article about UTI

Cochrane for Clinicians
Putting Evidence into Practice
Antibiotics for Recurrent Urinary Tract Infections

Clinical Scenario
A 26-year-old woman visits your clinic with dysuria. She is diagnosed with her fourth urinary tract infection (UTI) of the year.

Clinical Question
Should we use prophylactic antibiotics in patients with recurrent UTIs? If so, which antibiotic and schedule are best?

Practice Pointers
About 40 percent of all women will report having a UTI during their lives. Some studies estimate that 20 percent of young women with acute cystitis will develop recurrent episodes.
Risk factors for developing UTI in women include sexual intercourse, spermicide and diaphragm use, and a history of recurrent UTI. Other risk factors include having a first UTI at age 15 or younger and a mother with a history of UTI. After menopause, risk factors include cystocele, incontinence, and postvoiding residual urine.
There are many options for treating recurrent UTI. This review showed that prophylactic antibiotics are better than placebo in reducing the number of recurrences. The NNT to prevent one symptomatic recurrent UTI in one year was 2.2. However, after prophylactic therapy was stopped, rates of recurrence were equal to those in women who did not receive prophylactic therapy. The reviewed studies showed that side effects with the antibiotics were common and included nausea, rash, and oral and vaginal candidiasis. The number needed to harm for any side effect was 13.5. Thus, if 14 women are treated with antibiotic prophylaxis for one year, seven will have one fewer recurrent UTI, and one will experience a side effect.
Schedules for management of recurrent UTI include daily, weekly, or monthly prophylaxis, postcoital prophylaxis, and acute self-treatment. One study showed that sexually active young women who took postcoital ciprofloxacin had similar outcomes to women who took ciprofloxacin daily. Another study showed that weekly prophylaxis was better than monthly prophylaxis. No studies compared daily and weekly prophylaxis.
There are various antibiotics to consider in treating recurrent UTI. Antibiotics included in the review were fluoroquinolones, first-generation cephalosporins, trimethoprim, sulfamethoxazole, and nitrofurantoin. The review found that no antibiotic was superior.
Family physicians must weigh the costs versus the benefits when deciding whether to use prophylactic antibiotic treatment in patients with recurrent UTI. The decision to start prophylaxis should be individualized and based on the patient's preferences. Multiple factors must be considered, including the severity of UTI symptoms, cost, hassle, antibiotic resistance, and potential side effects. In patients who prefer not to use antibiotic prophylaxis, well-established protocols are available for empiric treatment by telephone.