Management of Uncomplicated Recurrent Urinary Tract Infections

Mostly young but also postmenopausal women are often affected by recurrent urinary tract infections (rUTIs), defined as three or more symptomatic UTI episodes per year or two or more UTIs within 6 mo. Approximately 20–30% of women with a UTI have a recurrence. UTIs are associated with considerable morbidity. Treatable predisposing factors in uncomplicated rUTI are rare but have to be considered. According to the 2015 European Association of Urology guidelines, the recommendations for prophylaxis of rUTI are first, behavioral changes and second, nonantimicrobial measures. Antibiotic prophylaxis should only be considered if the former recommendations are not sufficiently effective, to avoid adverse events and the collateral damage of unnecessary long-term antibiotic use. General behavioral recommendations can lower the recurrence rate by about 30%. Of the nonantimicrobial measures, immunoprophylaxis and local estriol substitution are effective to lower the recurrence rate, especially in postmenopausal women. Cranberry products on the market are widely variable and seem to have too low a proanthocyanidin content to prevent rUTI effectively. Other promising modalities need to be tested in further controlled trials to prove their preventive benefit. For long-term antibiotic prophylaxis, oral fosfomycin, nitrofurantoin, trimethoprim, cotrimoxazole, and oral cephalosporins (especially during pregnancy) are recommended. Placebo-controlled studies show a high efficacy of long-term antibiotic prophylaxis, but this strategy does not appear to modify the natural history of rUTI, and most of the studies were performed at a time when antibiotic resistance was not an issue.Patient summaryWomen of all ages experience recurrent urinary tract infections (rUTIs) that cause considerable morbidity. Treatable predisposing factors in uncomplicated rUTI are rare but have to be considered. Guidelines for the prophylaxis of rUTI episodes recommend behavioral changes followed by nonantimicrobial measures and only then by antibiotic prophylaxis to avoid adverse events and the collateral damage of unnecessary long-term antibiotic use.