Clinical Review

Recurrent UTIs in Women: How to Refine Your Care

Clinician Reviews. 2017 August;27(8):44-49

References

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8. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366:1028-1037.
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14. Hooton TM, Fennell CL, Clark AM, et al. Nonoxynol-9: differential antibacterial activity and enhancement of bacterial adherence to vaginal epithelial cells. J Infect Dis. 1991; 164: 1216-1219.
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20. Raz R, Gennesin Y, Wasser J, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis. 2000; 30:152-156.
21. Gupta K, Stapleton AE, Hooton TM, et al. Inverse association of H2O2-producing lactobacilli and vaginal Escherichia coli in women with recurrent urinary tract infections. J Infect Dis. 1998;178:446-450.
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24. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103-e120.
25. FDA. FDA drug safety communication. www.fda.gov/downloads/Drugs/DrugSafety/UCM500591.pdf. Accessed June 8, 2017.
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INITIAL EVALUATION OF RECURRENT UTI

Patients with recurrent UTI experience signs and symptoms similar to those with isolated uncomplicated UTI: dysuria, frequency, urgency, and hematuria. Focus your history interview on potential causes of complicated UTI (see Table 2).¹⁸ Likewise, perform a pelvic exam to evaluate for predisposing anatomic abnormalities.²² Finally, obtain a urine culture with antibiotic sensitivities to ensure that previous treatment was appropriate and to rule out microbes associated with infected uroliths.¹⁸ Given the low probability of finding abnormalities on cystoscopy or imaging, neither one is routinely recommended for the evaluation of recurrent UTI.¹⁸

TREATMENT OPTIONS AND PRECAUTIONS

As with isolated UTI, E coli is the most common pathogen in recurrent UTI. However, recurrent UTI is more likely than isolated UTI to result from other pathogens (odds ratio [OR], 1.5), such as Klebsiella, Enterococcus, Proteus, and Citrobacter.²³ Since a patient’s recurrent UTI most likely arises from the same pathogen that caused the prior infection, start an antibiotic you know is effective against it.⁸ Additionally, take into account local resistance rates; antibiotic availability, cost, and adverse effects; and a patient’s drug allergies.

Preferred antibiotics. Trimethoprim-sulfamethoxazole (TMP-SMX; 160 mg/800 mg bid for 3 d) has long been the mainstay of treatment for uncomplicated UTI. In recent years, however, resistance to TMP-SMX has increased. While it is still appropriate for many situations as firstline treatment, it is not recommended for empiric treatment if local resistance rates are higher than 20%.²⁴ Nitrofurantoin (100 mg bid for 5 d) has efficacy similar to that of TMP-SMX but without significant bacterial resistance. While fosfomycin (3 g as a single dose) is still recommended as firstline treatment, it is less effective than either TMP-SMX or nitrofurantoin. Table 3 summarizes these antibiotic choices and their efficacies.²⁴

Agents to avoid or use only as a last resort. For patients who are unable to take any of the mentioned drugs, consider ß-lactam antibiotics—although they are typically less effective for this indication. While fluoroquinolones are very effective and have low (but rising) resistance rates, they are also associated with serious and potentially permanent adverse effects. As a result, on May 12, 2016, the FDA issued a Drug Safety Communication recommending that fluoroquinolones be used only in patients without other treatment options.^24,25 Do not use ampicillin or amoxicillin, which lack effectiveness for this indication and are compromised by high levels of bacterial resistance.

Shorter course of treatment? When deciding on the length of treatment for recurrent UTI, remember that shorter antibiotic courses (3-5 d) are associated with similar rates of cure and progression to systemic infections as longer courses (7-10 d). Also, patients adhere better to the shorter treatment regimen and experience fewer adverse effects.^26,27

Standing prescription? Studies have shown that women know when they have a UTI. Therefore, for those who experience recurrent UTI, consider giving them a standing prescription for antibiotics that they can initiate when symptoms arise (see Table 3).²⁴ Patient-initiated treatment yields similar rates of efficacy as clinician-initiated treatment, while avoiding the adverse effects and costs associated with preventive strategies (see text).²⁸

TIME FOR IMAGING AND REFERRAL?

For patients with a high risk for complicated UTI or a surgically amenable condition, either ultrasound or CT of the abdomen and pelvis with and without contrast is appropriate to evaluate for anatomic anomalies. While CT is the more sensitive imaging study to identify anomalies, ultrasound is less expensive and minimizes radiation exposure and is therefore also appropriate.¹⁸

Consider referring patients to a urologist if they have an underlying condition that may be amenable to surgery, such as bladder outlet obstruction, cystoceles, urinary tract diverticula, fistulae, pelvic floor dysfunction, ureteral stricture, urolithiasis, or vesicoureteral reflux.¹⁸ Additional risk factors for complicated UTI, which warrant referral as outlined by the Canadian Urologic Association, are summarized in Table 2.¹⁸

Two weeks later … and it’s back? Finally, for women who experience recurrent symptoms within two weeks of completing treatment, obtain a urine culture with antibiotic sensitivities to ensure that the infecting organism is not one typically associated with urolithiasis (Proteus and Yersinia) and that it is susceptible to planned antibiotic therapy.¹⁸Proteus and Yersinia are urease-positive bacteria that may cause stone formation in the urinary tract system. Evaluate any patient who has a UTI from either organism for urinary tract stones.

Recurrent UTIs in Women: How to Refine Your Care

References

INITIAL EVALUATION OF RECURRENT UTI

TREATMENT OPTIONS AND PRECAUTIONS

TIME FOR IMAGING AND REFERRAL?

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