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JOGC

No. 250-Recurrent Urinary Tract Infection

      Abstract

      Objective

      To provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women.

      Options

      Continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives.

      Evidence

      A search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions.

      Values

      This update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

      Options

      Recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patient's characteristics.

      Recommendations

      • 1.
        Urinalysis and midstream urine culture and sensitivity should be performed with the first presentation of symptoms in order to establish a correct diagnosis of recurrent urinary tract infection (III-L).
      • 2.
        Patients with persistent hematuria or persistent growth of bacteria aside from Escherichia coli should undergo cystoscopy and imaging of the upper urinary tract (III-L).
      • 3.
        Sexually active women suffering from recurrent urinary tract infections and using spermicide should be encouraged to consider an alternative form of contraception (II-2B).
      • 4.
        Prophylaxis for recurrent urinary tract infection should not be undertaken until a negative culture 1 to 2 weeks after treatment has confirmed eradication of the urinary tract infection (III-L).
      • 5.
        Continuous daily antibiotic prophylaxis using cotrimoxazole, nitrofurantoin, cephalexin, trimethoprim, trimethoprim- sulfamethoxazole, or a quinolone during a 6- to 12-month period should be offered to women with 2: 2 urinary tract infections in 6 months or 2: 3 urinary tract infections in 12 months (I-A).
      • 6.
        Women with recurrent urinary tract infection associated with sexual intercourse should be offered post-coital prophylaxis as an alternative to continuous therapy in order to minimize cost and side effects (I-A).
      • 7.
        Acute self-treatment should be restricted to compliant and motivated patients in whom recurrent urinary tract infections have been clearly documented (I-B).
      • 8.
        Vaginal estrogen should be offered to postmenopausal women who experience recurrent urinary tract infections (I-A).
      • 9.
        Patients should be informed that cranberry products are effective in reducing recurrent urinary tract infections (I-A).
      • 10.
        Acupuncture may be considered as an alternative in the prevention of recurrent urinary tract infections in women who are unresponsive to or intolerant of antibiotic prophylaxis (I-B).
      • 11.
        Probiotics and vaccines cannot be offered as proven therapy for recurrent urinary tract infection (II-2C).
      • 12.
        Pregnant women at risk of recurrent urinary tract infection should be offered continuous or post-coital prophylaxis with nitrofurantoin or cephalexin, except during the last 4 weeks of pregnancy (II-1B).

      Key Words

      Abbreviations:

      E. coli (Escherichia coli), HPF (high-power field), TMP-SMX (trimethoprim-sulfamethoxazole), UTI (urinary tract infection)
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