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Recurrent UTI-Antibiotic prophylaxis

Definition of 
recurrent UTI (rUTI ) -Adults – repeated UTI with a frequency

♦ 2 or more UTIs in 6 months OR
♦ 3 or more UTIs in 12 months 
( EAU guideline 2017 )
 Children and younger people under 16

♦ 2 or more episodes of UTI with acute pyelonephritis / upper UTI OR

♦ 1 episode UTI episode with acute pyelonephritis plus 1 or more episode of UTI with cystitis / lower UTI OR

♦ 3 or more episodes of UTI with cystitis / lower UTI
 This guideline is for people without catheter Recurrent UTI includes
○ lower UTI and
○ upper UTI ie acute pyelonephritis
 rUTI may be due to 
○ relapse ie same strain of organism
○ reinfection – different strain or species
 rUTI is more common in women

UTI Trigger- NICE does not mention postcoital prophylaxis in 
this guidance but recognises that often women may be able to identify 1 or more triggers ( for eg sexual intercourse ) that often brings on a UTI. These triggers may vary
 Later in the guidance addressing the matter NICE says ” ensure that any current UTI has been adequately treated then consider single-dose antibiotic prophylaxis for use when exposed to an identifiable trigger “
 If after this measure women have no improvement then consider a trial of daily antibiotic prophylaxis

Trigger -ensure any current UTI is treated the consider single dose antibiotic prophylaxis when exposed to an identifiable trigger. 
Take into account. severity and frequency of previous symptoms risk of developing complications previous urine culture & susceptibility results previous antibiotic use ( resistance ) personal preference for antibiotic use .How to use Possible side effects particularly diarrhoea and nausea Review within 6 months Seek help if develops acute UTI symptoms.No improvement and any current UTI adequately treated

Self-care advice

A trial of D-mannose if not pregnant

♦ D-mannose -sugar related to glucose. It is part of the proteins on the epithelial cells of the urinary tract -E Coli anchors itself specifically to these proteins
♦ Studies have demonstrated that d-mannose based inhibitors of FimH can block UPEC* adhesion and invasion of uroepithelial cells
*UPEC- uropathogenic E Coli
♦ D-mannose comes as powder or tablet- it is not a medicine
♦ Evidence of effectiveness is uncertain
♦ Contains sugar
 Cranberry products if not pregnant

♦ Proanthocyanidin – is found in high conc in cranberyy , has a dose dependent effect on E Coli adherence to and diaplacement from urothilial cells
♦ Evidence of benefit uncertain
♦ Range of products are available – tablets more cost effective. 
♦ Beware sugar contents
♦ under 16s may wish to try cranberry products with specialist advice ( evidence uncertain )
 Probiotics ( lactobacillus ) evidence inconclusive

Post-menopausal women-

In post-menopausal women consider vaginal oestrogen ( Not oral ) if behavioral and personal hygiene measures not successful or appropriate 
eg estriol cream

Discuss the following to ensure shared decision making

 Severity and frequency of previous symptoms Possible complications from recurrent UTIs Benefits of treatment eg relief from vaginal dryness Potential adverse effects as
○ breast tenderness
○ vaginal bleeding – advice to report as it may need to be investigated further Inform about uncertainty of endometrial safety with long-term or repeated use Check preferences of treatment with topical oestrogens

Antibiotic prophylaxis –Any further investigations eg ultrasound to identify an underlying cause Severity and frequency of previous symptoms Risks of long term antibiotic use Risk of complications Previous urine culture and susceptibility results Previous antibiotic use and resistance Womens preference for antibiotic use. Risk of resistance with long term use Possible adverse effects Return for review within 6 months Seek help if develops an acute UTI

Men and pregnant women –Ensure that any current UTI has been adequately treated and then consider a trial of daily antibiotic prophylaxis if behavioral and personal hygiene measures alone are not effective or not appropriate , with specialist advice

In effect NICE recommends referral- see referral and specialist advice. It appears NICE is advising to treat the acute UTI and seek specialist advice. 

It further mentions that the following should be taken into account when prescribing prophylactic antibiotic

Referral and specialist advice – Men aged 16 and over People with recurrent upper UTI Recurrent lower UTI and underlying cause not known Pregnant women Children and young people under 16 
( as per NICE guidance UTI in under 16s ) People with suspected cancer

Trimethoprim ( Immediate release )
200 mg single dose when exposed to a trigger or
100 mg at night Nitrofurantoin ( Immediate release ) ensure GFR > 45
100 mg on trigger exposure or
50 to 100 mg at night

500 mg single dose on trigger exposure
250 mg at night Cefalexin
500 mg single dose on trigger exposure
125 mg at night



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