I Took Antibiotics for an Urinary Tract Infection and Now I Have It Again
Recurrent Urinary Tract Infections in Women: Diagnosis and Management
A more recent article on urinary tract infections is available.
Am Fam Physician. 2010 Sep 15;82(6):638-643.
Patient information: Encounter related handout on urinary tract infections in women.
Related letter: "Ultrasensitive Culture in Urinary Tract Infection Diagnosis"
Article Sections
- Abstruse
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Risk Factors
- Diagnosis
- Treatment
- Prevention
- Recurrent Complicated UTIs
- References
Recurrent urinary tract infections, presenting as dysuria or irritative voiding symptoms, are most commonly caused past reinfection with the original bacterial isolate in immature, otherwise good for you women with no anatomic or functional abnormalities of the urinary tract. Frequency of sexual intercourse is the strongest predictor of recurrent urinary tract infections in patients presenting with recurrent dysuria. In those who have comorbid conditions or other predisposing factors, recurrent complicated urinary tract infections represent a take chances for ascending infection or urosepsis. Escherichia coli is the well-nigh common organism in all patient groups, but Klebsiella, Pseudomonas, Proteus, and other organisms are more than common in patients with certain hazard factors for complicated urinary tract infections. A positive urine culture with greater than tentwo colony-forming units per mL is the standard for diagnosing urinary tract infections in symptomatic patients, although culture is frequently unnecessary for diagnosing typical symptomatic infection. Women with recurrent symptomatic urinary tract infections can be treated with continuous or postcoital prophylactic antibiotics; other treatment options include self-started antibiotics, cranberry products, and behavioral modification. Patients at risk of complicated urinary tract infections are all-time managed with broad-spectrum antibiotics initially, urine culture to guide subsequent therapy, and renal imaging studies if structural abnormalities are suspected.
Recurrent urinary tract infections (UTIs) are common in women and associated with considerable morbidity and health care use. The clinical features, diagnostic testing, and causative organisms are often like to those of single cases of UTI, although there are additional treatment strategies and prevention measures to consider with recurrent UTIs.
SORT: Central RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Testify rating | References |
|---|---|---|
| A urine culture with greater than x2 colony-forming units per mL is considered positive in patients who have symptoms of UTI. | C | 16 |
| Continuous and postcoital antimicrobial prophylaxis have demonstrated effectiveness in reducing the risk of recurrent UTIs. | A | nineteen |
| Cranberry products may reduce the incidence of recurrent symptomatic UTIs. | B | 23, 25 |
| Apply of topical estrogen may reduce the incidence of recurrent UTIs in postmenopausal women. | B | 26, 27 |
| Treatment of complicated UTIs should begin with broad-spectrum antibiotic coverage, with aligning of antimicrobial coverage guided by culture results. | C | 11 |
| Prophylactic antimicrobial therapy to prevent recurrent UTIs is not recommended for patients with complicated UTIs. | C | 6 |
Definitions and Epidemiology
- Abstruse
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Gamble Factors
- Diagnosis
- Handling
- Prevention
- Recurrent Complicated UTIs
- References
Recurrent UTIs are symptomatic UTIs that follow resolution of an earlier episode, usually after appropriate treatment.1 Recurrent UTIs include relapses (i.due east., symptomatic recurrent UTIs with the same organism following adequate therapy) and reinfection (i.e., recurrent UTIs with previously isolated bacteria after treatment and with a negative intervening urine culture, or a recurrent UTI caused past a second bacterial isolate).two Most recurrent UTIs are idea to represent reinfection with the same organism.1 Recurrent UTIs are mutual amongst otherwise healthy immature women with anatomically and physiologically normal urinary tracts.two One written report showed that of college women with a beginning UTI, 27 per centum had at least one cultureconfirmed recurrence within the following six months, and 2.7 percent experienced a 2nd recurrence over the same period.3 In a primary intendance setting, 53 percentage of women older than 55 years and 36 per centum of younger women had a recurrence within ane year.four
In symptomatic women, predictors of recurrent UTIs include symptoms following intercourse, signs or symptoms of pyelonephritis, and prompt resolution of symptoms with antibiotics. Nocturia and persistence of symptoms betwixt UTI episodes are strong negative predictors for recurrent infection.5
Some other group of patients who nowadays with recurrent UTIs are those who have predisposing medical conditions placing them at increased run a risk of developing complicated UTIs, with attendant risks of ascending infection (pyelonephritis) or urosepsis. The definition of complicated UTI is imprecise, but the term usually is applied to patients with a predisposing structural or functional abnormality of the genitourinary tract.6 Ascending infection, antibiotic resistance, and the demand for prolonged therapy are oft involved.
Causative Factors and Pathogenesis
- Abstract
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Risk Factors
- Diagnosis
- Handling
- Prevention
- Recurrent Complicated UTIs
- References
Escherichia coli is the predominant uropathogen (80 percent) isolated in astute customs-caused unproblematic UTIs, followed by Staphylococcus saprophyticus (x to 15 per centum). Enterococcus, Klebsiella, Enterobacter, and Proteus species are less common causes.7
In recurrent uncomplicated UTIs, reinfection occurs when the initially infecting bacteria persist in the fecal flora afterward elimination from the urinary tract, subsequently recolonizing the introitus and bladder.i A number of host factors appear to predispose otherwise healthy young women to recurrent UTIs. These include local pH and cervicovaginal antibiotic changes in the vagina; greater adherence of uropathogenic bacteria to the uroepithelium; and perchance pelvic anatomic differences, such as shorter urethra-to-anus altitude.
Diabetes mellitus, neurologic atmospheric condition, chronic institutional residence, and chronic indwelling urinary catheterization are important predisposing factors for complicated UTIs. In affected patients, organisms that are typically less virulent may crusade marked illness, although Eastward. coli infection remains the most common organism in nearly all patient groups. Klebsiella and group B streptococcus infections are relatively more mutual in patients with diabetes, and Pseudomonas infections are relatively more mutual in patients with chronic catheterization. Proteus mirabilis i s a c ommon u ropathogen i northward p atients with indwelling catheters, spinal cord injuries, or structural abnormalities of the urinary tract.7
Adventure Factors
- Abstract
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Chance Factors
- Diagnosis
- Treatment
- Prevention
- Recurrent Complicated UTIs
- References
The strongest risk factor for recurrent UTIs in immature women is frequency of sexual intercourse. This and other run a risk factors are listed in Table 1.8 At that place is no proven association between recurrent UTIs and pre- or postcoital voiding patterns, frequency of urination, wiping patterns, douching, utilize of tight undergarments, or delayed voiding habits.1,viii A case-command report of postmenopausal women found that mechanical and physiologic factors affecting bladder emptying (incontinence, cystocele, and postvoiding residuum urine) were strongly associated with recurrent UTIs.9 An increased postvoid residual urinary book (i.eastward., more than about l mL) is an independent risk factor for recurrent UTIs in postmenopausal women.10
Table one.
Risk Factors for Recurrent UTIs
| Take chances factor | Odds ratio (95% confidence interval) | |
|---|---|---|
| Intercourse in the past month | ||
| > ix times | 10.3 (5.8 to 18.3) | |
| 4 to 8 times | 5.viii (3.i to 10.6) | |
| Historic period at first UTI ≥ 15 years | 3.9 (1.9 to eight.0) | |
| Maternal history of UTIs | ii.3 (i.5 to 3.vii) | |
| New sex activity partner in the by year | 1.9 (1.2 to 3.ii) | |
| Spermicide employ in the past year | ane.viii (i.ane to ii.ix) | |
A diverseness of factors place patients at risk of complicated UTIs (Table 2),vi,xi and recurrent infection is common.
Tabular array two.
Predisposing Factors for Complicated Urinary Tract Infection
| Immunosuppression |
| Chronic renal insufficiency |
| Diabetes mellitus |
| Immunosuppressant medications |
| Renal transplant |
| Nosocomial factors and instrumentation |
| Exposure to antibody-resistant bacteria |
| Indwelling urinary catheter |
| Intermittent catheterization |
| Nephrostomy tube |
| Ureteral stent |
| Urinary tract anatomic abnormality |
| Polycystic kidney disease |
| Urethral valves |
| Vesicoureteral reflux |
| Urinary tract obstruction |
| Bladder outlet obstruction |
| Congenital abnormality |
| Ureteral or urethral stricture |
| Urolithiasis |
| Voiding dysfunction |
| Cystocele |
| Multiple sclerosis |
| Neurogenic bladder |
Diagnosis
- Abstruse
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Take a chance Factors
- Diagnosis
- Treatment
- Prevention
- Recurrent Complicated UTIs
- References
Common differential diagnoses for recurrent dysuria are listed in Table three.12
Table 3.
Differential Diagnosis of Recurrent Dysuria
| Diagnosis | Associated features |
|---|---|
| Acute pyelonephritis | Nausea, fever, flank pain, costovertebral angle tenderness, pyuria with casts |
| Atrophic vaginitis | Postmenopausal women, no infectious etiology |
| Bladder cancer | Frequency, urgency, hematuria |
| Cystitis | Frequency, urgency, pyuria, bacteriuria, urinary dipstick positive for nitrates |
| Genital canker | Dysuria, fever, vulvar pain, grouped vesicles, tender inguinal adenopathy |
| Interstitial cystitis | Frequency, urgency, long-standing symptoms, pain in float or urethra relieved by urination; negative urine cultures; ulcers or glomerulations (bladder hemorrhages) identified on cystoscopy |
| Irritant cystitis | Symptoms related to dietary intake, chemical irritant, or other exposures |
| Overactive bladder | Urgency, frequency, and possibly incontinence, |
| without dysuria | |
| Sexually transmitted infection | Vaginal discharge, history of unprotected sexual intercourse |
| Urethritis | Delayed symptoms or asymptomatic, history of unprotected sexual intercourse, positive test for Neisseria gonorrhoeae or Chlamydia trachomatis |
| Vaginitis | External irritation, dyspareunia, vaginal discharge, positive potassium hydroxide or wet-mount preparation |
Cardinal steps in the diagnostic evaluation for recurrent UTIs include confirming the presence of a bacterial UTI, assessing the patient for risk factors and predisposing factors for complicated infection, and identifying a potentially causative organism. Figure i provides an algorithm for the assessment of women presenting with one or more UTI symptoms.13
Figure ane.
Algorithmic approach to the assessment of women with symptoms of urinary tract infection (UTI).
Adjusted with permission from Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA . 2002;287(xx):2707.
Women with i symptom of UTI have an infection probability of about 50 pct.13 In 1 systematic review, a combination of symptoms (i.e., dysuria, frequency, and absenteeism of vaginal irritation or discharge) raised the probability of UTI to more than 90 percent,13 suggesting that history alone is often sufficient to confirm diagnosis. A decision aid to reduce unnecessary antibody utilise for acute cystitis revealed 3 variables (i.due east., dysuria, presence of greater than trace leukocytes, and any positive nitrites) that were almost strongly associated with a positive urine culture. xiv However, history, physical examination, or urine dipstick analysis alone is non sufficient to reliably rule out UTI.
The typical standard for diagnosing UTI is "significant" bacteria in a make clean-grab or catheterized urine specimen.thirteen Historically this has been defined as at least 105 colony-forming units per mL, but in symptomatic women a uropathogen concentration of greater than 102 colony-forming units per mL may have the best combination of sensitivity and specificity, and should be used for diagnosis when culture is required.thirteen,15,16 Although UTIs are often treated empirically in the office setting, with a urine culture obtained when the diagnosis is unclear or the symptoms continue despite antibody treatment, culture may be necessary in patients with recurrent UTIs to confirm the diagnosis and guide antibiotic therapy.
It is particularly important to review risk factors for complicated UTIs in women with UTI who practice non respond to antibiotics, or for those with recurrent UTIs and no evident predisposing factors. In patients with neurologic illnesses (e.g., spinal cord injury) or indwelling urinary catheters, a loftier index of suspicion for UTI is necessary in nonspecific presentations.vi
There are no specific guidelines or indications for imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions. Reasonable indications for ultrasonography or computed tomography (CT) include recurrent noncoital UTIs, persistent hematuria associated with UTIs, acute pyelonephritis, or prove of renal insufficiency.11
Recurrent UTIs are mutual amidst women with dysfunctional voiding, defined as increased external sphincter action during voluntary voiding in otherwise neurologically good for you patients; this may present equally urinary frequency, urgency, hesitancy, or incomplete bladder emptying. In that location are no guidelines for urodynamic evaluation in such patients.
Diagnostic evaluation in the setting of predisposing factors (i.e., complicated UTI) differs in that a urine culture including antibiotic sensitivities is almost ever required to guide therapy. Obtaining a serum chemical science console and assessing the patient'due south full general medical condition (e.g., hydration, toxicity) are of import. For older or immunocompromised patients and those who have congenital malformations of the kidney, CT or ultrasonography is usually required.eleven
Treatment
- Abstract
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Hazard Factors
- Diagnosis
- Handling
- Prevention
- Recurrent Complicated UTIs
- References
Treatment of an initial recurrence of UTI is the aforementioned equally for other cases of uncomplicated cystitis. The antimicrobial susceptibility contour for uropathogens in a community should guide treatment decisions. A threeday course of trimethoprim/sulfamethoxazole (TMPSMX; Bactrim, Septra) is the current standard therapy, with three days of trimethoprim or a fluoroquinolone (i.e., ofloxacin, norfloxacin [Noroxin], or ciprofloxacin [Cipro]) existence equally effective. 17 Because fluoroquinolones are commonly used to treat complicated UTIs and other nonurinary disorders, resistance to this drug class is a concern. Consequently, fluoroquinolones are not recommended as initial empiric therapy except in communities with high rates of resistance to other agents.17 With increasing concern for Eastward. coli resistance to TMP-SMX (up to 15 to 20 percentage in some areas of the United States), nitrofurantoin (Macrodantin) is a rubber and by and large constructive agent if administered for seven days.1
Equally the number and frequency of recurrences increment, the handling strategy is less well-defined. Fluoroquinolones and nitrofurantoin get better options as suspicion for TMP-SMX resistance increases.eighteen
In cases of recurrence, a test-of-cure urine culture performed approximately one to two weeks afterwards completion of antibody therapy may exist considered to ostend clearance.2
Patients with recurrent UTIs should be counseled about risk factors such as spermicide use, frequent sexual intercourse, and new sexual practice partners, as well every bit about preventive measures.
Prevention
- Abstract
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Risk Factors
- Diagnosis
- Treatment
- Prevention
- Recurrent Complicated UTIs
- References
ANTIBIOTIC PROPHYLAXIS
Antimicrobial prophylaxis has proved constructive in reducing the risk of recurrent UTIs in women with ii episodes of infection in the previous year. Continuous prophylaxis for six to 12 months reduces the rate of UTIs during the prophylaxis flow, with no difference betwixt the six-month and 12-month treatment groups after cessation of prophylaxis. nineteen Prophylactic antibiotic choice should be made on the basis of community resistance patterns, side effects, and local costs. Various dosages of prophylactic antibiotics have been suggested (Table 4),i,6,19,20 simply no conclusive evidence supports selection of a particular drug, dosage, or duration or schedule of treatment.
Table 4.
Continuous vs. Postcoital Antimicrobial Prophylaxis for Recurrent Urinary Tract Infections
| Antimicrobial agent | Continuous prophylaxis (daily dosage)* | Cost (make)† | Postcoital prophylaxis (i-time dose)‡ | In retail discount programs§ |
|---|---|---|---|---|
| Cephalexin (Keflex) | 125 to 250 mg | $14 ($66); just bachelor in 250-mg capsule | 250 mg | ✓ |
| Ciprofloxacin (Cipro) | 125 mg | $12 ($68); one-half tablet (250 mg) for thirty days | 125 mg | ✓ |
| Nitrofurantoin (Macrodantin) | 50 to 100 mg | $28 ($68) for 50-mg dose | 50 to 100 mg | |
| Norfloxacin (Noroxin) | 200 mg | NA ($63); one-half tablet (400 mg) for thirty days | 200 mg | |
| Trimethoprim (Proloprim) | 100 mg | $xx (NA) | 100 mg | |
| Trimethoprim/sulfamethoxazole (Bactrim, Septra) | 40/200 mg | $16 ($26); half tablet for thirty days | 40/200 to 80/400 mg | ✓ |
The duration of prophylaxis should exist guided by the severity of patient symptoms and by physician and patient preference. Half dozen months of treatment, followed by observation for reinfection after discontinuing prophylaxis, has been empirically recommended.1 Some government have recommended longer courses (two to five years) in patients who keep to have recurrent symptomatic infections.
Postcoital prophylaxis may be preferable in women with UTIs temporally related to intercourse. No marked departure in recurrent UTIs has been noted when using postcoital prophylaxis compared with daily prophylaxis, 19 and depending on the frequency of sexual intercourse, postcoital prophylaxis ordinarily results in less antibiotic employ.6,nineteen Various postcoital antibiotic regimens are described in Table iv.1,vi,19,20
Although not strictly a preventive strategy, self-initiated treatment is an option for some patients. Women with previous UTIs who are able to recognize the symptoms tin can be treated finer with cocky-started antibiotic therapy.21,22 Women tin can be given a prescription for a three-day antibiotic regimen and instructed to start therapy when symptoms develop. If there is no comeback in 48 hours, the patient should be evaluated clinically. two This strategy should be restricted to women who have conspicuously documented recurrent UTIs and are motivated, adhere to medical instructions, and have a good relationship with a health care professional.i
OTHER PREVENTIVE MODALITIES
Behavioral changes tin can affect the frequency of UTI recurrence. Managing recurrent infections should include modification of known hazard factors.
Cranberry products seem to notably reduce the recurrence of symptomatic cystitis. In one Cochrane review,23 cranberry juice showed moderate benefit in reducing the risk of UTI in women with a history of recurrent infection, based on two well-designed randomized trials. Although there is no clear evidence well-nigh dosage or duration of use,20 small studies have reported that a daily intake of 150 to 750 mL of cranberry juice or concentrated equivalent is constructive in preventing recurrent UTIs.24,25
Patients also may be counseled about the theory and anecdotal show behind postcoital voiding, although no controlled studies back up this intervention.
Several studies of postmenopausal women have demonstrated the effectiveness of using topical estrogen (0.5 mg of estriol vaginal foam nightly for two weeks, then twice weekly for 8 months), but adverse furnishings are mutual.26,27
Recurrent Complicated UTIs
- Abstract
- Definitions and Epidemiology
- Causative Factors and Pathogenesis
- Risk Factors
- Diagnosis
- Treatment
- Prevention
- Recurrent Complicated UTIs
- References
The principles of treating recurrent complicated UTIs include early use of wide-spectrum antibiotics, with aligning of antibiotic coverage based on civilisation results,11 and attempts to relieve whatsoever existing urinary obstruction based on the results of imaging studies. Antibiotic regimens and treatment recommendations are not well-defined in this patient population; the wide diversity of predisposing factors and causative organisms, and the variable antibiotic resistance patterns, make compatible recommendations difficult.6
Initiation of handling depends on development of new symptoms (which may be subtle) in patients with chronic bacteriuria. Antibiotic option should be based on community resistance patterns, and empiric initial treatment should be guided by likely organisms. The antibiotic regimen should be narrowed, when possible, to inside 48 to 72 hours based on culture results. In full general, patients who are hemodynamically stable and able to tolerate and absorb oral medications can be treated with oral agents such as fluoroquinolones. If parenteral therapy is needed, multiple agents (i.e., aminoglycosides, fluoroquinolones, ceftazidime [Fortaz], carbapenems, and piperacillin/tazobactam [Zosyn]) have been reported to achieve loftier rates of clinical cure. Duration of therapy should be determined on an individual basis but is typically 10 to 14 days. Selected guidelines for the direction of recurrent complicated UTIs are listed in Table 5.6
Table v.
Guidelines for the Management of Recurrent Complicated UT Is
| A single urine specimen with a quantitative count of at least 105 colony-forming units per mL is consequent with a diagnosis of UTI in asymptomatic patients. |
| If clinically feasible, initiation of antimicrobial therapy should be delayed until urine civilisation results are available. |
| Parenteral antimicrobial therapy is indicated if patients are unable to tolerate oral therapy, have impaired gastrointestinal assimilation, have hemodynamic instability, or if the infecting organism is known or suspected to be resistant to oral agents. |
| The duration of therapy should be seven days for patients with lower urinary tract symptoms, and 10 to 14 days for patients with upper urinary tract symptoms or sepsis syndrome. |
| Patients with chronic use of urologic devices should receive the shortest possible duration of therapy to limit antimicrobial force per unit area leading to resistance. |
| Whenever possible, genitourinary abnormalities should exist corrected. |
| Prophylactic antimicrobial therapy to foreclose recurrent UTIs is not recommended for patients with complicated UTIs. |
| Suppressive antimicrobial therapy is indicated to prevent frequent, recurrent infection for selected patients with persistent genitourinary abnormalities. |
| For young women with catheter-acquired UTIs, treatment of bacteriuria persisting 48 hours afterwards catheter removal may beconsidered. |
REFERRAL
There are no clear guidelines for referral of patients with recurrent or complicated UTIs. Nearly patients with recurrent simple UTIs tin can exist treated by family physicians. Patients with complicated UTIs may require consultation from subspecialists in urology, infectious disease, or renal medicine.
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REFERENCES
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4. Ikäheimo R, et al. Recurrence of urinary tract infection in a primary care setting: analysis of a i-year follow-upwardly of 179 women. Clin Infect Dis. 1996;22(1):91–99.
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thirteen. Bent South, et al. Does this adult female have an acute uncomplicated urinary tract infection? JAMA. 2002;287(20):2701–2710.
xiv. McIsaac WJ, et al. Validation of a determination aid to help physicians in reducing unnecessary antibiotic drug employ for acute cystitis. Arch Intern Med. 2007;167(20):2201–2206.
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xvi. Hooton TM, et al. Diagnosis and treatment of elementary urinary tract infection. Infect Dis Clin North Am. 1997;xi(3):551–581.
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18. Drekonja DM, et al. Urinary tract infections. Prim Intendance. 2008;35(2):345–367.
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20. Sen A. Recurrent cystitis in not-pregnant women. Clin Evid. 2006;(15): 2558–2564.
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22. Gupta K, et al. Patient-initiated handling of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med. 2001;135(one):nine–sixteen.
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