Recurrent Urinary Tract Infection

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

No single definition of the frequency of recurrent urinary tract infection (UTI) exists. A pragmatic definition is two proven episodes within six months or three within a year.[1]

Aetiology

Escherichia coli has been shown to be responsible for up to 95% of all UTIs.[1] Staphylococcus saprophyticus and Proteus mirabilis are culprits less regularly.

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Incidence

  • Women have a lifetime risk of UTI of 1 in 3, and men 1 in 20.
  • It accounts for 5% of women each year presenting with frequency and dysuria.
  • Up to 20% of non-pregnant women with cystitis will have a recurrence and most are due to re-infection.
  • UTI is rare in men aged 20-50 years and uncommon in young boys and elderly men.

Age and gender:

  • Women aged over 60 have 7-8% annual incidence of UTI.
  • Women aged over 80 have 20%.
  • In men, there is 3% annual incidence at age 60-70 years and 10% in those aged over 80.

After the age of 1 year, roughly 40% of girls and 30% of boys will have a recurrence.[2]

Risk factors

There is evidence to suggest that deregulation of candidate genes in humans may predispose patients to recurrent UTI.[3] Diabetes is also a predisposing factor.[4] In women:[5][6]

  • Sexual intercourse (honeymoon cystitis)
  • Atrophic urethritis and vaginitis (postmenopausal)
  • Abnormalities of urinary tracts (indwelling catheter, neuropathic bladder, vesico-ureteric reflux (VUR), outflow obstruction, anatomical anomalies)
  • Incomplete bladder emptying (dysfunctional urination)
  • Contraception - diaphragm, spermicide-coated condoms
  • History of urinary tract surgery
  • Immune compromise - eg, HIV

In men:[7] 

  • Abnormalities of urinary tract function
  • Incomplete bladder emptying (prostatic enlargement, chronic indwelling catheter)
  • Previous urinary tract surgery
  • Immunocompromised state
  • Anal intercourse

In children:[2]

  • Any condition that leads to urinary stasis (VUR in 41% cases, but also renal calculi, obstructive uropathy - or family history of VUR, voiding disorders) or poor urine flow - eg, phimosis
  • Constipation
  • Impaired immune function
  • Sexual abuse
  • Impaired renal function
  • Symptoms include:
    • Dysuria
    • Frequency
    • Urgency
    • Nocturia
    • Haematuria
    • Suprapubic discomfort
  • Signs may include:
    • Suprapubic tenderness
    • Cloudy or foul-smelling urine
    • In the elderly, incontinence, confusion, anorexia, fever, shock

Primary care

  • MSU culture, urine microscopy (especially in children):
    • A clean catch urine sample is the recommended method for urine collection
    • This is much easier in toilet-trained children
  • Consider ultrasound in children to visualise anatomical anomalies.

Secondary care

Imaging recommendations are specifically made for children within the latest National Institute for Health and Care Excellence (NICE) guidance, and are age-related.[2]

  • Dimercaptosuccinic acid (DMSA) scanning is used to demonstrate renal function.
  • Cystography to demonstrate VUR - may use indirect radionuclide cystography.

Women

  • Relapse:
    • Treat with an antimicrobial for three days and refer if the condition persists.
  • Re-infection:
    • Treat each recurrence with an antimicrobial for seven days and consider prophylaxis (if three episodes per year).
  • Prophylaxis:
    • If not related to sexual intercourse then consider either nightly or three times per week antibiotics, possibly up to five years.[8]
    • Consider a trial of cranberry juice.[9] However, an American study found it made little difference in a college age population.[10]
    • There is some evidence that topical vaginal oestrogens may help postmenopausal women.[11]
    • If related to sexual intercourse:
      • Change the contraceptive method if a diaphragm or spermicide is being used
      • Advise voiding after intercourse
      • Suggest using a lubricant
    • If the patient has more than three UTIs/year consider prophylactic antibiotics taken <2 hours after intercourse.
    • If prophylaxis fails, culture and sensitivity and change of antibiotic.

Refer if there is repeated failure. A study of UTI in young women found that:[12]

  • Prescribing amoxicillin first-line was more likely than trimethoprim to necessitate a second course of antibiotics.
  • There was no significant difference between the failure rates of trimethoprim, nitrofurantoin, norfloxacin, ciprofloxacin, or the cephalosporins.
  • Courses of three days were as effective as those of five or seven days.

Men

There is little high-quality evidence to inform this section, due the the relative rarity of UTI in men, compared with women.

  • Exclude chlamydial infection in sexually active men.[7] 
  • Recurrent cystitis in a man is likely to be secondary to associated conditions - eg, prostatitis, prostatic hyperplasia, calculi in the genitourinary tract, or VUR.
  • Prescribe an antibiotic to be taken for seven days. Bearing in mind local sensitivities, choose from trimethoprim, nitrofurantoin or cefalexin.
  • Consider referral for more than two episodes/year or features of urinary obstruction or other complications.

Children

General principles include:[2]

  • Following local policy when available.
  • Children with a high risk of serious illness and/or younger than 3 months should be referred immediately to secondary care. This should be assessed in accordance with NICE guidance "Feverish illness in children".[13] 
  • Do not delay treatment if the sample cannot be obtained and the infant or child is at high risk of serious illness.
  • Treat each episode of acute UTI the same as a first episode.
  • If a second episode occurs within a year, check for anatomical abnormalities, voiding problems and constipation. Make sure that the bladder and the bowel are emptied regularly.
  • Advise parents/carers on the importance of adhering to treatment regimes.

Antibiotic choice

  • Children aged 3 months and over with cystitis or lower UTI should be treated with three days of oral antibiotics according to local guidance.
  • A Cochrane systematic review suggests that treatment for 2-4 days seems to be as effective as treatment for 7-14 days for eradicating lower UTI in children.[14]
  • Carers should be advised to return for review if the child remains unwell after 24-48 hours.
  • There is little evidence to favour a particular antimicrobial.
  • Trimethoprim 50 mg/5 ml, 50 mg bd orally is commonly used.[15] However, it is not recommended for patients with renal insufficiency.

NB: quinolones should be avoided due to safety concerns.

Referral

  • Children with cystitis/lower UTI should only have ultrasound investigation if they are younger than 6 months old, or have had a recurrent UTI within 12 months.[2]
  • If the ultrasound is normal in a first time UTI, no further follow-up is required.
  • If the ultrasound is abnormal in a first episode, or normal in a recurrent UTI, they should be referred for paediatric opinion.

Prophylaxis

A Cochrane review concluded that neither the possible benefits (eg, prevention of UTI, or prevention of renal damage) nor the risks (eg, adverse effects or bacterial resistance) of prophylactic antibiotics had been adequately evaluated.[16]

  • NICE guidance does NOT advocate the use of routine antibiotic prophylaxis.[2]
  • Relief of voiding dysfunction, good hygiene, wiping from front to back after micturition in girls, avoiding constipation, bubble baths, chemical irritants and tight clothing are sensible recommendations.
  • Children with significant urinary tract abnormalities and/or frequent symptomatic UTI may benefit from prophylactic antibacterials (trimethoprim or nitrofurantoin).[17]
  • The efficacy of cranberry juice for prevention in children has not been studied.

Most people will recover fully with treatment.

  • VUR is found in about 1% of normal infants and normally resolves over several years.[18]
  • However, it is a risk factor for pyelonephritis, which can cause renal scarring which can lead to hypertension and impaired renal function.

Further reading & references

  • Schooff M, Hill K; Antibiotics for recurrent urinary tract infections. Am Fam Physician. 2005 Apr 1;71(7):1301-2.
  • Gupta K, Trautner BW; Diagnosis and management of recurrent urinary tract infections in non-pregnant women. BMJ. 2013 May 29;346:f3140. doi: 10.1136/bmj.f3140.
  1. Chung A, Arianayagam M, Rashid P; Bacterial cystitis in women. Aust Fam Physician. 2010 May;39(5):295-8.
  2. Urinary tract infection in children: diagnosis, treatment and long-term management; NICE Clinical Guideline (2007)
  3. Zaffanello M, Malerba G, Cataldi L, et al; Genetic risk for recurrent urinary tract infections in humans: a systematic J Biomed Biotechnol. 2010;2010:321082. Epub 2010 Mar 30.
  4. Gorter KJ, Hak E, Zuithoff NP, et al; Risk of recurrent acute lower urinary tract infections and prescription pattern Fam Pract. 2010 Aug;27(4):379-85. Epub 2010 May 12.
  5. Scholes D, Hooton TM, Roberts PL, et al; Risk factors for recurrent urinary tract infection in young women. J Infect Dis. 2000 Oct;182(4):1177-82. Epub 2000 Aug 31.
  6. Scholes D, Hooton TM, Roberts PL, et al; Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med. 2005 Jan 4;142(1):20-7.
  7. Guidelines on Urological Infections; European Association of Urology (Mar 2013)
  8. Albert X, Huertas I, Pereiro II, et al; Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev. 2004;(3):CD001209.
  9. Jepson RG, Craig JC; Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001321.
  10. Barbosa-Cesnik C, Brown MB, Buxton M, et al; Cranberry juice fails to prevent recurrent urinary tract infection: results from Clin Infect Dis. 2011 Jan;52(1):23-30.
  11. Perrotta C, Aznar M, Mejia R, et al; Oestrogens for preventing recurrent urinary tract infection in postmenopausal Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005131.
  12. Lawrenson RA, Logie JW; Antibiotic failure in the treatment of urinary tract infections in young women. J Antimicrob Chemother. 2001 Dec;48(6):895-901.
  13. Feverish illness in children - Assessment and initial management in children younger than 5 years; NICE Guideline (May 2013)
  14. Michael M, Hodson EM, Craig JC, Martin S, Moyer VA; Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Data Sys Review (2):CD003966. 2005. [abstract]
  15. Keren R, Chan E; A meta-analysis of randomized, controlled trials comparing short- and long-course antibiotic therapy for urinary tract infections in children. Pediatrics. 2002 May;109(5):E70-0.
  16. Williams GJ, Wei L, Lee A, et al; Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. 2006 Jul 19;3:CD001534.
  17. Le Saux N, Pham B, Moher D; Evaluating the benefits of antimicrobial prophylaxis to prevent urinary tract infections in children: a systematic review. CMAJ. 2000 Sep 5;163(5):523-9.
  18. Jakobsson B, Jacobson SH, Hjalmas K; Vesico-ureteric reflux and other risk factors for renal damage: identification of high- and low-risk children. Acta Paediatr Suppl. 1999 Nov;88(431):31-9.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Dr Colin Tidy
Last Checked:
28/05/2013
Document ID:
2708 (v23)
© EMIS