of culture-directed antibiotic therapy because this may indicate a relapsed infection, which typically occurs because of antibiotic resistance or a persistent nidus of infection.3,11,13,18 Patients with persistent symptoms but negative cultures should be evaluated for a noninfectious cause of dysuria, such as interstitial cystitis or bladder cancer.3,11, The usefulness of pelvic examination in women with recurrent UTIs is limited; however, findings that predispose patients to complicated UTIs (e.g., cystocele, urethral diverticulum, fistula) may be detected.14,23 Imaging of the upper and lower urologic system with ultrasonography or computed tomography is typically unnecessary and should be guided by the presence of risk factors (Table 1).3,12,14,23 The diagnostic yield of cystoscopy suggesting anatomic abnormalities is less than 15%; therefore, routine cystoscopy is unwarranted.23,2628 Cystoscopy in the setting of negative imaging findings is rarely diagnostic; therefore, noninvasive imaging should be completed first.23. Topical estrogen in the trial involved the use of 0.5 mg of estriol cream vaginally every night for 2 weeks, then twice a week for 8 months. As a library, NLM provides access to scientific literature. official website and that any information you provide is encrypted Before Recurrent urinary tract infections in postmenopausal women. The choice of antibiotic should be based upon the susceptibility patterns of the strains causing the patient's previous cystitis, history of drug allergies, and potential for interactions with other medications. Recurrent uncomplicated UTI may be defined as 3 or more uncomplicated UTIs in 12 months (Level 4 evidence, Grade C recommendation). Urinary tract infections (UTIs) are the most common bacterial infection in women of all ages. Postcoital administration of trimethoprim-sulfamethoxazole was effective in patients with both low (two or fewer times per week) and high (three or more times per week) intercourse frequencies. Urinary tract infections in women. Delaying antibiotic treatment for urinary test results in patients with typical UTI symptoms is not recommended. Enterococcus, Klebsiella, Enterobacter, and Proteus species are less common causes.7. A Cochrane Database systematic review updated in 2008 suggested that there is some evidence cranberry products may prevent recurrent UTI in women.39 This was based on randomized placebo-controlled trials by Stothers40 and Kontiokari and colleagues41 demonstrating a pooled relative risk of 0.61 (95% CI 0.400.91) favouring cranberry over placebo in 241 pooled patients. A prospective study of risk factors for symptomatic urinary tract infection in young women. Uncomplicated urinary tract infections are caused by a predictable group of susceptible organisms. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. Data Sources: A PubMed search was completed using the MeSH function with the key phrase recurrent urinary tract infections combined with at least one of the following terms: women, non-pregnant, pre-menopausal and post-menopausal. Jepson RG, Craig JC. Figure 1 provides an algorithm for the assessment of women presenting with one or more UTI symptoms.13. Nicolle LE, Harding GK, Thomson M, et al. http://www.uptodate.com/contents/recurrent-urinary-tract-infection-in-women, Indwelling catheter, nosocomial infection, surgery, Vesicoureteric reflux, neurologic disease, pelvic floor dysfunction, high post void residual, incontinence, Bladder outlet obstruction, ureteral stricture, ureteropelvic junction obstruction, Pregnancy, urolithiasis, diabetes or other immunosuppression, Gross hematuria after resolution of infection, Obstructive symptoms (straining, weak stream, intermittency, hesitancy), low uroflowmetry or high PVR, Urea-splitting bacteria on culture (e.g., Proteus, Yersinia), Bacterial persistence after sensitivity-based therapy, Pneumaturia, fecaluria, anaerobic bacteria or a history of diverticulitis, Repeated pyelonephritis (fevers, chills, vomiting, CVA tenderness), Asymptomic microhematuria after resolution of infection should be evaluated as per CUA guidelines, Trimethoprim/sulfamethoxazole (TMP/SMX) (40 mg/200 mg daily or thrice weekly). Definition of recurrent uncomplicated UTI, Investigation of recurrent uncomplicated UTI, Prophylactic measures against recurrent uncomplicated UTI. The duration of therapy should be seven days for patients with lower urinary tract symptoms, and 10 to 14 days for patients with upper urinary tract symptoms or sepsis syndrome. Diagnostic evaluation in the setting of predisposing factors (i.e., complicated UTI) differs in that a urine culture including antibiotic sensitivities is almost always required to guide therapy. Efficacy and safety of self-start therapy in women with recurrent urinary tract infections. The site is secure. In affected patients, organisms that are typically less virulent may cause marked illness, although E. coli infection remains the most common organism in nearly all patient groups. Martinez FC, Kindrachuk RW, Thomas E, et al. (Level 4 evidence, Grade C recommendation). However, compared with prophylactic strategies or physician-initiated treatment, this approach seems to minimize the physiologic and financial cost of frequent antibiotic use, cost of diagnosis, number of physician visits, and number of symptomatic days, by limiting doses to symptomatic events.12,15,19,2325,42, Continuous daily and postcoital low-dose antibiotic prophylactic regimens decrease recurrence of symptomatic UTIs by approximately 95%, although patients may revert to preprophylaxis recurrence rates once prophylaxis is discontinued. Continuous prophylaxis, post-coital prophylaxis and intermittent self-treatment with antimicrobials have all been demonstrated to be effective in the prevention of recurrent uncomplicated UTIs. Antimicrobial prophylaxis has proved effective in reducing the risk of recurrent UTIs in women with two episodes of infection in the previous year. The importance of the MSU in rUTIs cannot be underestimated. Unable to load your collection due to an error, Unable to load your delegates due to an error. A prospective, randomized, double-blind study of trimethoprim-sulfamethoxazole for prophylaxis of infection in renal transplantation: clinical efficacy, absorption of trimethoprim-sulfamethoxazole, effects on the microflora, and the cost-benefit of prophylaxis. Recommended regimens are the same for women with diabetes. Trimethoprim-sulfamethoxazole compared with ciprofloxacin for the prevention of urinary tract infection in renal transplant recipients. Diagnosis and Management of Patients with Recurrent Urinary Tract Infection. Kontiokari T, Sundqvist K, Nuutinen M, et al. Patients may then be re-cultured 1 to 2 weeks after initiating therapy adjusted to sensitivity to evaluate for bacterial persistence. The following topics are reviewed in this guideline. Inherited factors seem to influence a woman's susceptibility to recurrent UTIs. Several studies have demonstrated a very low incidence of anatomical abnormalities (0 to 15%) on cystoscopy performed for recurrent UTI.1924 It, therefore, seems unnecessary to perform cystoscopy on all women presenting with recurrent uncomplicated UTI given this low pre-test probability. Either continuous or postcoital prophylactic antibiotics were supported by all guidelines. The typical standard for diagnosing UTI is significant bacteria in a clean-catch or catheterized urine specimen.13 Historically this has been defined as at least 105 colony-forming units per mL, but in symptomatic women a uropathogen concentration of greater than 102 colony-forming units per mL may have the best combination of sensitivity and specificity, and should be used for diagnosis when culture is required.13,15,16 Although UTIs are often treated empirically in the office setting, with a urine culture obtained when the diagnosis is unclear or the symptoms continue despite antibiotic treatment, culture may be necessary in patients with recurrent UTIs to confirm the diagnosis and guide antibiotic therapy. Additionally, adjustment of empirical therapy based on sensitivity may eradicate resistant bacteria as a cause for bacterial persistence and recurrent UTI. and transmitted securely. Asymptomatic bacteriuria is the term used when the standard urine culture detects a uropathogen >10 5 CFU/mL in an individual with no lower urinary tract symptoms. Prophylaxis with daily cranberry tablets may reduce the risk of future UTIs in premenopausal women, but data are conflicting. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Careers. Related letter: "Ultrasensitive Culture in Urinary Tract Infection Diagnosis". The detection and management of vaginal atrophy. Correspondence: Dr. Anil Kapoor, Associate Professor of Surgery (Urology), McMaster University, Director, McMaster Urology Residency Program, 50 Charlton Av E, Hamilton, ON L8N 4A6; An uncomplicated UTI is one that occurs in a healthy host in the absence of structural or functional abnormalities of the urinary tract. 8600 Rockville Pike Fluoroquinolones and nitrofurantoin become better options as suspicion for TMP-SMX resistance increases.18, In cases of recurrence, a test-of-cure urine culture performed approximately one to two weeks after completion of antibiotic therapy may be considered to confirm clearance.2. Raz R, Boger S. Long-term prophylaxis with norfloxacin versus nitrofurantoin in women with recurrent urinary tract infection. However, such influences are largely nonmodifiable and therefore do not alter clinical recommendations. Bent S, Nallamothu BK, Simel DL, et al. Accessibility Persistence involves the same bacteria not being eradicated in the urine 2 weeks after sensitivity-adjusted treatment. Self-start antibiotic therapy is an additional option for women with the ability to recognize UTI symptomatically and start antibiotics.5961 Patients should be given prescriptions for a 3-day treatment dose of antibiotics. Host factors that classify a urinary tract infection as complicated, Physicians should document symptoms patients consider indicative of a UTI, results of any investigations, and responses to treatment. doi: 10.1136/bmjopen-2016-015233. Dielubanza EJ, Schaeffer AJ. Another group of patients who present with recurrent UTIs are those who have predisposing medical conditions placing them at increased risk of developing complicated UTIs, with attendant risks of ascending infection (pyelonephritis) or urosepsis. Imaging in the setting of all women with recurrent UTI is also unnecessary with a low pre-test probability of complicated UTI (absence of criteria in Table 2). Ann Intern Med. Specialist referral is recommended for investigation of women with risk factors for complicated UTI (. The history and physical examination should be focused on ruling out structural or functional abnormalities of the urinary tract (complicated UTI) (Table 1).15, If available, postvoid residual and uroflowmetry are optional tests in postmenopausal women. Because the optimal prophylactic antibiotic is unknown, allergies, prior susceptibility, local resistance patterns, cost and side effects should determine the antibiotic choice.39 Nitrofurantoin followed by cephalexin display the highest rates of treatment dropout.39 Prior to prophylaxis, patients should understand the potential for common side effects and the fact that severe side effects do occur rarely with all antibiotics.44, After discontinuing prophylaxis, women were found to revert to their previous frequency of UTI. In a study of 149 postmenopausal women with recurrent uncomplicated UTI and 53 age-matched controls, higher postvoid residual (23% recurrent UTI vs. 2% control, p < 0.001) and reduced urine flow (45% recurrent uncomplicated UTI vs. 23% control, p = 0.004) were present in women with recurrent uncomplicated UTI.16 In combination with other clinical parameters, abnormalities in these tests may suggest complicated UTI (Table 1). Value of urologic investigation in a targeted group of women with recurrent urinary tract infections. In prospective studies, patient suspicion of UTI is more than 85% accurate in predicting culture-positive infections; this is more accurate than urine dipstick testing.13,15,1822 However, additional evaluation and treatment are warranted in patients with fever, nausea, vomiting, acute back pain, previous urogenital surgery, bladder catheterization, vaginal discharge, pelvic pain, or exposure to a sexually transmitted infection, because these may be signs of a complicated infection or another disease process.13,14,18,23 Pregnancy testing should be considered in premenopausal women. An uncomplicated UTI is one that occurs in a healthy host in the absence of structural or functional abnormalities of the urinary tract.10 All other UTIs are considered complicated UTIs (Table 1). Sixteen patients were randomized to receive postcoital administration of a combination product of trimethoprim and sulfamethoxazole, while 11 received postcoital placebo. Physical examination, laboratory testing, and imaging have limited utility and are not universally recommended. Side effects included vaginal and oral candidiasis, as well as gastrointestinal symptoms. In over 6 months of observation, postcoital administration of trimethoprim-sulfamethoxazole was highly effective in preventing recurrent urinary tract infections. 1 An estimated 30% to 44% of women will have a second UTI within six months of an initial. Please enable it to take advantage of the complete set of features! Society of Obstetricians and Gynaecologists of Canada SOGC clinical practice guidelines. Neal DE., Jr Complicated urinary tract infections. Nickel JC, Wilson J, Morales A, et al. 2017 May 29;7(5):e015233. Women with recurrent symptomatic urinary tract infections can be treated with continuous or postcoital prophylactic antibiotics; other treatment options include self-started antibiotics, cranberry products, and behavioral modification. eCollection 2020. Handley MA, Reingold AL, Shiboski S, et al. Independent risk factors for recurrent UTIs in premenopausal women include sexual intercourse three or more times per week, spermicide use, new or multiple sex partners, and having a UTI before 15 years of age. 91: Treatment of urinary tract infections in nonpregnant women. Pooling 2 studies demonstrated a 0.82 relative risk (95% CI 0.441.53) of microbiologic recurrence per patient-year relative to placebo after discontinuing prophylaxis.39 Six to 12 months of therapy was used in trials demonstrating a benefit; there is no clear evidence to guide treatment after this point, although low-dose trimethoprim/sulfamethoxazole has been tried for up to 5 years.57 If patients wish to continue antibiotic prophylaxis for longer periods, they should be advised that there is no long-term safety data for this and there is a small chance of severe side effects44 and resistant breakthrough infections.9. government site. Melekos MD, Asbach HW, Gerharz E, et al. Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis. Cranberry products may reduce the incidence of recurrent symptomatic UTIs. Klebsiella and group B streptococcus infections are relatively more common in patients with diabetes, and Pseudomonas infections are relatively more common in patients with chronic catheterization. Nonetheless, some factors suggest complicated UTI and warrant cystoscopy (Table 2). Ahmed H, Davies F, Francis N, Farewell D, Butler C, Paranjothy S. BMJ Open. Grabe M, Bjerklund-Johansen TE, Botto H, et al. Abad CL, Safdar N. The role of lactobacillus probiotics in the treatment or prevention of urogenital infectionsa systematic review. The differences in the incidence of UTI prior to and following institution of postcoital prophylaxis were statistically highly significant. coli infection compared with those who have isolated acute cystitis.33 However, both disease processes are caused by similar pathogens and are treated according to local resistance patterns, patient factors, and drug availability (Table 2).1,3,5,11,12,21,23,2932,3436 Compared with longer treatment durations, three-day courses of bactericidal antimicrobials are associated with fewer adverse effects, improved treatment adherence, and similarly low risk of progression to pyelonephritis (less than 1%).11,2931, Ciprofloxacin: 250 mg two times per day for three days, Levofloxacin: 250 to 500 mg per day for three days, Amoxicillin/clavulanate: 500/125 mg two times per day for three days, Cefaclor: 250 mg three times per day for five days, Cefdinir: 300 mg two times per day for five days, Cefpodoxime: 100 mg two times per day for three days, Cephalexin: 500 mg two times per day for seven days, Persistent bacteriuria after resolution of clinical symptoms should be considered asymptomatic bacteriuria and should not be further treated in nonpregnant women.37,38 Furthermore, treatment of asymptomatic bacteriuria may increase the risk of UTI recurrence by altering normal flora.37,38, Although UTIs in women with diabetes have historically been classified as complicated,3,23 new limited data suggest that causative pathogens and resistance rates are comparable to those of UTIs in women without diabetes.3941 Two recent systematic reviews suggest that UTIs in women with diabetes should be treated in the same manner as those in women without diabetes unless risk factors for functionally or anatomically altered voiding are present.11,20. The usual uropathogens include Escherichia coli, Staphylococcus saprophyticus, Klebsiella pneumoniae and Proteus mirabilis.7. Obtaining a serum chemistry panel and assessing the patient's general medical status (e.g., hydration, toxicity) are important. Stapleton and colleagues conducted a randomized placebo-controlled trial with 16 patients in the treatment arm and 11 placebo to demonstrate an 0.3 CRPY in the treatment arm and 3.6 CRPY in the placebo.58 A further randomized controlled trial found no difference in the efficacy of post-intercourse and daily oral ciprofloxacin with 70 patients in the post-intercourse and 65 in the daily group.48 Additional uncontrolled trials have suggested equivalency of other antibiotic regimens.8 Post-coital treatment involves taking a course of antibiotics within 2 hours of intercourse allowing for decreased cost and presumably side effects (Table 3). the contents by NLM or the National Institutes of Health. The latter is supported by cultures that. Three or more uncomplicated UTIs in 12 months is used to define recurrent uncomplicated UTI. Pfau A, Sacks TG. Urinary tract infection: self-reported incidence and associated costs. Although uncomplicated UTI includes both lower tract infection (cystitis) and upper tract infection (pyelonephritis), repeated pyelonephritis should prompt consideration of a complicated etiology. Echols RM, Tosiello RL, Haverstock DC, et al. Postcoital antimicrobial prophylaxis for recurrent urinary tract infection. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. 2013 Mar;65(1):9-20. doi: 10.21037/tau.2017.06.09. A more recent article on urinary tract infections is available, Ultrasensitive Culture in Urinary Tract Infection Diagnosis. MeSH GMS Infect Dis. Recurrent lower urinary tract infection (rUTI) is defined as: 2 or more episodes of lower urinary tract infection in the last 6 months, or 1,11 3 or more episodes of lower urinary tract infection in the last 12 months. The site is secure. Where applicable, English studies based on humans from 1980 to April 2011 were included. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain, and flank pain. Effective postcoital quinolone prophylaxis of recurrent urinary tract infections in women. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Recurrent urinary tract infection. Antibiotic dosing for continuous or postcoital prophylaxis of recurrent cystitis in women The choice of antibiotic should be based upon the susceptibility patterns of the strains causing the patient's previous cystitis, history of drug allergies, and potential for interactions with other medications. The relative risk for severe side effects (requiring treatment withdrawal) was 1.58 (95% CI 0.475.28) and other side effects was 1.78 (95% CI 1.063.00) favoring placebo. If there is no improvement in 48 hours, the patient should be evaluated clinically. Most patients with recurrent uncomplicated UTIs can be treated by family physicians. . The treatment groups were similar with respect to age, parity, diaphragm use, history of lifetime urinary tract infections, frequency of intercourse, and number of lifetime sexual partners. Postmenopausal women with atrophic vaginitis may benefit from topical estrogen therapy. Long-term antibiotics for prevention of recurrent urinary tract infection in older adults: systematic review and meta-analysis of randomised trials. Vaginal estrogen may be an effective prophylaxis measure for UTI in postmenopausal women.62 A 2007 Cochrane Database systematic review found two randomized studies which demonstrated a relative risk of symptomatic UTI during the study period of 0.25 (95% CI 0.130.50)63 and 0.64 (95% CI 0.470.86)64 favouring estrogen in both. Excretory urography, cystography, and cystoscopy in the evaluation of women with urinary-tract infection: a prospective study. Furthermore, variations in urogenital tract anatomy, including a short urethral-anal distance, may predispose some women to UTIs.57. The women were treated Placement and management of urinary bladder catheters in adults Wollin T, Laroche B, Psooy K. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults. Although there is no clear evidence about dosage or duration of use,20 small studies have reported that a daily intake of 150 to 750 mL of cranberry juice or concentrated equivalent is effective in preventing recurrent UTIs.24,25. 1980 Jun;92(6):770-5. doi: 10.7326/0003-4819-92-6-770. Patients may be counselled on modifiable predisposing factors for UTI, including sexual activity and spermicide use.14,3335 Voiding before or after coitus is also unlikely to be harmful, but there is no evidence for this practice.36 The evidence behind lactobacillus probiotics in UTI prophylaxis is also inconclusive.37,38, Evidence for the effectiveness of cranberry products to prevent UTI is conflicting and no recommendation can be made for or against their use. Escherichia coli causes approximately 75% of recurrent UTIs; most other infections are caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus.1,2,5 This article addresses common questions about recurrent UTIs in otherwise healthy nonpregnant women. A randomized, double-blind, placebo-controlled trial. Wong ES, McKevitt M, Running K, et al. Use of spermicide-coated condoms and other risk factors for urinary tract infection caused by Staphylococcus saprophyticus. Diabetes mellitus, neurologic conditions, chronic institutional residence, and chronic indwelling urinary catheterization are important predisposing factors for complicated UTIs. To evaluate the effect of prophylactic fluconazole for very low birth weight infants (VLBWI) in a neonatal intensive care unit (NICU) with a 7.8% incidence of invasive candidiasis (IC). Accessibility Brumfitt W, Smith GW, Hamilton-Miller JM, et al. An official website of the United States government. A history suggestive of uncomplicated acute cystitis in patients with a previous culture-confirmed UTI is typically sufficient for diagnosis of recurrent infection. Prior to referral, culture of the urine while symptomatic and 2 weeks after sensitivity-adjusted treatment may aid in confirming the diagnosis of UTI, as well as guiding further specialist evaluation and management. Imaging and cystoscopy are rarely necessary in healthy women with recurrent UTIs, unless risk factors for complicated infection are present. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Recurrent UTIs are symptomatic UTIs that follow resolution of an earlier episode, usually after appropriate treatment.1 Recurrent UTIs include relapses (i.e., symptomatic recurrent UTIs with the same organism following adequate therapy) and reinfection (i.e., recurrent UTIs with previously isolated bacteria after treatment and with a negative intervening urine culture, or a recurrent UTI caused by a second bacterial isolate).2 Most recurrent UTIs are thought to represent reinfection with the same organism.1 Recurrent UTIs are common among otherwise healthy young women with anatomically and physiologically normal urinary tracts.2 One study showed that of college women with a first UTI, 27 percent had at least one cultureconfirmed recurrence within the following six months, and 2.7 percent experienced a second recurrence over the same period.3 In a primary care setting, 53 percent of women older than 55 years and 36 percent of younger women had a recurrence within one year.4, In symptomatic women, predictors of recurrent UTIs include symptoms following intercourse, signs or symptoms of pyelonephritis, and prompt resolution of symptoms with antibiotics. There are no guidelines for urodynamic evaluation in such patients. Raz R, Stamm WE. Cystoscopy in women with recurrent urinary tract infection. These include local pH and cervicovaginal antibody changes in the vagina; greater adherence of uropathogenic bacteria to the uroepithelium; and possibly pelvic anatomic differences, such as shorter urethra-to-anus distance. Raz R, Gennesin Y, Wasser J, et al. The authors thank Margaret Freiberg for her assistance in the preparation of the manuscript. Kodner CM, Thomas Gupton EK. 2023 Feb 10;11(4):525. doi: 10.3390/healthcare11040525. A variety of factors place patients at risk of complicated UTIs (Table 2),6,11 and recurrent infection is common. Search dates: October 1, 2014, to February 14, 2016. Would you like email updates of new search results? Patient information: See related handout on recurrent urinary tract infections, written by the authors of this article. Management of recurrent urinary tract infections with patient-administered single-dose therapy. The .gov means its official. Suppressive antimicrobial therapy is indicated to prevent frequent, recurrent infection for selected patients with persistent genitourinary abnormalities. Imaging is rarely warranted. HHS Vulnerability Disclosure, Help Urgency, frequency, and possibly incontinence, Vaginal discharge, history of unprotected sexual intercourse, Delayed symptoms or asymptomatic, history of unprotected sexual intercourse, positive test for, External irritation, dyspareunia, vaginal discharge, positive potassium hydroxide or wet-mount preparation, $14 ($66); only available in 250-mg capsule, $12 ($68); half tablet (250 mg) for 30 days, NA ($63); half tablet (400 mg) for 30 days, Trimethoprim/sulfamethoxazole (Bactrim, Septra), A single urine specimen with a quantitative count of at least 10. Presence of anaerobic organisms (with the exception of facultative anaerobes [e.g., Repeat episodes of pyelonephritis or treatment-resistant pyelonephritis, Voiding dysfunction (e.g., elevated postvoid residual volume, incontinence), Hypersensitivity to fosfomycin, suspected pyelonephritis, Minimal change in gut flora; effective against methicillin-resistant, Single dose is appropriate for acute cystitis despite concerns about effectiveness, Glomerular filtration rate less than 40 to 60 mL per minute, history of cholestatic jaundice or hepatic dysfunction with previous use, pregnancy (greater than 38 weeks' gestation), pulmonary or hepatic fibrosis, suspected pyelonephritis; use with caution in patients with G6PD deficiency, Flatus, headache, hemolytic anemia, nausea, neuropathy; risk of pulmonary and hepatic fibrosis with long-term use, Minimal change in gut flora; should be taken with meals; may turn urine orange; effective against, Five-day course is as effective as three-day course of trimethoprim/ sulfamethoxazole for treatment of acute cystitis, 160/800 mg two times per day for three days, History of drug-induced thrombocytopenia or other hematologic disorder, local resistance rates greater than 20%, pregnancy, sulfa allergy, use in previous three to six months; use with caution in patients with hepatic or renal impairment, porphyria, or G6PD deficiency, Bone marrow suppression, electrolyte abnormalities, hepatotoxicity, nausea, nephrotoxicity, photosensitivity, rash, Stevens-Johnson syndrome, Three-day course is appropriate if local resistance rates do not exceed 20%, Fluoroquinolones (e.g., ciprofloxacin, levofloxacin [Levaquin]), Concurrent use with medications that prolong QT interval, hypokalemia, hypomagnesemia, local resistance rates greater than 10%, myasthenia gravis, pregnancy; use with caution in patients with renal impairment, Diarrhea, drowsiness, headache, insomnia, nausea, QT interval prolongation, tendon rupture, Alters gut flora; ciprofloxacin is preferred over other fluoroquinolones; limit use to patients with pyelonephritis or resistant cystitis, Three-day course is highly effective for treatment of cystitis; reserve for treatment of more severe conditions (e.g., pyelonephritis), Beta-lactams (e.g., amoxicillin/clavulanate [Augmentin], cefaclor, cefdinir, cefpodoxime, cephalexin [Keflex]), Cephalosporin or penicillin allergy, history of cholestatic jaundice with previous use; use with caution in patients with renal or hepatic impairment, history of infectious colitis, or active mononucleosis; use cephalexin with caution in patients with elevated international normalized ratios, Alters gut flora; use with caution because of increasing prevalence of ESBL-producing, Courses of three to seven days are appropriate if other agents cannot be used; fewer supporting data for cephalexin; high resistance rates should preclude use of amoxicillin, 40/200 mg (one-half of an 80/400-mg tablet) per day or 40/200 mg three times per week (alternative). No marked difference in recurrent UTIs has been noted when using postcoital prophylaxis compared with daily prophylaxis, 19 and depending on the frequency of sexual intercourse, postcoital prophylaxis usually results in less antibiotic use.6,19 Various postcoital antibiotic regimens are described in Table 4.1,6,19,20, Although not strictly a preventive strategy, self-initiated treatment is an option for some patients. Hibberd PL, Tolkoff-Rubin NE, Doran M, Delvecchio A, Cosimi AB, Delmonico FL, Auchincloss H Jr, Rubin RH. A decision aid to reduce unnecessary antibiotic use for acute cystitis revealed three variables (i.e., dysuria, presence of greater than trace leukocytes, and any positive nitrites) that were most strongly associated with a positive urine culture. Management Scenario: Recurrent UTI (no visible haematuria, not pregnant or catheterized) Urinary tract infection (lower) - women: Scenario: Suspected recurrent UTI without haematuria in women who are not catheterized or pregnant Last revised in February 2023 From age 16 years onwards. This workup confirms a UTI as the cause for the patients recurrent lower urinary tract symptoms. Bethesda, MD 20894, Web Policies Vaginal estrogen creams or rings may also reduce the risk of clinical UTI relative to placebo or no treatment in postmenopausal women (Level 1 evidence, Grade A recommendation). Jent P, Berger J, Kuhn A, Trautner BW, Atkinson A, Marschall J. This content is owned by the AAFP. A 2008 Cochrane Database systematic review pooled 10 trials enrolling 430 women in evaluating continuous antibiotic prophylaxis versus placebo.43 A meta-analysis of these trials demonstrated that the relative risk for clinical recurrence per patient-year (CRPY) was 0.15 (95% CI 0.080.28) favouring antibiotics. Spencer J, Lindsell D, Mastorakou I. Ultrasonography compared with intravenous urography in investigation of urinary tract infection in adults. This and other risk factors are listed in Table 1.8 There is no proven association between recurrent UTIs and pre- or postcoital voiding patterns, frequency of urination, wiping patterns, douching, use of tight undergarments, or delayed voiding habits.1,8 A case-control study of postmenopausal women found that mechanical and physiologic factors affecting bladder emptying (incontinence, cystocele, and postvoiding residual urine) were strongly associated with recurrent UTIs.9 An increased postvoid residual urinary volume (i.e., more than about 50 mL) is an independent risk factor for recurrent UTIs in postmenopausal women.10. sharing sensitive information, make sure youre on a federal Continuous prophylaxis for six to 12 months reduces the rate of UTIs during the prophylaxis period, with no difference between the six-month and 12-month treatment groups after cessation of prophylaxis. Recurrent urinary tract infection in women. Roles of the vagina and the vaginal microbiota in urinary tract infection: evidence from clinical correlations and experimental models. Clipboard, Search History, and several other advanced features are temporarily unavailable. Having a first-degree female relative with a history of five or more UTIs is a risk factor for recurrent UTIs.7 Specific inheritance patterns, such as nuanced neutrophil receptors and nonsecretor status of blood-type antigens, may decrease the immune system's ability to clear bacteria or prevent their attachment to uroepithelium. 14 However, history, physical examination, or urine dipstick analysis alone is not sufficient to reliably rule out UTI. doi: 10.3205/id000046. The antimicrobial susceptibility profile for uropathogens in a community should guide treatment decisions. Double blind, randomized, parallel group, placebo controlled study. The following guidelines were also reviewed: Society of Obstetricians and Gynecologists of Canada (SOGC, 2010),3 European Association of Urology (EAU, Updated 2010),4 American College of Radiology (ACR, Updated 2011)5 and American College of Obstetrics and Gynecology (ACOG, 2008).6, A UTI reflects an infection of the urinary system causing an inflammatory response. 5,11,16, A large meta-analysis conducted in 2004 demonstrated that clinical recurrence of UTI is greatly reduced during antibiotic prophylaxis (relative risk [RR] = 0.15; 95% confidence interval [CI], 0.08 to 0.28; number needed to treat = 2).16 However, once prophylaxis was discontinued, patients reverted to pretreatment frequency of UTI.16, Clinicians should be mindful of local resistance patterns, patient factors, and drug availability when selecting the antimicrobial agent. Antibiotic selection should be based on community resistance patterns, and empiric initial treatment should be guided by likely organisms. Patients with recurrent UTIs may be at higher risk of nonE. Author disclosure: No relevant financial affiliations. Women with previous UTIs who are able to recognize the symptoms can be treated effectively with self-started antibiotic therapy.21,22 Women can be given a prescription for a three-day antibiotic regimen and instructed to start therapy when symptoms develop. Nine of 11 patients who took the placebo developed urinary tract infections (infection rate, 3.6 per patient-year), compared with only two of 16 patients who received postcoital trimethoprim-sulfamethoxazole (infection rate, 0.3 per patient-year). Patients with recurrent UTIs should be counseled about risk factors such as spermicide use, frequent sexual intercourse, and new sex partners, as well as about preventive measures. Lawrentschuk N, Ooi J, Pang A, et al. 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. Rudenko N, Dorofeyev A. When working up recurrent uncomplicated UTI, culture and sensitivity analysis should be performed at least once while the patient is symptomatic. FOIA At least one symptomatic episode should be verified by urine culture to confirm the diagnosis and guide treatment. ACR Appropriateness Criteria. Beta-lactams are less effective. Recurrent urinary tract infections, presenting as dysuria or irritative voiding symptoms, are most commonly caused by reinfection with the original bacterial isolate in young, otherwise healthy women with no anatomic or functional abnormalities of the urinary tract. Recurrent urinary tract infections (UTIs) are common in women and associated with considerable morbidity and health care use. 2017 Jul;6(Suppl 2):S142-S152. HHS Vulnerability Disclosure, Help Cetti RJ, Venn S, Woodhouse CR. Episodes of recurrent UTI are typically characterized by dysuria and urinary frequency or hesitancy. Bookshelf Eriksen B. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Several series demonstrate a low yield of non-incidental findings following imaging for recurrent UTI and it is not routinely recommended by the Society of Obstetricians and Gynecologists of Canada (SOGC), American College of Radiology (ACR), European Association of Urology guidelines.3,5,9,2024, When there is high clinical suspicion of an abnormality (Table 2), a computed tomography image of the abdomen and pelvis with and without contrast is the best imaging technique for detecting causes of complicated UTI.25 To minimize radiation exposure, ultrasound imaging of the urinary tract with an optional abdominal X-ray is also appropriate.2631 Imaging to rule out specific causes of UTI (Table 1) is optimized in consultation with a radiologist or the 2011 ACR guidelines.5. Bailey RR, Roberts AP, Gower PE, et al. A positive urine culture with greater than 102 colony-forming units per mL is the standard for diagnosing urinary tract infections in symptomatic patients, although culture is often unnecessary for diagnosing typical symptomatic infection. Patients also may be counseled about the theory and anecdotal evidence behind postcoital voiding, although no controlled studies support this intervention. A UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which then ascend to cause a bacterial cystitis. 17 Because fluoroquinolones are commonly used to treat complicated UTIs and other nonurinary disorders, resistance to this drug class is a concern. In one Cochrane review,23 cranberry juice showed moderate benefit in reducing the risk of UTI in women with a history of recurrent infection, based on two well-designed randomized trials. A UTI may be recurrent when it follows the complete clinical resolution of a previous UTI.8 A threshold of 3 UTIs in 12 months is used to signify recurrent UTI.3 The pathogenesis of recurrent UTI involves bacterial reinfection or bacterial persistence, with the former being much more common.8 In bacterial persistence, the same bacteria may be cultured in the urine 2 weeks after initiating sensitivity-adjusted therapy. *Division of Urology, Department of Surgery, McMaster University, Hamilton, ON; Department of Family Medicine, McMaster University, Hamilton, ON, Recurrent uncomplicated urinary tract infection (UTI) is a common presentation to urologists and family doctors. Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. The duration of prophylaxis should be guided by the severity of patient symptoms and by physician and patient preference. Sen A. Recurrent cystitis in non-pregnant women. Copyright 2023 American Academy of Family Physicians. Can ultrasound replace the intravenous urogram in preliminary investigation of renal tract disease? Data are conflicting about the effectiveness of cranberry products for preventing recurrent UTI in premenopausal women.4650 A 2012 meta-analysis demonstrated a decrease in UTI rates in women who received daily cranberry tablets (RR = 0.53; 95% CI, 0.33 to 0.83).48 However, a 2012 Cochrane review found insufficient evidence to recommend routine use of cranberry products for pro-phylaxis.50 They are generally a low-risk intervention and may prove to be another means to reduce UTI episodes and antibiotic use. These infections can be empirically treated without the need for urine cultures. Fox BC, Sollinger HW, Belzer FO, Maki DG. Proteus mirabilis i s a c ommon u ropathogen i n p atients with indwelling catheters, spinal cord injuries, or structural abnormalities of the urinary tract.7, The strongest risk factor for recurrent UTIs in young women is frequency of sexual intercourse. van Haarst EP, van Andel G, Heldeweg EA, et al. Unauthorized use of these marks is strictly prohibited. . Six months of treatment, followed by observation for reinfection after discontinuing prophylaxis, has been empirically recommended.1 Some authorities have recommended longer courses (two to five years) in patients who continue to have recurrent symptomatic infections. In 2011, a randomized placebo-controlled trial of cranberry juice versus placebo juice with 319 participants showed no significant difference in UTI recurrence rates between these two groups.42 Various criticisms have been made of each of these studies.9,39,42. The treatment's effectiveness can be explained by two features of the two antibacterial agents involved: both reach high bactericidal concentrations in the urinary tract and induce no (or minimal) resistance in the introital gram-negative bacterial flora. PMC A threeday course of trimethoprim/sulfamethoxazole (TMPSMX; Bactrim, Septra) is the current standard therapy, with three days of trimethoprim or a fluoroquinolone (i.e., ofloxacin, norfloxacin [Noroxin], or ciprofloxacin [Cipro]) being equally effective. However, compared with treatment based on self-diagnosis, this strategy is not preferred because it may increase the number of symptomatic days and cost of diagnosis.11,24,25, Cranberries contain proanthocyanidins, which may prevent adherence of E. coli to uroepithelial cells. Frequent intercourse likely causes inoculation of the urethra and bladder by fecal flora, whereas spermicide use disrupts the healthy Lactobacillus flora of the vaginal canal, thereby allowing ascent of uropathogens.68 In premenopausal women, intercourse three or more times per week triples the risk of UTI.8 Well-designed case-control studies suggest that body mass index, wiping back-to-front after bowel movements, hot tub use, douching, frequent tampon use, increased hydration, and wearing cotton underwear have no effect on the risk of recurrence.5,6 Postcoital urination seems to have little protective effect but is a reasonable and safe practice.6, In otherwise healthy postmenopausal women, estrogen deficiency is a risk factor for recurrent UTIs because of changes in Lactobacillus flora and vaginal pH.9 Other risk factors in postmenopausal women include incontinence, a postvoid residual urinary volume exceeding 150 mL, structural abnormalities (e.g., cystocele), type 1 or 2 diabetes mellitus, or a history of more than five UTIs.6,9 Activities that increase intra-abdominal pressure (e.g., long-distance walking or traveling) may exacerbate incontinence, cystocele, or postvoid residual urine, and may predispose women who engage in these activities to UTIs.9,10. Continuous and postcoital antimicrobial prophylaxis have demonstrated effectiveness in reducing the risk of recurrent UTIs. Based on consensus opinion and limited data, an initial six- to 12-month course should be offered.3,11,16 Small studies have shown effectiveness for up to five years, although long-term adverse effects such as antibiotic resistance and reversible pulmonary fibrosis from several years of nitrofurantoin use have been reported.3 Common dosing options for antibiotic prophylaxis are listed in Table 3.3,12,14,16,23. Escherichia coli is the most common organism in all patient groups, but Klebsiella, Pseudomonas, Proteus, and other organisms are more common in patients with certain risk factors for complicated urinary tract infections. Gupta K, Hooton TM, Roberts PL, et al. Cranberries for preventing urinary tract infections. Various dosages of prophylactic antibiotics have been suggested (Table 4),1,6,19,20 but no conclusive evidence supports selection of a particular drug, dosage, or duration or schedule of treatment. Antimicrobial prophylaxis of recurrent urinary tract infections: a double-blind, placebo-controlled trial. Common differential diagnoses for recurrent dysuria are listed in Table 3.12, Key steps in the diagnostic evaluation for recurrent UTIs include confirming the presence of a bacterial UTI, assessing the patient for risk factors and predisposing factors for complicated infection, and identifying a potentially causative organism. The same species that caused previous infections is typically responsible for recurrences. Systemic symptoms and even sepsis may occur with kidney infection. Foxman B, Barlow R, DArcy H, et al. Ultrasound of the pelvis and renal tract combined with a plain film of abdomen in young women with urinary tract infection: can it replace intravenous urography? A double-blind, randomized controlled trial. A clinical comparison between Macrodantin and trimethoprim for prophylaxis in women with recurrent urinary infections. Copyright 2016 by the American Academy of Family Physicians. Consequently, fluoroquinolones are not recommended as initial empiric therapy except in communities with high rates of resistance to other agents.17 With increasing concern for E. coli resistance to TMP-SMX (up to 15 to 20 percent in some areas of the United States), nitrofurantoin (Macrodantin) is a safe and generally effective agent if administered for seven days.1, As the number and frequency of recurrences increase, the treatment strategy is less well-defined. Segal AJ, Amis ES, Jr, Bigongiari LR, et al. The definition of complicated UTI is imprecise, but the term usually is applied to patients with a predisposing structural or functional abnormality of the genitourinary tract.6 Ascending infection, antibiotic resistance, and the need for prolonged therapy are often involved. JAMES J. ARNOLD, DO, LAURA E. HEHN, MD, AND DAVID A. KLEIN, MD, MPH. In postmenopausal women, risk is primarily increased by sequelae of lower estrogen levels. Recommendations are made based on systematic searches of Ovid MEDLINE, the Cochrane Library, EMBASE and MacPLUS FS. ACOG Practice Bulletin No. Federal government websites often end in .gov or .mil. and transmitted securely. The antibiotic regimen should be narrowed, when possible, to within 48 to 72 hours based on culture results. Survey data suggest that 1 in 3 women will have had a diagnosed and treated UTI by age 24 and more than half will be affected in their lifetime.1 In a 6-month study of college-aged women, 27% of these UTIs were found to recur once and 3% a second time.2. Epp A, Larochelle A, Lovatsis D, et al. Transl Androl Urol. National Library of Medicine Most patients with recurrent uncomplicated UTI may be treated successfully by family physicians.32 Specialist referral for recurrent uncomplicated UTI is indicated when risk factors for complicated UTI are present (Table 2). Lewis-Jones HG, Lamb GH, Hughes PL. Patient-initiated treatment lowers the cost of diagnosis, physician visits, and symptomatic days compared with physician-initiated treatment, and reduces antibiotic exposure compared with antibiotic prophylaxis. Managing recurrent infections should include modification of known risk factors. Mogensen P, Hansen LK. Urinary tract infections (UTIs) are the most common bacterial infection in women of all ages.1 An estimated 30% to 44% of women will have a second UTI within six months of an initial infection.24 Healthy women with normal urologic anatomy account for most patients who have recurrent UTIs.15, Recurrent UTI is typically defined as three or more UTIs in 12 months, or two or more infections in six months.25 Recurrence is thought to occur by ascent of uropathogens in fecal flora along the urogenital tract and by reemergence of bacteria from intracellular bacterial colonies in uroepithelial cells. 8600 Rockville Pike Women with one symptom of UTI have an infection probability of about 50 percent.13 In one systematic review, a combination of symptoms (i.e., dysuria, frequency, and absence of vaginal irritation or discharge) raised the probability of UTI to more than 90 percent,13 suggesting that history alone is often sufficient to confirm diagnosis. A three-day course of trimethoprim/sulfamethoxazole, a one-day course of fosfomycin (Monurol), or a five-day course of nitrofurantoin is as effective as longer treatment courses in achieving clinical cure of an isolated or recurrent UTI. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Barrons R, Tassone D. Use of Lactobacillus probiotics for bacterial genitourinary infections in women: a review. 19 Prophylactic antibiotic selection should be made on the basis of community resistance patterns, side effects, and local costs. Persisting 48 hours after catheter removal may beconsidered for young women was highly effective the... Reingold al, Shiboski S, Woodhouse CR urogenital infectionsa systematic postcoital prophylaxis for uti and meta-analysis of randomised trials patterns, chronic! 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