Urinary tract infections (UTIs) are common. It’s estimated that 60% of women will have a UTI in their lifetime and as many a 10% of women will have repeated UTIs, defined as ≥ 3 infections in a 12-month period. Given the frequency of this problem, an approach is offered below to help providers manage these patients, including several steps for managing repeated UTIs.

1. Decide whether an infection is present: Asymptomatic bacteriuria is common and characterized by a significantly positive urine culture with or without pyuria but lacking acute clinical evidence of infection. Treating asymptomatic bacteriuria does the patient no good and may be harmful (increased resistance and adverse drug events). Look for new acute dysuria (<one week), new urinary urgency or frequency, gross hematuria, suprapubic or costovertebral angle pain or tenderness, and fever to make a UTI diagnosis. In cognitively impaired patients, change in mental status and character of the urine may indicate infection but an evaluation and treatment for other causes should be considered first. Chronic urgency, frequency, pelvic pain and even dysuria are poorly predictive of UTI and may respond better to symptomatic treatment. Atrophic vaginitis, overactive bladder, and constipation may all mimic UTI symptoms.

2. Decide if the problem is a recurrent or relapsing problem: Relapsing UTIs tend to occur within two weeks of treatment discontinuation and have the same bacterial organism repeatedly. This would indicate anatomic issue such as obstruction, stones, bladder pathology, high post-void residual or bacterial resistance. Further evaluation such as imaging or cystoscopy should be considered in setting of relapsing infections. Recurrent disease tends to occur less frequently and have a variety of bacterial pathogens. This is more likely to indicate post-coital, post-menopausal, fecal contamination or other systemic disease.

3. Take more history: Diabetes, functional disability such as previous CVA, associated sexual activity, bowel and urinary incontinence, previous urologic procedure or malignancy, feculent urine, and nephrolithiasis are associated with repeated UTIs and should be assessed.

4. Do a physical: A pelvic examination should be done on patients with repeated UTIs noting any vaginal atrophy, periurethral masses, pelvic masses, pelvic organ prolapse, foreign bodies, or fistulous tracts.

5. Consider urine testing: A urine dipstick with or without microscopy has good negative predictive value when the diagnosis is uncertain but is of limited use above and beyond history otherwise. Urine culture should be done when repeated UTI is suspected. As noted above, this may be useful in deciding whether this is recurrence or relapse and will help to decide whether a given antibiotic will be effective.

6. Consider treatment: unless the patient is toxic, waiting for culture results is reasonable. First line medications include trimethoprim/sulfamethoxazole (TMP/SXT) and nitrofurantoin (NTF) if pyelonephritis is not suspected. NTF can be given to patients with GFR’s down to 40 ml/min. NTF may be a poor choice for relapsing E coli UTIs, due to poor tissue penetration resulting in failure to resolve the infection. Fosfomycin 3 gm sachets may be useful in more resistant E coli infections. Fluoroquinolones currently have many draw backs including QT interval prolongation, increasing resistance, AAA, and tendonitis concerns, and should be reserved for resistant bacteria as noted in cultures sensitivities. Referral to infectious disease may be indicated for bacteria requiring IV antibiotics due to resistance in the setting of acute infection.

7. Consider further evaluation: As noted above, relapsing or in some recurrent cases, infections associated with prolapse, mass, or fistula are indications for referral to urology or uro-gynecology. Relapsing disease without these clues should be further evaluated with ultrasound or CT for masses, stones, or obstruction. Post-void residual should also be obtained. Again, appropriate referrals should be made based on positive findings.

8. Consider prevention: This can be difficult; some suggestions are noted below:

• Encourage hydration, good personal hygiene and post-coital voiding.
• Address constipation, which is a large risk factor for UTI.
• Correction of anatomic findings to the degree possible.
• Post-coital single dose antibiotics when associated with sexual activity.
• Topical estrogens if post-menopausal.
• 6-12 months of suppressive therapy with TMP/SXT or NTF.
• In setting of asymptomatic bacteriuria with chronic symptoms, consider symptomatic treatment with pyridium and NSAIDs.

Other more questionable but sometimes helpful interventions, include Hiprex 1 gm BID, D mannose, Cranberry extract and probiotics (vaginal have been shown to be more beneficial than oral).

Repeated UTIs can be challenging and even frustrating but an organized approach can frequently provide patients with relief.

**Note: The guidelines in the above article above are intended for the care of adult female patients and other adult patients who were assigned female at birth.**

References:

Anger, J et al “Recurrent uncomplicated urinary tract infection in women: AUA/CUA/SUFU guidelines” The Journal of Urology, 202;282-289, 2019

Jung, C et al “The etiology and management of recurrent urinary tract infections in postmenopausal women”, Climacteric, 22; 242-249, 2019

Mody, L et al “Urinary tract infections in older women” JAMA 311;844-854, 2014

Nicolle, L et al “Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America” 68; e82 – e110, 2019