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)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Obstetrics and Gynaecology CanadaAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Update on acute uncomplicated urinary tract infection in women.Postgrad Med. 2006; 119: 39-45
- Self reported incidence of urinary tract infection and associated costs.Ann Epidemiol. 2000; 10: 509-515
- A prospective study for risk factors for symptomatic urinary tract infection in young women.N Engl J Med. 1996; 335: 468
- Predictors of urinary tract infection after menopause.Am J Med. 2004; 117: 903
- Clinical symptoms predictive of recurrent urinary tract infection.Am J Obstet Gynecol. 2007; 197 (e1-4): 74
- Uncomplicated urinary tract infections in women.Obstet Gynecol Clin North Am. 2008; 35: 235-248
- Treatment of urinary tract infection in non pregnant women. ACOG Practice Bulletin No. 91, March 2008.Obstet Gynecol. 2008; 11: 785-794
- Recurrent urinary tract infection in women.Int J Antimicrob Agents. 2001; 17: 259-268
- The natural history of symptomatic recurrent bacteruria in women.Medicine (Baltimore). 1977; 56: 55-60
- Pathogenesis and management of recurrent urinary tract infecitons in women.World J Urol. 1999; 17: 415-420
- Risk fctors for second urinary tract infection among college women.Am J Epidemiol. 2000; 151: 1194-1205
- Does this woman have an acute urinary tract infection?.JAMA. 2002; 287: 2701-2710
- Patient-initiated treatment of recurrent urinary tract infection in women.Ann Intern Med. 2001; 135: 9-16
- Demographic, clinical and treatment parameters influencing the outcome of acute cystitis.Clin Infect Dis. 1999; 29: 113-119
- Establishment of a persistent Escherichia coli reservoir during the acute phase of a bladder infection.Infect Immun. 2001; 69: 4572-4579
- Detection of intracellular bacterial communities in human urinary tract infection.PLoS Med. 2007; 4: e329
- Acute uncomplicated urinary tract infection in women.N Engl J Med. 2003; 349: 259-266
- Sharing of virulent Escherichia coli clones among household members of a woman with acute cystitis.Clin Infect Dis. 2006; 43: e101-e108
- Inverse association of H202-producing Lactobacilli and vaginal E. coli colonization in women with recurrent urinary tract infection.J Infect Dis. 1998; 178: 446-450
- Risk factors for recurrent urinary tract infection in young women.J Infect Dis. 2000; 182: 1177-1182
- Perineal ultrasound evaluation of dysfunctional voiding in women with recurrent urinary tract infections.J Urol. 2008; 179: 947-951
- Recurrent urinary tract infection in women.BMJ. 2003; 327: 1204
- Urinary tract infections in women: diagnosis and management in primary care.BMJ. 2006; 332: 94-97
- Outpatient urine culture. Does collection technique matter?.Arch Intern Med. 2000; 160: 2537-2540
- Urinalysis: a comprehensive review.Am Fam Physician. 2005; 71: 1153-1162
- Urinary tract infections.Prim Care. 2008; 35: 345-367
- Diagnosis and treatment of uncomplicated urinary tract infection.Infect Dis Clin North Am. 1997; 11: 551-581
- Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis.J Am Med Assoc. 1999; 281: 736-738
- Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women.Clin Infect Dis. 1999; 29: 745-758
- Trimethoprim-sulfamethoxazole resistance among urinary coliform isolates.J Gen Intern Med. 1999; 14: 606-609
- Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women.Arch Intern Med. 2007; 167: 2207-2212
- Recurrent urinary tract infections.Best Pract Res Clin Obstet Gynaecol. 2005; 19: 861-873
- Potential preventive strategies and therapies in urinary tract infection.World J Urol. 1999; 17: 359-363
- Urinary tract infections and asymptomatic bacteriuria in pregnancy.(UpToDate)2008 (version 16.2 (May 31, 2008))
- Antibiotics for preventing recurrent urinary tract infection in non-pregnant women.Cochrane Database Syst Rev. 2004; (CD001209)
- Prevention of urinary tract infection.Infect Dis Clin North Am. 1997; 11: 719-733
- Urinary tract infections in adults.Am Fam Physician. 1999; 59 (1237): 1225-1234
- Recurrent urinary tract infection in the female.Curr Opin Obstet Gynecol. 2002; 14: 537-543
- Urinary tract infection: traditional pharmacologic therapies.Am J Med. 2002; 113: 35S-44S
- Antibioprevention of recurrent cystitis. A randomized double-blind comparative trial of 2 dosages of pefloxacin.Presse Med. 1995; 24: 213-216
- Post-intercourse versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal women.J Urol. 1997; 157: 935-939
- Evaluation of and antimicrobial therapy for recurrent urinary tract infections in women.Urol Clin North Am. 1998; 25: 685-701
- Postcoital antimicrobial prophylaxis for recurrent urinary tract infection. A randomized, double-blind, placebo-controlled trial.JAMA. 1990; 264: 703-706
- Antimicrobial prophylaxis of recurrent urinary tract infections: a double-blind, placebo-controlled trial.Ann Intern Med. 1980; 92: 770-775
- Prophylaxis: recurrent urinary tract infections in women.Infection. 1992; 20: S203-S205
- Effects of sub-inhibitory antimicrobial concentration (sub-MICs) on in-vitro bacterial adherence to uroepithelial cells.J Antimicrob Chemother. 1992; 29: 617-627
- Nitrofurantoin-induced pulmonary fibrosis: a case-report.J Med Case Rep. 2008; 2: 169
- Efficacy of five year of continuous, low-dose trimethoprim-sulfamethoxazole prophylaxis for urinary tract infection.J Infect Dis. 1988; 157: 1239-1242
- Prophylactic efficacy of cinoxacin in recurrent urinary tract infection: biologic effects on the vaginal and fecal flora.J Urol. 1982; 127: 1128-1131
- A systematic review of estrogens for recurrent urinary tract infections: third report of the hormones and urogenital therapy (HUT) committee.Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12: 15-20
- Oestrogens for preventing recurrent urinary tract infection in postmenopausal women.Cochrane Database Syst Rev. 2008; (CD005131)
- A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections.N Engl J Med. 1993; 329: 753-756
- A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women.Am J Obstet Gynecol. 1999; 180: 1072-1079
- Hormone replacement therapy or prophylaxis in postmenopausal women with recurrent urinary tract infection.J Infect Dis. 2001; 183: S74-S76
- Effectiveness of estriol-containing vaginal pessaries and nitrofurantoin macrocrystal therapy in the prevention of recurrent urinary tract infection in postmenopausal women.Clin Infect Dis. 2003; 36: 1362-1368
- Prevention and treatment of recurrent urinary system infection with estrogen cream in postmenopausal women.Zhonghua Fu Chan Ke Za Zhi. 2001; 36: 531-533
- An examination of the antiadherence activity of cranberry juice on urinary and non-urinary bacterial isolates.Microbios. 1988; 55: 173-181
- Inhibitory activity of craberry juice on adherence of type 1 and type P fimbriated Escherichia coli to eucaryotic cells.Antimicrob Agents Chemother. 1989; 33: 92-98
- Cranberries for preventing urinary tract infections.Cochrane Database Syst Rev. 2008; (CD001321)
- Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women.BMJ. 2001; 322: 1571-1573
- Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? A double-blind, placebo-controlled trial.Age Ageing. 2005; 34: 256-261
- A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women.Can J Urol. 2002; 9: 1558-1562
- Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury.J Spinal Cord Med. 2004; 27: 35-40
- Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women.Scand J Prim Health Care. 1998; 16: 37-39
- Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women.Am J Public Health. 2002; 92: 1609-1611
- Probiotics to prevent urinary tract infections: the rational and evidence.World J Urol. 2006; 24: 28-32
- Instillation of Lactobacillus and stimulation of indigenous organisms to prevent recurrence of urinary tract infections.Microecol Ther. 1995; 23: 32-45
- A pilot study evaluating the safety and effectiveness of Lactobacillus vaginal suppositories in patients with recurrent urinary tract infection.Int J Antimicrob Agents. 2006; 28: S30-S34
- Vaginal application of lactobacilli in the prophylaxis of recurrent urinary tract infection in women.Scand J Prim Health Care. 1994; 12: 239-243
- Probiotics for prevention of recurrent urinary tract infections in women.Drugs. 2006; 66: 1253-1261
- Treatment of bacterial infections of the female urinary tract by immunization of the patiets.Urol Int. 1987; 42: 338-341
- Vaginal mucosal immunization for recurrent urinary tract infection: extended phase II clinical trial.J Infect Dis. 2001; 183: S81-S83
- Vaccine development for the prevention of urinary tract infections.Curr Infect Dis Rep. 2002; 4: 509-513
- Bacterial interference—is deliberate colonization with Escherichia coli 83972 an alternative treatment for patients with recurrent urinary tract infection?.Int J Antimicrob Agents. 2006; 28: S26-S29
- Prevention of recurrent bacterial urinary tract infections by intravesical instillation of hyaluronic acid.Int J Gynaecol Obstet. 2007; 96: 192-195
- Prevention of recurrent bacterial cystitis by intravesical administration of hyaluronic acid: a pilot study.BJU Int. 2004; 93: 1262-1266
- Inhibition of experimental ascending urinary tract infection by an epithelial cell-surface receptor analogue.Nature. 1982; 298: 560-562
- Oligosaccharides anti-infectives agents.Lancet. 1996; 347: 1017-1021
- Meta-analysis of the relationship between asymptomatic bacteriuria and preterm delivery/low birth weight.Obstet Gynecol. 1989; 73: 576-582
- Effective prophylaxis for recurrent urinary tract infections during pregnancy.Clin Infect Dis. 1992; 14: 810-814
- Urinary tract infections in pregnancy.Curr Opin Urol. 2001; 11: 55-59
- Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care.CMAJ. 2003; 169: 207-208
Article info
Publication history
No. 250 (Reaffirmed October 2017)
Footnotes
This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice women should be provided with information and support that is evidence based, culturally appropriate and tailored to their needs. The values, beliefs and individual needs of each woman and her family should be sought and the final decision about the care and treatment options chosen by the woman should be respected.
Identification
Copyright
Copyright © 2017 Published by Elsevier Inc. on behalf of The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada
