Recurrent UTI in adults is defined as repeated UTI with a frequency of:

• 2 or more UTIs in the last 6 months or
• 3 or more UTIs in the last 12 months

Recurrent UTI is diagnosed in children and young people under 16 years if they have:

• 2 or more episodes of UTI with acute pyelonephritis/upper UTI or
• 1 episode of UTI with acute pyelonephritis plus 1 or more episode of UTI with cystitis/lower UTI or
• 3 or more episodes of UTI with cystitis/lower UTI

Recurrent UTI is particularly common in women and includes lower UTI and upper UTI (acute pyelonephritis), but repeated pyelonephritis should prompt further investigation.

Risk factors in young and pre-menopausal women include sexual intercourse, new sexual partner, mother with a history of UTI, and history of UTI as a child.

Risk factors in post-menopausal and elderly women include history of UTI before menopause, urinary incontinence, atrophic vaginitis due to oestrogen deficiency, increased post-void urine volume, and urine catheterisation and functional status deterioration in elderly institutionalised women.

Self-care advice:

• Consider self-care options as listed in the UTI section introduction (above)
• Some women with recurrent UTI may wish to try D mannose, if they are not pregnant. D-mannose is available to buy as powder or tablets (it is not a medicine)
• Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI

Consider giving advice about behavioural and personal hygiene measures that may help reduce the risk of recurrent infections, i.e. increasing fluid intake, not delaying habitual and post-coital urination and not wearing occlusive underwear.

Refer or seek specialist advice on further investigation and management for:

• men aged 16 years and over
• people with recurrent upper UTI
• people with recurrent lower UTI when the underlying cause is unknown
• pregnant women
• children and young people under 16 years
• people with suspected cancer

Treatment with vaginal oestrogen for postmenopausal (non-pregnant) women

Consider the lowest effective dose of vaginal oestrogen, i.e. estriol cream, for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures alone are not effective or not appropriate.

Estriol cream 0.1%

• One applicator dose (0.5mg estriol) applied topically at night for 2 weeks then twice weekly (off-label indication)

Estradiol vaginal ring 7.5 micrograms/24 hours

• One ring (7.5 micrograms/24 hour) worn continuously for 12 weeks then replace, maximum duration of continuous treatment 36 weeks (off-label indication)

Review treatment within 12 months, or earlier if agreed with the woman.

Do not offer oral oestrogens (hormone replacement therapy) or oestrogen administered via a pessary.

See section 7.2.1 Preparations for vaginal and vulval changes

Antibiotic prophylaxis for women with recurrent UTI who are not pregnant

Take into account the considerations when prescribing antibiotics.

If behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate:

• Ensure that any current UTI has been adequately treated, then
• Consider single-dose antibiotic prophylaxis for use when exposed to an identifiable trigger or
• Consider self-start antibiotic therapy as an alternative option for women with the ability to recognise UTI symptomatically and start antibiotics at home. Inform patient to seek advice if symptoms do not improve within 48 hours

If there is no improvement after single-dose antibiotic prophylaxis or there are no identifiable triggers, a trial of daily antibiotic prophylaxis may be appropriate (consider seeking specialist advice).

Review antibiotic prophylaxis for recurrent UTI at least every 3 months, with the review to include:

• assessing the success of prophylaxis
• discussion of continuing, stopping or changing prophylaxis
• a reminder about behavioural and personal hygiene measures and self-care treatments

Consider seeking specialist advice if patient develops an acute UTI during treatment with daily antibiotic prophylaxis

1st line

Nitrofurantoin

• 100mg modified-release as a single dose when exposed to a trigger (off-label) or
• 100mg modified-release at night (if eGFR ≥ 45ml/min/1.73m²)

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 45 mL/min/1.73m² when the duration of the course is more than 7 days
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• An alternative agent to nitrofurantoin should be used if symptoms of upper urinary tract infection or systemic infection (loin pain, fever, rigors) are present, as nitrofurantoin lacks systemic activity.
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

2nd line

Amoxicillin

• 500mg single dose when exposed to a trigger or
• 250mg at night

Notes

• Off-label indication

Cefalexin

• 500mg single dose when exposed to a trigger or
• 125mg at night (off-label)

3rd line

Methenamine hippurate

• 1g twice daily
• Urine acidification advised

See section 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.13 Urinary-tract infections