UTI is the one of most common infections among the reproductive age group and older females. It usually presents as a burning sensation while urination with or without lower abdominal pain, frequency or urgency. According to the latest report, the incidence of
uncomplicated recurrent UTI among young females is 40%. A short antibiotic is usually sufficient in most cases. However, 36% of females end up having recurrent UTI at end of one year. Recurrence of infection can be with the same organisms after adequate treatment
(relapse) or another organism or same organism after urine culture is negative (reinfection) In apparently healthy females with no previous known comorbidities or anatomical abnormalities, recurrent UTI needs to be evaluated thoroughly. Sexual activity is the strongest risk factor followed by first UTI at an early age, maternal history of UTI, new sex partner, and use of a spermicidal agent. Among post-menopausal women, incontinence and incomplete bladder emptying are risk factors.
The first step in the management of recurrent UTI is the correct diagnosis. Although symptoms are straightforward, infrequently it can be mimicked by certain noninfective pathologies like irritant cystitis, interstitial cystitis, and overactive bladder. Infective etiologies like genital herpes, vaginal candidiasis can present as frequency and dysuria, and therefore, detailed history and physical examination cannot be overemphasized. Once the clinician is certain about the diagnosis, every possible effort should be made to rule out functional and anatomical abnormalities in the urinary tract which require completely different management. A baseline complete blood profile, renal function test, blood sugar levels, urine routine as well as culture should be obtained. In cases where there is suspicion of complicated UTI for example vesicoureteric reflux, appropriate investigations should be done. There are no guidelines for imaging in cases of UTI, however, a CT or ultrasonography can be done where there is a family history of kidney disease, pyuria associated with hematuria or significant proteinuria, suspicion of pyelonephritis, or in presence of renal dysfunction.
In recurrent UTI, antibiotics should always be guided by the culture sensitivity pattern. Oral antibiotics that are most effective against uropathogens are sulfamethoxazole- trimethoprim(cotrimoxazole), nitrofurantoin, fluroquinolones, fosfomycin, and oral carbapenems. A short course of 3-7 days is more than sufficient in most cases. For prevention, in symptomatic, troublesome recurrent UTI, long-term antimicrobial prophylaxis can be prescribed. Most commonly, nitrofurantoin and cotrimoxazole for 6-12 months or longer can be given. In resistant cases, especially non-E.Coli UTI, a weekly course of Fosfomycin for 4-6 weeks can be prescribed. In patients who are not willing for a long
course of antibiotics, they can be trained to recognize the symptoms and with the aid of dipsticks, a self-administered short course of antibiotics is also an effective method. In female, whose UTI is temporally related to intercourse, a short postcoital antibiotic
prophylaxis is also useful. Role of cranberry juice and other cranberry products have not been convincing in most of the studies, nevertheless, they can be tried in selected patients where symptoms are mild and patient may not be willing for antibiotic prophylaxis. Good
hygiene and adequate water intake should be advised to all patients.
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