Recurrent urinary tract infections

Antimicrobial prescribing: NHS Lothian
NHS Lothian

Definition of recurrent UTI:

  • 2 symptomatic UTI in the last 6 months or at least 3 in the last 12 months (confirmed with MSU)

If MSU confirmation not possible then ALL symptoms of:

  • Frequency
  • Dysuria
  • Urgency and/or bladder pain
  • Prompt resolution with antibiotics

Recommendations

Non-prescription treatments:

  • Encourage better hydration (>1.6L/day) and more frequent urination
  • Encourage urge-initiated voiding & post-coital voiding
  • Patients may wish to try supplements such as cranberry extract (avoid if on warfarin) or D-mannose (if E.coli UTI).

CONTINUED RECURRENT INFECTIONS despite above, consider the following:

  • Post-menopausal, atrophic vaginitis: topical vaginal oestrogen (review within 12 months)
  • Trial of methenamine 1g every 12 hours + over the counter high dose vitamin C 1000mg for 6 months.
  • Post coital antibiotics – trimethoprim 200mg once (or as per sensitivities) within 2 hours of intercourse. Alternative: Nitrofurantoin MR 100mg once (if eGFR>30ml/min)
  • Self-start antibiotics – 3 day course of antibiotic as per recent sensitivities or empirically based on Lower Urinary Tract Infection/Cystitis guidance. Ensure urine culture is submitted prior to initiating antibiotics and review and revise current and future treatment based on results.

CONTINUED RECURRENT INFECTIONS despite above, consider the following:

  • Long-term prophylactic antibiotics trimethoprim 100mg at night for 3 months then stop and assess.
  • If trimethoprim resistance identified on urine culture consider risks and benefits of using an alternative such as nitrofurantoin or cephalexin including development of further resistance, side effects, and Clostridium difficile risk.
  • Postmenopausal women, no risk factors: consider referral to urology.

Further guidance is available here.