By Krista Reagan, MD
SOUTH PUGET SOUND – Many women experiencing recurrent urinary tract infections are currently being referred to the Urogynecology practice for care that can often be effectively managed in a primary care setting. As a result, UroGyn appointment availability is increasingly limited, making it more difficult for patients with urgent surgical needs to be seen in a timely manner. By strengthening support and care pathways within primary care, we can better manage reoccurring UTIs at the front line, reduce unnecessary specialty referrals and preserve timely access to UroGyn services for patients who truly need specialized or surgical care.
Primary care management of recurrent UTIs in female patients
Diagnosis
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Two or more culture confirmed UTIs in less than 6 months or 3 or more in 1 year
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It is critical to get cultures for these patients as they often present to urgent care with symptoms and a urine dip and symptoms are used for diagnosis, but no culture is sent
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Some patients are “self-treating” based on results on over the counter at home testing – this is not recommended for patients with concern for recurrent UTIs
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Pyuria and bacteria on properly collected sample, culture with >10,000 of single bacteria (true “clean catch” without epithelial cells, consider cath if unable to give quality sample)
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Perform history and exam to evaluate for urinary incontinence, pelvic organ prolapse, incomplete bladder emptying (via bladder scanner or straight catheter)
Treatment
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Antibiotic sparing strategies
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Consider cranberry supplementation (likely beneficial)
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Consider D-mannose, probiotics (mixed data)
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Methenamine Hippurate (1g orally 2x daily) (converts in acidified urine to formaldehyde, toxic to bacteria)
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Should not be co-administered with sulfa drugs (Bactrim)
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Monitor LFTs periodically (especially in patients with pre-existing liver disease)
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Antibiotics
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General principals (treat acute episodes for 3-5 days)
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Try to avoid daily antibiotics, use only when other strategies have failed
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Be aware of local resistance patterns, review allergies
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If cystitis episodes are related to sexual intercourse, use post-coital prophylaxis rather than continuous
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Choose prophylactic antibiotic based on susceptibility of prior uropathogens
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Avoid prophylaxis in patients with mental status changes without genitourinary symptoms even if associated with bacteriuria because this often reflects asymptomatic bacteriuria
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Options
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Nitrofurantoin 50-100 mg PO daily
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Avoid use longer than 12 months, avoid if Cr Cl <30 mL/min
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Trimethoprim-sulfamethoxazole ½ of single-strength tablet )(40 mg/200 mg) once daily to 3x weekly)
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Caution if using warfarin, ACE inhibitors, diuretics (high potassium), metformin, methotrexate, stop Hiprex when treating acute infections
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Cephalexin 125-250 mg once daily
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Fosfomycin 3 g once every 7-10 days
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Duration
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Assess at 3 months, consider continuing for 6 months. Review risk of chronic abx use at length prior to continuing longer
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Prevention Strategies
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All perimenopausal and postmenopausal females should be started on low dose vaginal estrogen
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Estradiol (Estrace) 0.01% cream (apply 0.5 g to the vagina nightly x 2 weeks then 2 nights per week thereafter)
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Avoid only in patients actively on anti-estrogen medications for cancer treatment
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Hydration: encourage 2-3 L per day
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In patients who drink <1.5 L per day, increased fluid intake → 50% decreased incidence of cystitis
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Avoid spermicide, encourage postcoital voiding (not great data but reasonable to suggest), encourage wiping “front to back”
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Bowel management – avoid constipation and fecal incontinence
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For all patients - encourage appropriate hydration, use of daily fiber supplements (Konsyl, Metamucil, Citrucel, Benefiber), daily exercise.
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If constipation persists → add MiraLAX, titrate to soft, formed stools daily or every other day
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If fecal incontinence persists → add Imodium as needed, consider starting at ½ tab per day
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Diabetic management
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Improve glucose control if not well managed
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Avoid diabetic medications that increase risk for UTIs (Jardiance, SGL-T2 inhibitors)
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Special Populations
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Relapsing infections: recurrence of same bacteria within 2 weeks of treatment → consider upper tract imaging (CT urogram or renal US) to assess for stones or anatomic abnormalities
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Recurrent Proteus infections or patients with hx of stones → consider upper tract imaging
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Patients with repeat symptomatic episodes but negative cultures (consider interstitial cystitis and recommend starting low acid diet, avoiding bladder irritants), see handout from AUGS
Instances where patients should be referred to Urogynecology:
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If patient has bothersome urinary incontinence, using several pads per day
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If prolapse is identified during pelvic exam
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If elevated post-void residual (PVR)(>150 mL) is identified
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Persistent microscopic hematuria that does not resolve with treatment of acute infection
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