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recurrent urinary tract infection

Diagnostic criteria: - 2 or more UTIs within 6 months - 3 or more UTIs within 12 months - presents > 2 weeks after completion of therapy for index UTI [5] Etiology: 1) risk factors a) young women - sexual intercourse - use of diaphragm or spermicides - history of urinary tract infection b) healthy elderly women* - prior history of urinary tract infection - genetic predisposition - cystocele - increased post-void residual volume - urinary incontinence c) frail elderly women - poor functional status - requirement for skilled nursing care - foley catheter d) elderly men: underlying urologic disorder e) children: vesicoureteral reflux [11] 2) caused by a different organism than the index UTI [5] * estrogen deficiency & sexual activity may also play a role Clinical manifestations: - presents > 2 weeks after treatment completion of previous infection Laboratory: - urinalysis & urine culture [5] Special laboratory: - voiding cystourethrogram [13] - includes post-void residual volume Management: 1) treat incontinence, bladder obstruction, urinary stasis 2) fluids - drinking an additional 1.5 L of water daily helpful (RR=0.53) [14] - cranberry juice may or may not be of benefit [4] - effective [1] - associated with a protective effect [7] 3) topical vaginal estrogen for postmenopausal women [1] 4) antibiotic therapy - nitrofurantoin 100 mg PO BID for 5 days (uncomplicated recurrent UTI in women) - trimethoprim-sulfamethoxazole within past 3-6 months associated with risk for resistance - use ciprofloxacin if previous treatment with TMP-SMX - ref [15] (NEJM Knowledge+) denies this - says flouroquinolone not recommended - since recurrent UTI is caused by a different organism than the index UTI, a different antibiotic may be prudent [5] 5) antibiotic prophylaxis [2] a) indications - >= 3 UTI in past years of >= 2 UTI in past 6 months - post-coital prophylaxis b) antibiotic (daily dose) 1] trimethoprim/sulfamethoxazole (TMP/SMX) - 40 mg/200 mg (1/2 single-strenth tab) - 80 mg/400 mg (1 single strength tab) daily more effective than cranberry juice in premenopausal women [4] - TMP/SMX resistance higher in children receiving prophylaxis, but resistance declines with time [11] 2] nitrofurantoin 50-200 mg 3] ciprofloxacin 125 mg 4] Cephalexin 125-250 mg c) continuous prophylaxis QHS dosing d) post-coital prophylaxis 1] ciprofloxacin 125 mg 2] Cephalexin 125-250 mg e) acute self-treatment 1] ciprofloxacin 250 mg BID for three days 2] Bactrim DS BID for 2 days 3] nitrofurantoin 100 mg PO BID for 5 days [5] f) ref [1] cites risks for antibiotic resistance, C difficile, & adverse effects g) older men with recurrent UTI & underlying urologic disorder that cannot be identified or corrected may need long-term antibiotic therapy [10] - suspect chronic bacterial prostatitis if recurrent UTI with same organism 6) lactobacillus as effective as trimethoprim/sulfamethoxazole - Lactobacillus rhamnosus GR-1 & L reuteri RC-14 BID at standard doses [3]

General

urinary tract infection (UTI) recurrent infection

References

  1. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  2. Prescriber's Letter 19(4): 2012 Prevention of Recurrent Urinary Tract Infections in Women Detail-Document#: 280411 (subscription needed) http://www.prescribersletter.com
  3. Beerepoot MAJ et al. Lactobacilli vs antibiotics to prevent urinary tract infections: A randomized, double-blind, noninferiority trial in postmenopausal women. Arch Intern Med 2012 May 14; 172:70 PMID: 22782199 http://archinte.jamanetwork.com/article.aspx?articleid=1151418
  4. Beerepoot MA et al Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. Arch Intern Med. 2011 Jul 25;171(14):1270-8. PMID: 21788542
  5. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
  6. Dielubanza EJ, Schaeffer AJ. Urinary tract infections in women. Med Clin North Am. 2011 Jan;95(1):27-41 PMID: 21095409
  7. Wang CH et al Cranberry-Containing Products for Prevention of Urinary Tract Infections in Susceptible Populations: A Systematic Review and Meta-analysis of Randomized Controlled Trials Arch Intern Med. 2012;172(13):988-996 PMID: 22777630
  8. McMurdo ME, Argo I, Phillips G, Daly F, Davey P Cranberry or trimethoprim for the prevention of recurrent urinary tract infections? A randomized controlled trial in older women. J Antimicrob Chemother. 2009 Feb;63(2):389-95. PMID: 19042940
  9. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med 2012 Mar 16; 366:1028. PMID: 22417256
  10. Schaeffer CG, Nicolle LE Urinary Tract Infections in Older Men. N Engl J Med 2016; 374:562-571. February 11, 2016 PMID: 26863357 http://www.nejm.org/doi/full/10.1056/NEJMcp1503950
  11. Judge C, Sadoughi S, Sofair A TMP-SMX Resistance in Pediatric Recurrent UTIs Higher after Prophylaxis but Declines Over Time. Physician's First Watch, March 14, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Nelson CP, Hoberman A, Shaikh N et al Antimicrobial Resistance and Urinary Tract Infection Recurrence. Pediatrics. April 2016 PMID: 26969273 http://pediatrics.aappublications.org/content/early/2016/03/09/peds.2015-2490
  12. Anonymous Prevention of recurrent urinary tract infections in women. Drug Ther Bull. 2013 Jun;51(6):69-72 PMID: 23766394
  13. NEJM Knowledge+ Question of the Week. July 18, 2017 https://knowledgeplus.nejm.org/question-of-week/4371/
  14. Hooton TM, Vecchio M, Iroz A et al - Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections. A Randomized Clinical Trial. JAMA Intern Med. Published online October 1, 2018 PMID: 30285042 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2705079 - Grady D Drinking More Water for Prevention of Recurrent Cystitis. JAMA Intern Med. Published online October 1, 2018 PMID: 30285051 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2705077
  15. NEJM Knowledge+