Recurrent urinary tract infection in women – are antibiotics the answer?

What is the evidence?

This interesting paper from 2010 discusses the natural history of UTI in women and distinguishes two conditions – the ‘urethral’ (or ‘dysuria/frequency’) syndrome’ (US) which affects a proportion of women with recurrent symptoms and many courses of treatment.  It is known that US is a self-limited condition in a majority of patients.  Some women are said to have ‘interstitial cystitis’ (IC); associated with long histories of symptoms and antibiotic treatment. In these cases, pyuria is found and bladder wall biopsy shows evidence of chronic inflammation.  Based on limited evidence, one precedes the other and antibiotic therapy for urethral syndrome may paradoxically increase propensity to development of IC.

Additionally, antibiotic exposure alters the gut, vaginal and skin microbiome (bacterial and fungal flora) for a prolonged period, possibly influencing future recurrence.   Novel oral non-antibiotic treatments for urethral syndrome and trigonitis are under study

There is (only) one small blinded randomised trial (79 patients) that compared use of short course oral ciprofloxacin or ibuprofen for treatment of uncomplicated UTI in adult women from community setting –  no significant differences in outcome nor serious adverse events.   A tantalising study !

What to do in the absence of definitive evidence in such a common condition ? My personal opinions:

No/delayed antibiotics for uncomplicated UTI in women? 

When episodic urinary symptoms are not associated with signs of sepsis, it is clearly safe (?safer) NOT to use antibiotics initially and to manage symptoms with urine alkalinisers, pushing of fluids and ibuprofen or similar.

Prevent future episodes 

  • trial application of topical oestrogens to the vaginal introitus
  • exclude presence of bladder stones, anatomical problems such as urethrocoele etc
  • manage vaginal pruritus if that is present

The data on efficacy of cranberry products are conflicting.

Avoid antibiotic prophylaxis for recurrent UTI

Multi-resistant Gram negative bacteria are now circulating in the Australian community, antibiotic prophylaxis encourages colonisation and infection with these resistant pathogens.  We need to preserve the antibiotics for complicated UTI where lives may depend upon having an active antibiotic.

In this northern Indian location, resistant Gram negative uropathogens have become highly prevalent and are now causing virtually untreatable complicated UTI. Many of these patients present from the community and mortality is significant.

Locally in the Hunter New England region, resistance amongst uropathogens is tracked closely. Stay tuned for updated cumulative antibiograms next month – there have been recent increases in resistance.

2 comments

  1. […] Uncomplicated UTI – no signs of systemic sepsis: avoid antibiotics if possible. See this recent discussion […]

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  2. I was taught at UNE during lectures (Bachelor of Nursing) that cranberry should be first line treatment for uncomplicated UTIs in women. Have used cranberry juice myself and resolved a very severe UTI (2 bottles of Ocean Spray Cranberry Juice) to clear urine with very visible blood, feeling unwell. I was well soon after completing first bottle and including drinking water. Drank second bottle over the next day for insurance.

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