Recurrent UTI

No single definition of the frequency of recurrent UTI exists. A pragmatic definition is 3 or more per year.¹

Aetiology

Usual cause of UTI is bacterial source from GI tract. Common organisms are E. coli, Staph. saprophyticus, Proteus mirabilis.

Incidence

• UTI accounts for 1-3% of all GP consultations.
• 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.
• Approx. 90% of these are due to re-infection and 10% are relapses.
• Relapse is assumed to occur when infection recurs within 2 weeks.
• UTI is rare in men aged 20-50 years and uncommon in children and elderly men.

Risk Factors

In women:^2,3

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

In men:⁴

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

In children:⁵

• Constipation
• Any condition that leads to urinary stasis (renal calculi, obstructive uropathy, vesicoureteric reflux (VUR) - or family history of VUR, voiding disorders) or poor urine flow e.g. phimosis
• Impaired immune function
• Sexual abuse
• Impaired renal function

Age:

• Women over 60 have 7-8% annual incidence UTI
• Women >80 years have 20%
• Men 3% at age 60-70 years and 10% in age >80 years

20% boys and 30% girls with UTI have at least one recurrence and 4% boys and 8% girls have more than one.

• Symptoms include:
  • Dysuria
  • Frequency
  • Urgency
  • Nocturia
  • Haematuria
  • Suprapubic discomfort

• Signs may include:
  • Suprapubic tenderness
  • Cloudy or foul smelling urine
  • In 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 NICE guidance, and are age-related.⁶

• DMSA scanning is used to demonstrate renal function.
• Cystography to demonstrate vesicoureteric reflux - may use indirect radionuclide cystography.

Women

• Relapse:
  • Treat with antimicrobial for 3 days and refer if persists.
• Reinfection:
  • Treat each recurrence with antimicrobial for 7 days and consider prophylaxis if (3 episodes per year).¹
• Prophylaxis:
  • If not related to sexual intercourse then consider either nightly or 3x a week antibiotics from above, possible up to 5 years.⁷
  • Consider trial of cranberry juice.^8,9 Optimum dose and method of delivery has not been determined.
  • If related to sexual intercourse:
    • Change contraceptive method if diaphragm or spermicide being used.
    • Advise voiding after intercourse.
    • Suggest using a lubricant.
  • If more than 3 UTIs/year consider prophylactic antibiotics taken <2 hours after intercourse.
  • If prophylaxis fails, culture and sensitivity and change of antibiotic.

• Prescribing amoxicillin first line was more likely to necessitate a second course of antibiotics than trimethoprim.
• There was no significant difference between the failure rates of trimethoprim, nitrofurantoin, norfloxacin, ciprofloxacin, or the cephalosporins.
• Courses of 3 days were as effective as those of 5 or 7 days.

Men

• Exclude chlamydia infection in sexually active men.⁴
• Recurrent cystitis in a man is likely to be secondary to associated conditions e.g. prostatitis, prostatic hyperplasia, calculi in the genito-urinary tract, or vesico-ureteric reflux.
• Antibiotic for 7 days. Bearing in mind local sensitivities, choose from trimethoprim, nitrofurantoin or cefalexin.⁴
• Consider referral for >2 episodes/year or features of urinary obstruction or other complications.⁴

Children

General principles include:

• 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".¹¹
• 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 month and over with cystitis or lower urinary tract infection 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 tract UTI in children.¹²
• 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 b.d. orally is commonly used.¹³ 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.⁶
• 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 e.g. prevention of urinary tract infection, or prevention of renal damage, nor the risks e.g. adverse effects or bacterial resistance, of prophylactic antibiotics had been adequately evaluated.¹⁴

• NICE Guidance does NOT advocate the use of routine antibiotic prophylaxis.⁶
• 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).¹⁵
• Clinical Knowledge Summaries suggest that children who suffer a second UTI within a year should receive short-term prophylactic antibiotics and be referred for their assessment for long-term use.⁵
• The efficacy of cranberry juice for prevention in children has not been studied.

Most people will recover fully with treatment.

• Vesicoureteric reflux (VUR) is found in about 1% of normal infants and normally resolves over several years.¹⁶
• However, it is a risk factor for pyelonephritis, which can cause renal scarring, which can lead to hypertension and impaired renal function.