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 Prophylaxis

Prevention strategies have been proven to reduce the number and frequency of UTIs. In addition, these strategies give the patient an offensive (instead of defensive) approach and puts them in control of their health.[7,12] Multiple studies have demonstrated the efficacy of both antibiotic and nonantibiotic prophylaxis regimens.[1,13,14] Here, we highlight those studies mentioned by the 2019 AUA guidelines and several other recent studies in the recent literature.

There is a substantial amount of literature pertaining to the efficacy of antibiotic prophylaxis, although many of the trials were conducted decades ago. In the development of the 2019 AUA Recurrent UTI Guidelines, a total of 28 trials on antibiotic prophylaxis were identified for the systematic review and meta-analysis.[5] These trials compared antibiotic prophylaxis against placebo and compared various antibiotic prophylaxis agents against one another.

There were eleven studies that compared prophylactic antibiotic use to placebo or no antibiotic in the meta-analysis. These trials all used a daily dosing of antibiotics except for one that used a postcoital dose of TMP–SMX. Antibiotic use was found to decrease the likelihood of experiencing one or more UTI recurrence (relative risk 0.26, 95% confidence interval 0.18–0.37).[5] While there is a clear clinical benefit to using antibiotics for prophylaxis of rUTI, there are a variety of adverse events associated with antibiotic use. These include hepatic, gastrointestinal, and pulmonary consequences.[15] In addition, antibiotic resistance remains an important concern. The benefits and risks of these regimens must be discussed with each patient.

A number of antibiotics are now recommended for prophylaxis including TMP, TMP–SMX, nitrofurantoin, cephalexin, and fosfomycin. The dosing regimen for each antibiotic can also vary based on the antibiotic and indication although daily dosing has the best evidence. The exception of Fosfomycin prophylaxis, which is dosed every 10 days. In addition, women who experience recurrent postcoital UTIs should only need to take antibiotic prophylaxis before or after sexual intercourse (within 1 h) for maximal benefit. Ultimately, the overall duration of antibiotic prophylaxis needs further investigation. The duration studied in the literature has usually been from 6 months to 1 year. Once antibiotic prophylaxis is stopped, the frequency of UTIs have been shown to increase back to baseline. Thus, longer durations of antibiotic prophylaxis may provide some clinical benefit.[5]