Recurrent Urinary Tract Infection

Recurrence of uncomplicated cystitis in reproductive-age women is common, and some form of preventive strategy is indicated if three or more symptomatic episodes occur in 1 year. However, risk factors specific to women with recurrent cystitis have received little study (Sen, 2008). Several antimicrobial strategies are available, but before initiating therapy, the patient should try such simple interventions as voiding immediately after sexual intercourse and using a contraceptive method other than a diaphragm and spermicide. Ingestion of cranberry juice has been shown to be effective in decreasing bacteriuria with pyuria, but not bacteriuria alone or symptomatic UTI, in an elderly population. Cranberry juice may be effective for preventing UTI in young, otherwise healthy women.

If simple nondrug measures are ineffective, continuous or postcoital—if the infections are temporally related to intercourse—low-dose antimicrobial prophylaxis with TMP-SMX, a fluoroquinolone, or nitrofurantoin should be considered. Typically, a prophylactic regimen is initially prescribed for 6 months and then discontinued. If the infections recur, the prophylactic program can be instituted for a longer period. An alternative approach to antimicrobial prophylaxis for women with less frequent recurrences (<4 a year) is to supply TMP-SMX or a fluoroquinolone and allow the patient to self-medicate with short-course therapy at the first symptoms of infection.

A minority of patients have relapsing UTI, as evidenced by finding the same bacterial strain within 2 weeks after completion of antimicrobial therapy. Two factors can contribute to the pathogenesis of relapsing infection in women: (1) deep tissue infection of the kidney that is suppressed but not eradicated by a 14-day course of antibiotics and (2) structural abnormality of the urinary tract, particularly calculi. Patients with true relapsing UTIs should undergo renal ultrasound, intravenous pyelogram (IVP), or voiding cystourethrogram, and longer-term therapy should be considered.

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