Comments from Expert Advisory Committee
Scope of this guidance
This guidance refers to non-pregnant adult females with a diagnosis of uncomplicated recurrent UTIs supported by laboratory evidence.
It does not apply to men, children under 16, pregnant women, those who are immunocompromised, those with anatomic or functional abnormalities of the urinary tract, those who self-catheterise or have indwelling catheters, or those who have signs or symptoms of an upper UTI.
N.B. Specialist opinion should be considered for patients with recurrent UTI. In particular, it is advisable to refer men, pregnant women and children under 16 for specialist opinion. Antimicrobial prophylaxis should only be considered in these groups following specialist advice.
This guideline refers to symptomatic culture-proven recurrent urinary tract infection (UTI).
Recurrent lower urinary tract symptoms are often NOT due to infection, and it is important to consider other diagnoses, to avoid unnecessary antibiotic exposure.
- Definition of recurrent UTI. Recurrent UTI in adults is defined as 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months.
- Evaluation of clinical features of recurrent UTIs should include sending a mid-stream urine (MSU) sample for culture.
- Recurrent UTI may be due to relapse (same strain of bacteria) or reinfection (different strain or species of bacteria).
- Persistent asymptomatic bacteriuria is NOT the same as recurrent UTI
- Urinary growth of bacteria in an asymptomatic individual (asymptomatic bacteriuria) is common, particularly in older people. It does NOT require treatment in most cases, except in pregnant women and prior to urological procedures which breach the mucosa.
- Recurrent or persistent lower urinary tract symptoms are not always due to recurrent UTI. Many conditions can cause similar symptoms. Clinical examination is important to identify dermatological conditions affecting this area. In women who do not have laboratory evidence of UTI, consider:
- Sexually-transmitted infections
- Postmenopausal atrophic vaginitis
- Vulvovaginal candidiasis
- Vulval lichen sclerosis, psoriasis or other dermatological conditions
- In non-pregnant females with recurrent lower UTI, try non-antimicrobial measures prior to antimicrobial prophylaxis
- Give advice on behavioural measures which may reduce the risk of recurrent UTI. Note that there is limited evidence for these interventions but, anecdotally, many patients find them effective.
- Increase fluid intake
- Vulval care: Vulval skin is easily irritated. Avoid use of potential irritants such as soaps, perfumes, talcs, cleansing wipes, disinfectants etc. Do not wash too often (once a day is usually sufficient). Use an emollient-based product or plain warm water to wash. Consider a barrier cream or ointment in incontinence.
- Post-coital voiding
- Do not habitually delay urination
- Avoid constipation
- Wipe from front to back after defaecation
- Consider vaginal oestrogens in post-menopausal women
- Antimicrobial prophylaxis, either single-dose (e.g. post-coital) or continuous, can be effective and should be considered if non-antimicrobial measures are unsuccessful. However, the side-effects of antibiotic prophylaxis should also be considered.
- All antibiotics are associated with a risk of C. difficile infection
- Long-term nitrofurantoin use is associated with multiple adverse effects, including liver damage, pulmonary fibrosis and peripheral neuropathy. Patients on long-term nitrofurantoin should be monitored closely for these conditions and treatment should be withdrawn if they emerge.
- When a trial of antimicrobial prophylaxis is given, advise the patient regarding:
- The risk of resistance with long term antibiotics
- The possible adverse effects of long term antibiotics
- The need to seek medical help if symptoms of an upper UTI develop
- In patients with an identifiable trigger (e.g. sexual intercourse), single-dose prophylaxis (e.g. post-coital) is as effective as continuous prophylaxis in preventing recurrent UTI, but with fewer side-effects, and should thus be the preferred option.
- While there is no evidence for the effectiveness of “standby” antibiotics (i.e. a course of antibiotics to keep at home to take if UTI symptoms develop), there is evidence that self-diagnosis of cystitis has a high positive predictive value and the rationale for this approach is to facilitate early treatment. Thus, it may be appropriate to use standby antibiotics in selected patients.
- Consider methenamine hippurate 1g every 12 hours but note there is limited evidence for this (Cochrane Review 2012: “Methenamine hippurate may be effective for preventing UTI in patients without renal tract abnormalities, particularly when used for short-term prophylaxis. It does not appear to work in patients with neuropathic bladder or in patients who have renal tract abnormalities. The rate of adverse events was low, but poorly described.”). Methenamine is a urinary antimicrobial agent so its potential for resistance development is to be considered. Methenamine is available in Ireland as an exempt medicinal product (i.e. unlicensed), and has a GMS unlicensed medicines code.
- Review antimicrobial prophylaxis at 3- 6 months, with a view to stopping.
We recommend patients use the website developed by HSE/ICGP/IPU partnership www.undertheweather.ie for tips on how to get better from common infections without using antibiotics, what you can do for yourself or a loved one and when to seek help.
- Penicillin allergy – tips on prescribing in penicillin allergy
- Renal impairment dosing table
- Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
- Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).
Reviewed March 2020