Recurrent UTIs in women: How you can refine your care
Which risk factors are (really) associated with recurrence? Which prophylactic and nonpharmacologic strategies are useful? This guide provides the answers.
PRACTICE RECOMMENDATIONS
› Avoid routine use of cystoscopy and imaging when evaluating women with recurrent urinary tract infection (UTI).
› Keep in mind that 3- to 5-day courses of antibiotics (nitrofurantoin, trimethoprim- sulfamethoxazole, fosfomycin, or beta-lactams) for UTIs are as effective as longer courses, and are associated with better compliance and fewer adverse effects.
› Assure patients considering prophylaxis for recurrent UTI that either continuous or postcoital antibiotics are effective.
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Ascorbic acid (which is bacteriostatic), methenamine salts (which are hydrolysed 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 of recurrent UTI are discontinuing the use of spermicides/spermicide-coated condoms or oral contraceptives, and decreasing the frequency of intercourse.13
CASE › Ms. B is started on a 3-day course of TMP-SMX. Further questioning reveals that each of her 3 UTIs followed sexual intercourse. Her physician 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.
CORRESPONDENCE
Jeffrey D. Quinlan, MD, FAAFP, Family Medicine, Room A-1038A, 4301 Jones Bridge Road, Bethesda, MD 20814-4712; jeffrey.quinlan@usuhs.edu.
