Clinical Review

Recurrent UTIs in Women: How to Refine Your Care

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

References

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2. CDC. Annual number and percent distribution of ambulatory care visits by setting type according to diagnosis group: United States, 2009-2010. www.cdc.gov/nchs/data/ahcd/combined_tables/2009-2010_combined_web_table01.pdf. Accessed June 8, 2017.
3. Griebling TL. Urologic Diseases in America project: trends in resource use for urinary tract infections in women. J Urol. 2005;173:1281-1287.
4. Ikaheimo R, Siitonen A, Heiskanen T, et al. Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women. Clin Infect Dis. 1996;222:91-99.
5. Sammon JD, Sharma P, Rahbar H, et al. Predictors of admission in patients presenting to the emergency department with urinary tract infection. World J Urol. 2014;32:813-819.
6. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40:643-654.
7. Barber AE, Norton JP, Spivak AM, et al. Urinary tract infections: current and emerging management strategies. Clin Infect Dis. 2013;57:719-724.
8. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366:1028-1037.
9. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 91: treatment of urinary tract infections in nonpregnant women. Obstet Gynecol. 2008;111:785-794.
10. Sheinfeld J, Schaeffer AJ, Cordon-Cardo C, et al. Association of the Lewis blood group phenotype with recurrent urinary tract infections in women. N Engl J Med. 1989;320:773-777.
11. Foxman B, Gillespie B, Koopman J, et al. Risk factors for second urinary tract infection among college women. Am J Epidemiol. 2000;151:1194-1205.
12. Twaij M. Urinary tract infection in children: a review of its pathogenesis and risk factors. J R Soc Health. 2000;120:220-226.
13. Scholes D, Hooton TM, Roberts DL, et al. Risk factors for recurrent urinary tract infection in young women. J Infect Dis. 2000;182:1177-1182.
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.
15. Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med. 1996;335:468-474.
16. Hooton TM, Hillier S, Johnson C, et al. Escherichia coli bacteriuria and contraceptive method. JAMA. 1991;265:64-69.
17. Foxman B, Marsh J, Gillespie B, et al. Condom use and first-time urinary tract infection. Epidemiology. 1997;8:637-641.
18. Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Can Urol Assoc J. 2011;5:316-322.
19. Hooton TM. Pathogenesis of urinary tract infections: an update. J Antimicrob Chemother. 2000;46(suppl 1):1-7.
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.
22. Neal DE. Complicated urinary tract infections. Urol Clin North Am. 2008;35:13-22.
23. Amna MA, Chazan B, Raz R, et al. Risk factors for non-Escherichia coli community-acquired bacteriuria. Infection. 2013;41:473-477.
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.
26. Katchman EA, Milo G, Paul M, et al. Three-day vs longer duration of antibiotic treatment for cystitis in women: systematic review and meta-analysis. Am J Med. 2005;118:1196-1207.
27. Milo G, Katchman EA, Paul M, et al. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2005;(2):CD004682.
28. Gupta K, Hooton TM, Roberts PL, et al. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med. 2001;135:9-16.
29. Nicolle LE, Ronald AR. Recurrent urinary tract infection in adult women: diagnosis and treatment. Infect Dis Clin North Am. 1987;1:793-806.
30. Ronald AR, Conway B. An approach to urinary tract infections in ambulatory women. Curr Clin Top Infect Dis. 1988; 9:76-125.
31. Aydin A, Ahmed K, Zaman I, et al. Recurrent urinary tract infections in women. Int Urogynecol J. 2015;26:795-804.
32. McLaughlin SP, Carson CC. Urinary tract infections in women. Med Clin North Am. 2004;88:417-429.
33. Albert X, Huertas I, Pereiro II, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev. 2004;(3):CD001209.
34. Melekos MD, Asbach HW, Gerharz E, et al. Post-intercourse versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal women. J Urol. 1997;157: 935-939.
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39. Beerepoot MA, ter Riet G, Nys S, et al. Lactobacilli vs antibiotics to prevent urinary tract infections: a randomized, double-blind, noninferiority trial in postmenopausal women. Arch Intern Med. 2012;172:704-712.
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PREVENTION DOS AND DON’TS

Popular myth suggests that recurrent UTIs are more common in patients who do not void after intercourse or those who douche, consume caffeinated beverages, or wear noncotton underwear. Research, however, has failed to show a relationship between any of these factors and recurrent UTIs.^13,18 Clinicians should therefore stop recommending that patients modify these behaviors to decrease recurrent infections.

Antibiotic prophylaxis decreases the rate of recurrent UTI by 95%.²⁹ It has been recommended for women who have had two or more UTIs in the past six months or three or more UTIs in the past year.^29,30 Effective strategies to prevent recurrent UTI are low-dose continuous antibiotic prophylaxis or postcoital antibiotic prophylaxis.

While a test-of-cure culture is not typically recommended following treatment for uncomplicated UTI, you will want to obtain a confirmatory urine culture one to two weeks before starting low-dose antibiotic prophylaxis. Base your choice of antibiotic on known patient allergies and previous culture results. Agents typically used are trimethoprim, TMP-SMX, or nitrofurantoin (see Table 4), none of which demonstrated superiority in a Cochrane review.^31-33 Although the same review showed no optimal duration of treatment, six to 24 months of treatment is usually recommended.^29,33

A single dose of antibiotic following intercourse may be as effective as daily low-dose prophylaxis for women whose UTIs are related to sexual activity.³⁴ Studies have shown that single doses of TMP-SMX, nitrofurantoin, cephalexin, or a fluoroquinolone (see earlier notes about the FDA warning on fluoroquinolone use) are similarly effective in decreasing the rate of recurrence (see Table 4).^31,35,36

Several nonpharmacologic strategies have been suggested for prevention of recurrent UTI. Among them are use of cranberry products, lactobacillus, vaginal estrogen in postmenopausal women, methenamine salts, and D-mannose.

A 2012 Cochrane review of 24 studies found that cranberry products were less effective in preventing recurrent UTIs than previously thought, with no statistically significant difference between women who took them and those who did not.³⁷

Results have been mixed in using lactobacilli or probiotics to prevent recurrent UTIs. One study examining the use of lactobacilli to colonize the vaginal flora found a reduction in the number of recurrent infections in premenopausal women taking intravaginal lactobacillus over 12 months.³⁸ A second study, involving postmenopausal women, found that those who were randomized to take lactobacillus tablets for 12 months had more frequent recurrences of UTIs than women randomized to take daily TMP-SMX.³⁹ However, this last study was designed as a noninferiority trial, and its results do not negate the prior study’s findings. Additionally, vaginal estrogen, which is thought to work through colonization of the vagina with lactobacilli, has prevented recurrent UTIs in postmenopausal women.⁴⁰

Ascorbic acid (which is bacteriostatic), methenamine salts (which are hydrolyzed to bactericidal ammonia and formaldehyde), and D-mannose (which inhibits bacterial adherence) have been shown—in limited studies—to decrease recurrence of UTIs.^41-43 Further study is necessary to confirm their efficacy in preventing UTIs.

As noted, the only behavioral modifications that have been shown to decrease the risk for recurrent UTI are discontinuing the use of spermicides/spermicide-coated condoms or oral contraceptives, and decreasing the frequency of intercourse.¹³

Joan is started on a three-day course of TMP-SMX. Further questioning reveals that each of her three UTIs followed sexual intercourse. Her clinician discusses the options of self-directed therapy using continuous prophylaxis or postcoital prophylaxis, either of which would be an appropriate evidence-based intervention for her. After engaging in shared decision-making, she is prescribed TMP-SMX to be taken as a single dose following intercourse in the future.

Recurrent UTIs in Women: How to Refine Your Care

References

PREVENTION DOS AND DON’TS

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