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

Antibiotic Treatment and Stewardship

Patients with rUTI should be treated during symptomatic episodes with as short of an antibiotic duration as possible, typically no longer than 7 days, including patients who require parenteral antibiotics due to bacterial resistance to oral antibiotics. The current three 1st-line antibiotic therapies are: nitrofurantoin 100 mg twice daily for 5 days (cure rate 88–93%), Trimethoprim–Sulfamethoxazole double strength (TMP–SMX) twice daily for 3 days (cure rate 90–100%), or Fosfomycin 3 g, single dose (cure rate 83–91%).[5] In a systematic review of over 6000 patients, Zalmanovici Trestioreanu et al.[8] found no differences between β-lactams, TMP–SMX, nitrofurantoin, or fluoroquinolones in symptomatic improvement or bacteriologic cure. TMP–SMX and β-lactams, did, however, have a higher rate of rash. Given that all first-line agent have a high rate of cure, an important secondary focus of therapy is reducing the emergence of resistant organisms and minimizing damage to normal body flora.[9] In a recent systematic review of antibiotic duration effects, Kim et al. analyzed 61 studies with a total of 20 780 patients. They found that a single dose of third-generation fluoroquinolone (i.e., levofloxacin) had similar clinical responses with moderate evidence. Third-generation cephalosporins also had similar outcomes for single and 3-day course. However, the quality of evidence was low. Generally, a 3-day course of antibiotics did not show a statistically significant difference in short-term or long-term bacteriologic failure compared with a 5–10-day course.[10]

The importance of antibiotic stewardship has been highlighted in recent years due to the recognized unintended effects of antibiotic use. They have side effects including nausea, diarrhea, rashes, and fatigue.[8] In addition, antibiotics can wipe out the human microbiome and alter the natural periurethral and vaginal flora, which reduces competition for pathogenic strains.[3] It is not surprising then that antibiotics can even paradoxically even increase the rate of subsequent UTIs, especially with resistant organisms.[11] Thus, the 2019 AUA rUTI guidelines advocate to against treating ASB, meaning a patient with a positive urine culture without cystitis symptoms should not receive antibiotic therapy.[5]