Recurrent UTI – SOGC Guideline 2010

Recurrent UTI 

  • 2 uncomplicated UTIs in 6 months or >= 3 positive cultures within the preceding 12 months.

Relapse

  • Recurrent infection with the same organism despite adequate Tx

Reinfection

  • Recurrent UTI caused by a different bacteria or previously isolated bacteria after a negative intervening culture or adequate time period (>=2 wk) between infections
  • More common than relapse and most occur in 3 months after the 1o infeciton

Hx:

Classic symptoms: dysuria, urinary frequency, suprapubic pain +/- hematuria.

PPF:

  1. Symptoms after intercourse
  2. Hx of pyelonephritis
  3. Absence of nocturia
  4. Prompt resolution of symptoms after Tx (48hr)
  5. No vaginal discharge

NPF:

  • Nocturia
  • persistence of symptoms between episodes of treated infection

DDx: vaginitis, acute urethritis, interstitial cystitis, PID


Main causative pathogens:

  • E. Coli (80% – high recurrence in 6mo), Staph saprophyticus, Klebsiella pneumoniae, Proteus mirabilus. Citrobactoer & Enterococci.

Uncommon causes – proteus, pseudomonas, enterobactor, klebsiella

  • ↑ structural abnormalities or renal calculi
  • upper urinary tract and cystoscopy indicated

ddx: Chlamydia, Gonorrhea, Candida, BV, HSV


Risk Factors:

Premenopausal Women

  • Behavioural Risk factors
    1. ↑frequency of intercourse
    2. spermicide use
    3. new sexual partner
    4. dysfunctional voiding patterns
  • Non-behavioural risk factors:
    1. Hx of UTI before 15yo
    2. maternal hx of UTI – most women don’t have function / anatomical abnormality of urinary tract & extensive radiologic & cystoscopic exam is not indicated

Postmenopausal women

  1. Incontinence
  2. Sig pelvic floor prolapse
  3. elevated post-void residual volume
  4. DM
  5. prev Hx of UTI
  6. Non-secretors of histocompatibility blood-group antigens

Investigations

  • Physical exam – evaluate urogenital anatomy, estrogenization of vaginal tissues, detect prolapse
  • Post-void residual volume
  • DM screening
  • Urologic workup if persistent hematuria after resolution of uncommon bacterial causes
  • Pre-treatment midstream Urine C & S – dx accuracy, uropathogen, abx susceptibilities
    • >100,000 CFU per HPF (high specificity but 50% sensitivity)
    • >1000 CFU per HPF (90% specificity & 80% sensitivity
    • >20 epithelial cells per HPF – contamination by vaginal secretions
  • U/A –
    • Nitrite 92% specificity & 19-48% sensitivity; negative doesn’t r/o UTI (Staph saprophyticus or urine in bladder < 4hr)
    • Leukocytes esterase – Pyuria – 41-86% specific & 72-97% sensitive
    • Blood -42-46% specific & 68-92% sensitive

Tx of acute uncomplicated cystitis

  • 3-day of Trimethoprim, TMP-SMX, fluoroquinolone (2nd line)
  • 7 days of nitrofurantoin (Macrobid)

Risk Factors of resistance

  • DM, recent hospitalization, abx use in the past 3-6 months, recent TMP-SMX use
  • Recurrent cystitis within the 1st wk following tx – relapse
  • consider fluoroquinolone x 7 days as 1st line

Prevention of recurrent UTI

Lifestyle Modification

  • Alt contraception to avoid spermicide use
  • No association of recurrent UTI with pre-post-coital patterns, urinary frequency, delayed voiding habits, douching, use of hot tubs, bubble baths, BMI, frequent use of pantyhose or tights, use of tight clothing, type of clothing, bicycle riding, or volume of fluid consumed.

Antimicrobial Tx – Rely on community patterns of resistance, adverse events, local costs. Prophylaxis should not be undertaken until a negative Cx 1-2 weeks after Tx has confirmed eradication of the UTI.

  1. Continuous antimicrobial prophylaxis (>2/6mo or >=3 UTI/yr) for 6 months
    • TMP-SMX  40/200mg daily or 3x/week
    • Macrobid 50-100 mg daily
    • Keflex 125-250mg daily
  2. Post-coital prophylaxis (>=3 UTI / yr or UTI associated with intercourse) – less s/e
    • TMP-SMX 40/200 or 80/400mg x 1
    • Keflex 125-250mg x 1
    • Macrobid 100mg x 1
  3. Patient-administered self Tx (<=2 UTI / yr) – clearly documented recurrent infection. ↑ overtreatment
    • TMP-SMX 160/800 bid x 3 days
    • Ciprofloxacin 250mg bid x 3 days

Others:

  1. Vaginal estrogen in postmenopausal women
  2. Cranberry products are effective in reducing recurrent UTI
  3. Acupuncture may be considered as an alt in the prevention of recurrent UTI
  4. Probiotics and vaccines – no evidence

Pregnant women

  • Bacteriuria (+/- symptoms) ↑ preterm & low BW
    • requires f/u culture 1 week after Tx and monthly f/u until completion of pregnancy
  • continuous or post-coital prophylaxis with macrobid 50mg or keflex 250mg except last 4 weeks of pregnancy if
    1. pre-pregnancy hx of recurrent UTI
    2. Persistent symptomatic or asymptomatic bacteriuria after 2 abx Tx
    3. UTI (only 1) for women at ↑ risk of c/i (DM, sickle cell trait)

Adverse Events

  • Nausea, vaginal & oral candidiasis
  • Nitrofurantoin: Aplastic anemia, polyneuritis, acute cholestatic and hepatocellular reactions, pulmonary toicity

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Posted in 95 UTI, 99 Priority Topics, ID

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