New Paradigms in the Management of Recurrent Urinary Tract Infections

Lior Taich; Hanson Zhao; Camila Cordero; Jennifer T. Anger


Curr Opin Urol. 2020;30(6):833-837. 

In This Article

Abstract and Introduction


Purpose of Review: Recurrent urinary tract infections (rUTIs) represent a large burden on the healthcare system. Recent guidelines from the AUA/CUA/SUFU and advancements in the field reflect a paradigm shift for clinician and patients, steering away from empiric antibiotic therapy towards judicious antibiotic use.

Recent Findings: Antibiotic stewardship, including increasing awareness of the collateral damage of antibiotics and the risks of bacterial resistance are a major focus of the new guidelines. Accurate diagnosis of rUTIs is imperative. Urine cultures are necessary to document rUTI and should be obtained prior to any treatment. First line treatment options (trimethoprim–sulfamethoxazole, nitrofurantoin, and fosfomycin) should be used whenever possible. Asymptomatic bacteriuria should not be treated in these patients with rUTI. Although antibiotic prophylaxis methods are effective, nonantibiotic regimens show promise.

Summary: The management of rUTIs has evolved significantly with the goal of antibiotic stewardship. It is increasingly important to ensure the accuracy of diagnosis with a positive urine culture in the setting of cystitis symptoms, and standardize treatment with first-line therapies to minimize antibiotic side effects.


Recurrent urinary tract infections (rUTI) are a burdensome condition affecting women of all ages and backgrounds. By definition, urinary tract infections (UTIs) refer to culture proven acute cystitis associated with acute onset of symptoms including dysuria with or without new urgency, frequency, hematuria, or incontinence. These UTIs are considered uncomplicated in healthy patients with an anatomically and functionally normal urinary tract and no known risk factors. rUTIs are defined as two separate culture-proven episodes within 6 months or three episodes within 1 year.[1]

The overall prevalence of UTIs in females in the United States is estimated to be 11%. There are approximately 10.5 million outpatient visits for cystitis symptoms per year, which make it the most commonly encountered outpatient infection.[2,3] Within their lifetime, 50–60% of women will develop acute bacterial cystitis, of which 20–40% will undergo a repeat infection.[1] Once a woman experiences a repeat episode, there is a 2.7% risk she will undergo an additional infection within 6 months from the first infection and 25–50% likelihood she will go on to have multiple recurrent infections[4] Due to the frequency and discomfort of these recurrent infections, rUTIs can be a challenging and frustrating condition for patients and providers alike. In addition, they carry a tremendous financial burden for patients and the healthcare system with an estimated economic burden in the United States of $3.5 billion each year.[2]

Historically, the spectrum of patients who received treatment spanned those who have asymptomatic bacteriuria (ASB) and patients with urinary symptoms but no evidence of infection in their urine culture. However, recent advances have led to a better understanding of the pathophysiology of rUTI and a focus on antibiotic stewardship. There is much more recognition of the collateral damage that occurs with the misuse of antibiotics. As evidenced by these advances, a new set of rUTI guidelines outlined in the table below was published in 2019 from the American Urologic Association, Canadian Urologic Association, and the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction.[5] These guidelines present a paradigm shift in the diagnosis, treatment, and prophylaxis of rUTI with a focus on patient safety. In this review, we will discuss key aspects of these guidelines and recent advances in the management of rUTI (Table 1).