Jeffrey D. Quinlan, MD, FAAFP; Sarah K. Jorgensen, DO Recurrent UTIs in women: Department of Family Medicine, Uniformed Services University How you can refine your care of the Health Sciences, Bethesda, Md (Dr. Quinlan); National Which risk factors are (really) associated with Capital Consortium Family Medicine Residency recurrence? Which prophylactic and nonpharmacologic Program, Fort Belvoir Community Hospital, Va strategies are useful? This guide provides the answers. (Dr. Jorgensen) jeffrey.quinlan@usuhs. edu CASE For the third time in 9 months, 28-year-old Joan B The views expressed in this PRACTICE article are those of the authors comes into the office with complaints of painful, frequent, and and do not necessarily reflect the RECOMMENDATIONS official policy or position of the urgent urination. Ms B is sexually active and her medical history ❯ Avoid routine use of Department of Defense or the is otherwise unremarkable. In each of the previous 2 episodes, Uniformed Services University of cystoscopy and imaging the Health Sciences. her urine culture grew Escherichia coli, and she was treated when evaluating women with a 5-day course of nitrofurantoin. At this current visit, she The authors reported no with recurrent urinary potential conflict of interest B asks about the need for additional work-up, treatment for relevant to this article. tract infection (UTI). her symptoms, and whether there is a way to prevent further ❯ Keep in mind that 3- to infections. 5-day courses of antibiotics (nitrofurantoin, trimethoprim- sulfamethoxazole, fosfomycin, rinary tract infections (UTIs) are the most common 1 or beta-lactams) for UTIs are bacterial infection in women and account for an as effective as longer courses, estimated 5.4 million primary care office visits and U 2 and are associated with 2.3 million emergency room visits annually. For women, the better compliance and fewer lifetime risk of developing a UTI is greater than 50%.3 In one adverse effects. A study of UTI in a primary care setting, 36% of women under ❯ Assure patients 55 and 53% of women over 55 had a recurrent infection within considering prophylaxis a year.4 Most women with UTI are treated as outpatients, but for recurrent UTI that either 16.7% require hospitalization.5 In the United States, direct costs continuous or postcoital for evaluation and treatment of UTI total $1.6 billion each year.5 antibiotics are effective. A Strength of recommendation (SOR) Accurately characterizing recurrent UTI 5 A Good-quality patient-oriented Bacteriuria is defined as the presence of 10 colony form- evidence ing units (ie, viable bacteria) per milliliter of urine collected B Inconsistent or limited-quality midstream on 2 consecutive urinations.6 UTIs are symptom- patient-oriented evidence atic infections of the urinary tract and may involve the ure- C Consensus, usual practice, opinion, disease-oriented thra, bladder, ureters, or kidneys.7 Infections of the lower tract evidence, case series (bladder and urethra) are commonly referred to as cystitis; infections of the upper tract (kidney and ureters) are referred to as pyelonephritis. Most UTIs are uncomplicated and do not progress to more serious infections. However, patients who are pregnant, have chronic medical conditions (eg, renal insufficiency or use of immunosuppressant medications), urinary obstruction, or calculi may develop complicated UTIs.8 94 THE JOURNAL OF FAMILY PRACTICE | FEBRUARY 2017 | VOL 66, NO 2 ❚ Recurrent UTI is an infection that fol- in relative risk for UTI.15 Those who had daily lows resolution of bacteriuria and symptoms intercourse had a 9-fold increase in relative of a prior UTI, and the term applies when risk of UTI development.15 This elevated risk such an infection occurs within 6 months of is due to trauma to the lower urogenital tract the last UTI or when 3 or more UTIs occur (urethra) and introduction of bacteria into within a year.7 Recurrent infection can be fur- the urethra via mechanical factors.16,17 ther characterized as relapse or reinfection. Relapse occurs when the patient has a sec- Postmenopausal women ond UTI caused by the same pathogen within Atrophic vaginitis, catheterization, declin- 2 weeks of the original treatment.9 Reinfec- ing functional status, cystocele, incomplete tion is a UTI that occurs more than 2 weeks emptying, incontinence, and history of after completion of treatment for the original premenopausal UTIs are all risk factors for UTI. The pathogen in a reinfection may be recurrent UTI in postmenopausal women.19,20 the same one that caused the original UTI or Decreased estrogen and resulting vaginal it may be a different agent.9 atrophy appear to be associated with It’s also important to differentiate between increased rates of UTI in these women. recurrent and resistant UTI. In resistant UTI, Additionally, postmenopausal women’s bacteriuria fails to resolve following 7 to vaginas are more likely to be colonized with 14 days of appropriate antibiotic treatment.9 E coli and have fewer lactobacilli than those of premenopausal women,21 which is thought Neither to predispose them to UTI. These risk factors cystoscopy Factors that increase the risk are summarized in TABLE 1.10-21 nor imaging of recurrent UTI is routinely Premenopausal women recommended Both modifiable and non-modifiable fac- Initial evaluation of recurrent UTI for the tors (TABLE 110-21) have been associated with Patients with recurrent UTI experience signs evaluation increased risk of recurrent UTI in premeno- and symptoms similar to those with isolated of recurrent pausal women. Among women with specific uncomplicated UTI: dysuria, frequency, urinary tract blood group phenotypes (Lewis non-secretor, urgency, and hematuria. Focus your history infection. in particular), rates of UTI rise secondary to interview on potential causes of complicated increased adherence of bacteria to epithe- UTI (TABLE 218). Likewise, perform a pelvic lial cells in the urinary tract.10 Other non- examination to evaluate for predisposing modifiable risk factors include congenital anatomic abnormalities.22 Finally, obtain a urinary tract anomalies, obstruction of the urine culture with antibiotic sensitivities to urinary tract, and a history of UTI.11,12 Women ensure that previous treatment was appropri- whose mothers had UTIs are at higher risk for ate and to rule out microbes associated with recurrent UTI than are women whose moth- infected uroliths.18 Given the low probabil- ers had no such history.13 ity of finding abnormalities on cystoscopy or Modifiable risk factors for recurrent imaging, neither one is routinely recom- UTI include contraceptive use (spermicides, mended for the evaluation of recurrent UTI.18 spermicide-coated condoms, and oral con- traceptives) and frequency of intercourse (≥4 times/month).13 Spermicides alter the Treatment options and precautions normal vaginal flora and lead to increased As with isolated UTI, E coli is the most colonization of E coli, which increases the common pathogen in recurrent UTI. risk for UTI.14 Women with recurrent UTIs However, recurrent UTI is more likely than iso- were 1.27 to 1.45 times more likely to use oral lated UTI to result from other pathogens (odds contraceptives than those without recurrent ratio [OR]=1.5; 95% confidence interval [CI], UTIs.13 Compared with college women who 1.0-2.26), such as Klebsiella, Enterococcus, had not had intercourse during the week, sex- Proteus, and Citrobacter.23 Since a patient’s ually active college women who had engaged recurrent UTI most likely arises from the in intercourse 3 times had a 2.6-fold increase same pathogen that caused the prior infec- JFPONLINE.COM VOL 66, NO 2 | FEBRUARY 2017 | THE JOURNAL OF FAMILY PRACTICE 95 TABLE 1 for 5 days has effi- Risk factors for recurrent UTIs in women10-21 cacy similar to that of TMP-SMX, but with- Premenopausal women out significant bacte- Modifiable Non-modifiable rial resistance. While fosfomycin 3 g as a Contraceptive use Lewis non-secretor blood type single dose is still rec- • Spermicides ommended as first- • Spermicide-coated condoms line treatment, it is • Oral contraceptives less effective than either TMP-SMX or Intercourse ≥4 times/month Congenital urinary tract anomalies nitrofurantoin. TABLE 324 Urinary tract obstruction summarizes these History of UTI in the patient or her ant ibiotic choices and mother their efficacies. ❚ Agents to avoid Postmenopausal women or use only as a last Atrophic vaginitis History of premenopausal UTI resort. For patients Cystocele Catheterization unable to take any of With recurrent Incontinence Declining functional status the drugs above, con- UTI, start sider beta-lactam anti- an antibiotic Incomplete emptying biotics, although they that's effective Not proven to be associated with UTI in pre- or postmenopausal women are typically less effec- against Postcoital voiding habits tive for this indication. the organism While fluoroquino- cultured during Douching lones are very effec- the prior Caffeine consumption tive and have low (but infection. Bubble baths rising) resistance rates, they are also associ- Sexually transmitted infections ated with serious and Body mass index potentially permanent Non-cotton underwear adverse effects. As a result, on May 12, 2016, Chronic disease the Food and Drug UTI, urinary tract infection. Administration issued a Drug Safety Com- munication recom- tion,8 start an antibiotic you know is effec- mending that fluoroquinolones be used only tive against it. Additionally, take into account in patients without other treatment options.24,25 local resistance rates; antibiotic availability, Do not use ampicillin or amoxicillin, which lack cost, and adverse effects; and a patient’s drug effectiveness for this indication and are com- allergies. promised by high levels of bacterial resistance. ❚ Preferred antibiotics. Trimethoprim- ❚ Shorter course of treatment? When de- sulfamethoxazole (TMP-SMX), 160 mg/800 ciding on the length of treatment for recurrent mg twice daily for 3 days, has long been the UTI, remember that shorter antibiotic courses mainstay of treatment for uncomplicated (3-5 days) are associated with similar rates of UTI.