Most women experience a urinary tract infection (UTI) at some point in their lives. It is noted as the most common bacterial infection in women, affecting roughly 60% percent of female patients. An uncomplicated UTI is one of the most widespread indications for antimicrobial exposure in otherwise healthy women. Antibiotic overuse and the development of antibiotic-resistant organisms have prompted the need for an updated guideline that focuses on treating symptoms combined with positive cultures.
An expert panel developed a new 2019 joint guideline released by the American Urological Association (AUA), Canadian Urological Association and Society of Urodynamics, and Female Pelvic Medicine & Urogenital Reconstruction on the diagnosis and treatment of recurrent UTIs (rUTIs). The guideline was distributed to peer reviewers of varying backgrounds as part of the AUA's extensive peer-review process before being approved by the AUA Board of Directors.
To be defined as an rUTI, there should be two culture-proven UTIs within 6 months or three culture-proven events within 1 year. The guideline advises and defines the panel's recommendations, things to avoid, and considerations for healthcare providers to make. A patient should provide a complete medical history and receive a pelvic exam. This helps to identify any treatable contributor, such as vaginal atrophy or cystocele. Before diagnosing rUTIs, document all prior episodes with urine cultures. Many symptoms can mimic a UTI, including overactive bladder and interstitial cystitis/bladder pain.
Following this, a clinician should obtain repeat urine studies when an initial urine specimen is suspect for contamination. It should be noted that epithelial contamination or other factors implicating contamination, such as an indication of "mixed flora," warrants obtaining a catheterized sample. Additionally, obtain a urinalysis and urine culture with each symptomatic acute cystitis episode prior to initiating treatment. First-line therapy for treating symptomatic UTIs in women is based on the local antibiogram and may include nitrofurantoin
, or fosfomycin
Patients with rUTI with an acute cystitis episode should be treated with as short a duration of antibiotics as possible, extending no longer than 7 days. If a patient's UTI symptoms persist following antimicrobial therapy, it is advisable to repeat a urine culture to guide further management. For patients who are peri-menopausal and post-menopausal with recurrent UTIs, vaginal estrogen therapy can be prescribed to reduce the risk of future UTIs.
The panel has advised avoiding routine cystoscopy and upper tract imaging in the index patient presenting with rUTI. In asymptomatic bacteriuria (ASB), do not obtain surveillance urine testing, including urine culture. Clinicians should not treat ASB. Asymptomatic patients do not require post-treatment testing of cure urinalysis or urine culture.
Clinicians may consider offering patient-initiated treatment to select rUTI patients while awaiting urine cultures. Self-start therapy still a good option in reliable patients committed to checking cultures before starting antibiotics. In patients with rUTIs with acute cystitis episodes associated with urine cultures resistant to oral antibiotics, clinicians may treat with culture-directed parenteral antibiotics for as short a course as possible (generally fewer than 7 days). Antibiotic prophylaxis may be considered after careful consideration and discussion. This may decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs.
It is also permissible to offer cranberry prophylaxis for rUTIs. Systematic review identified eight randomized trials, including cranberry versus placebo/no cranberry (six randomized controlled trials, one with a lactobacillus arm) and cranberry versus antibiotics (two randomized controlled trials). Several factors contribute to limitations in the use of cranberry consumption in the setting of rUTI outside of a research setting, including variability in juices and dosages of cranberry tablets. Consideration of prophylaxis is based on the safety profile of cranberry; however, studies of commercially available products are needed before specific product recommendations can be made.
Anger J, et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J Urol. 2019 Aug;202(2):282-289. doi: 10.1097/JU.0000000000000296. Epub 2019 Jul 8. PMID: 31042112.