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Recurrent Urinary Tract Infection

Definition = 3 or more UTIs in 1 year

General points:

  1. Confirm the patient is actually symptomatic
  2. ASymptomatic Bacteriuria (ASB) is common in and should not be treated (EXC in pregnancy).
  3. Catheter-associated bacteriuria is inevitable; catheter-associated ‘infections’ are difficult to diagnose and manage (see below) – discourage Nursing Homes from sending CSUs except on clinical advice: we have a standard letter we can send out to Nursing Homes: email us if it would help – rduh.MicroConsultants@nhs.net
  4. Only Dipstick urines in specific circumstances:

Do dipstick

Don’t dipstick

For WCC & Nitrites:
Symptomatic patient
with ?UTI (symptoms
may include falls and
confusion in frail older
At Annual QOF – send
urine to Chemistry for
ACR (lab will add PCR
automatically when
For non-infectious
reasons eg Renal disease,
Catheter Urines – send
CSU to Microbiology ONLY
if clinical signs of
infection, never dip!
In pregnancy – send
screening MSU to
Microbiology at 1st
trimester booking clinic

Red flags: Consider referral to Urology


Management Pathway for Recurrent UTI:

1. Send an MSU:
(a) to confirm UTI
(b) to check for resistant organisms [organisms which cause recurrent UTI are generally more resistant than others]
2. Consider starting empirical antibiotics according to the Joint Formulary
3. Adjust treatment once MSU results are available
4. Consider a longer course of antibiotic treatment [to allow penetration into the bladder wall +/- the prostate]. Use the highest licensed doses.
(a) 2 weeks for women
(b) 4 weeks for men


In addition: Consider underlying causes/risk factors:

This requires a thorough examination +/- PR / PV, +/- referral to Urology for post voiding ultrasound of the bladder +/- cystoscopy:

  1. Constipation
  2. Bubble baths
  3. Atrophic vaginitis: consider treating with nightly Oestrogen creams for 2-3 weeks, then maintenance with twice weekly application.
  4. Diabetes
  5. Post sexual intercourse in women – give advice on post coital voiding, and avoid using diaphragm/spermicides; consider post coital prophylactic trimethoprim 100mg.
  6. Sexually transmitted infections (e.g. Chlamydia can cause cystitis with negative urine culture)
  7. Residual urine or other structural abnormality (e.g. stones, cysts or tumours)
  8. Uterine prolapse
  9. Prostatitis – tender prostate on PR



1. Ms U is pre-menopausal and has had 4 episodes of UTI this year – should I offer her prophylactic

    1. Advise re: post-coital voiding, check not using diaphragm/spermicides +/- try post-coital antibiotics eg Trimethoprim 100mg within 2 hours of intercourse.
    2. Standby antibiotics – 3 day course dependant on current sensitivities
    3. Regular prophylaxis – we only recommend this once all above risk factors have been excluded. Choose antimicrobial agent (eg Trimethoprim, Amoxil, Cephalexin, NOT nitrofurantoin) based on reported sensitivities. Stop after 6 months, if UTI frequency returns to pre-prophylaxis levels, restart prophylaxis, and refer to urology for assessment.


2. Mrs M is post-menopausal and has had 4 episodes of UTI this year – should I offer her prophylactic


    1. Confirm each episode meets the clinical criteria for treatment & send MSU, examine for
      underlying causes as above
    2. Try a longer course of treatment-dose antibiotic – initially 2 weeks, but up to 6 weeks may be
    3. Exclude underlying pathology eg treat atrophic vaginitis with nightly Oestrogen creams for 2-3
      weeks, then maintenance with twice weekly application.
    4. If all else fails, try prophylaxis as in Q1 above.


3. Ms/Mr R responds to antibiotics but becomes symptomatic again after a few days.

This sounds like relapse (as opposed to re-infection).


4. Child X has recurrent UTIs (Ref: NICE CG: Urinary tract infection in children)

Refer to paediatricians who need to assess and investigate. They will advise on use of antimicrobial prophylaxis.

The NICE guidance recommends consider antimicrobial prophylaxis for recurrent UTI, but not for first-time UTI.

In the meantime, consider risk factors for recurrent UTI in infants and children:


5. Mrs P is 26 weeks pregnant and has had x4 UTIs in this pregnancy – how should I manage this?

Refer to Obstetrics for recurrent UTI – they will consider prophylactic antimicrobials.

There is evidence that UTIs (and even ASymptomatic Bacteriuria) in pregnancy are associated with renal complications, chorioamnionitis and pre-term labour; antibiotic treatment has been shown to reduce these outcomes. [Pregnancy is one of the few situations where treatment of ASB is recommended].

Treat each episode with a 7 day course of antibiotics according to Joint Formulary; take MSU for a Test-of-Cure 1 week after stopping antibiotics, then screen monthly throughout the remainder of the pregnancy.


6. What is the specific risk with prophylactic nitrofurantoin?

Nitrofurantoin is NOT recommended for prophylaxis in East Devon:


7. Will cranberry products help?

Probably not:


8. Mrs C has a long-term catheter in situ which keeps getting infected – what should I do?

There is no easy answer here I am afraid:

(a) Confirm diagnosis:

      1. New costovertebral tenderness
      2. Rigors
      3. New onset delirium
      4. Fever greater than 37.9°C or 1.5°C above baseline on two occasions during 12 hours.

(b) Treat:

(c) Don’t offer Antimicrobial prophylaxis

(d) Refer to Urology.


9. Why aren’t Red Cells reported on urines anymore?

On discussion with urology, we decided to omit the Red Blood Cells from the report in line with NICE guidance:

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