Editing AUA & CUA Recurrent UTI (2019)



'''See [https://pubmed.ncbi.nlm.nih.gov/31042112/ Original Guideline]'''

*This guideline only describes diagnosis and treatment of recurrent episodes of UNCOMPLICATED cystitis in women.
** “Uncomplicated” means that the patient has no known factors that would make her more susceptible to develop a UTI, while '''“complicated” indicates infection with multi-drug resistant bacteria or presence of risk factor(s)''' for UTI and decreased treatment efficacy.
*** '''See from [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202002/table/t1-cuaj-5-316/ Table 1] from 2011 CUA Guideline on Recurrent UTI for host factors that classify a urinary tract infection as complicated'''
* '''The index patient for this guideline is an otherwise healthy adult female with an uncomplicated rUTI'''. The infection is culture-proven and associated with acute-onset symptoms. This guideline does not apply to complicated UTI or those exhibiting signs or symptoms of systemic bacteremia, such as fever and flank pain.

== Background ==

* ≈60% of females will experience at least 1 symptomatic episode of acute bacterial cystitis in their lifetime. Of these, 20-40% will experience at least 1 other episode, of which 25-50% of whom will experience multiple recurrent episodes.

== Acute Bacterial Cystitis ==

=== Definition ===
*'''<span style="color:#ff0000">Diagnosis of acute bacterial cystitis requires (2):</span>'''
*# '''<span style="color:#ff0000">Laboratory confirmation of significant bacteriuria AND</span>'''
*# '''<span style="color:#ff0000">Acute-onset symptoms (lower urinary tract symptoms)</span>'''
*In this guideline, the term UTI will refer to culture-proven acute bacterial cystitis and associated symptoms unless otherwise specified.

=== Diagnosis and Evaluation ===

==== History and Physical Exam ====
* '''History'''
** '''<span style="color:#ff0000">Symptoms</span>'''
*** '''<span style="color:#ff0000">Urinary tract infection symptoms include dysuria, central to the diagnosis of UTI, with variable degrees of:</span>'''
***# <span style="color:#ff0000">'''Increased urinary urgency and frequency'''</span>
***# <span style="color:#ff0000">'''Hematuria'''</span>
***# <span style="color:#ff0000">'''Suprapubic pain'''</span>
***# <span style="color:#ff0000">'''New or worsening incontinence'''</span>
*** '''<span style="color:#ff0000">In older adults, the symptoms of UTI may be less clear.</span>'''
**** Given the subjective nature of these symptoms, '''careful evaluation of their chronicity becomes an important consideration.'''
***** Older females frequently have nonspecific symptoms that may be perceived as a UTI, such as dysuria, cloudy urine, vaginal dryness, vaginal/perineal burning, bladder or pelvic discomfort, urinary frequency and urgency, or urinary incontinence, but these tend to be more chronic
***** '''Acute-onset dysuria, particularly when associated with new or worsening storage symptoms, remains a reliable diagnostic criterion in older females''' living both in the community and in long-term care facilities.

==== Labs ====
*'''<span style="color:#ff0000">Urine culture/laboratory confirmation of significant bacteriuria</span>''' 
** '''Urine culture remains the mainstay of diagnosis of an episode of acute cystitis'''
*** '''Clinical judgment is needed to determine when a culture result represents clinically significant bacteriuria''' considering the patient presentation, urine collection method, and the presence of other suggestive factors such as pyuria.
**** '''<span style="color:#ff0000">The definition for clinically significant bacteriuria of >10<sup>5</sup> colony forming units (CFU)/mL represents an arbitrary cut-off.</span>'''
**** '''Although > 10<sup>5</sup> CFU/mL for bacterial growth on midstream voided urine''' '''may help distinguish bladder bacteriuria from contamination in asymptomatic, pre-menopausal women,''' '''<span style="color:#ff0000">a lower 10<sup>2</sup> CFU/mL threshold may be appropriate in symptomatic individuals</span>'''
**'''Obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen'''
*** '''Urine culture contamination should be suspected when (3):'''
***# '''Mixed cultures containing ≥2 organisms'''
***# '''Low quantities (<103 CFU/mL) of a pathogenic organism in an asymptomatic patient'''
***# '''Specimen exhibits growth of normal vaginal flora (e.g. Lactobacilli, Group B Streptococci, Corynebacteria, or non-saprophyticus coagulase-negative Staphylococci)'''
***#* '''Growth of these organisms are thought to be contaminant and generally do not require treatment'''
*** '''Concomitant urinalysis can also be useful (presence of epithelial cells or mucus on microscopic urinalysis may also suggest contaminant).'''
*** When there is high suspicion for contamination, consider obtaining a catheterized specimen for further evaluation prior to treatment.
*** '''Urine specimens should not sit at room temperature for > 30 minutes''' to facilitate lab diagnosis of UTI.
=== Differential Diagnosis ===
*'''<span style="color:#ff0000">Differential Diagnosis of UTI (10):</span>'''
*# '''<span style="color:#ff0000">Interstitial cystitis/bladder pain syndrome</span>'''
*# '''<span style="color:#ff0000">Overactive Bladder</span>'''
*# '''<span style="color:#ff0000">Urinary calculi</span>'''
*# '''<span style="color:#ff0000">Infectious bacterial or fungal vaginitis</span>'''
*# '''<span style="color:#ff0000">Vulvar dermatitis</span>'''
*# '''<span style="color:#ff0000">Non-infectious vulvovestibulitis</span>'''
*# '''<span style="color:#ff0000">Vulvodynia</span>'''
*# '''<span style="color:#ff0000">Hypertonic pelvic floor muscle dysfunction</span>'''
*# '''<span style="color:#ff0000">Genitourinary syndrome of menopause</span>'''
*# '''<span style="color:#ff0000">CIS of the bladder</span>''' (less commonly)
* A lack of correlation between microbiological data and symptomatic episodes should prompt a diligent consideration of alternative/comorbid diagnoses (many females with gross hematuria may be incorrectly treated for a UTI when they should be evaluated for bladder cancer; a negative culture would prompt further investigation of GH)

== Asymptomatic Bacteruria ==
* '''<span style="color:#ff0000">Definition: bacteriuria of any magnitude without symptoms</span>'''
*'''<span style="color:#ff0000">Management</span>'''
**'''<span style="color:#ff0000">DO NOT routinely treat asymptomatic bacteriuria</span>'''
*** No evidence that treatment of asymptomatic bacteriuria improves outcomes
** '''<span style="color:#ff0000">Indications for screening/treatment of asymptomatic bacteriuria (2):</span>'''
**# '''<span style="color:#ff0000">Pregnant females</span>'''
**# '''<span style="color:#ff0000">Patients undergoing elective urologic surgery</span>'''
**# '''[Neonatal candiduria, not technically bacteruria but should be treated even if asymptomatic]'''
** '''Asymptomatic bacteriuria and struvite stones'''
*** '''Routine treatment of urease-producing bacteriuria in the absence of UTI symptoms or documented urinary tract stones is not recommended'''
*** There is no clear evidence that identification and treatment of asymptomatic bacteriuria caused by urease-producing organisms (recall that urease-producing organisms include proteus, pseudomonas, klebsiella, mycoplasma, and staphylococcus) prevents struvite stone formation. However, '''in certain patients with recurrent struvite stones, screening for and treating urease-producing bacteriuria may be indicated if other measures have not been able to prevent stone formation.'''

== Recurrent UTI ==

=== Definitions ===
*'''<span style="color:#ff0000">Definition of Recurrent UTI: Either (2):</span>'''
*#'''<span style="color:#ff0000">≥2 episodes of acute bacterial cystitis within 6 months or</span>'''
*# '''<span style="color:#ff0000">≥3 episodes within 1 year</span>'''
*#* These episodes are considered to be separate infections with resolution of symptoms between episodes, and do not include those who require >1 course of antibiotics for symptomatic resolution, as can occur with inappropriate initial or empiric treatment
*#* '''<span style="color:#ff0000">For diagnosis of recurrent UTI, each symptomatic episode must be associated with a document positive urine culture'''
*Patients with a long history of culture-proven symptomatic episodes of cystitis that occur at a lower frequency than this definition will likely benefit from management strategy similar to that for patients with rUTI.

=== Diagnosis and Evaluation ===

==== UrologySchool.com Summary ====

* '''<span style="color:#ff0000">Mandatory (1):</span>''' 
*# '''<span style="color:#ff0000">History and Physical Exam</span>'''
* '''<span style="color:#ff0000">Optional (1):</span>''' 
*# '''<span style="color:#ff0000">PVR</span>'''
* '''Not recommended'''
** '''Cystoscopy'''
** '''Upper tract imaging'''

==== Mandatory ====

===== History and Physical Exam =====
* '''<span style="color:#ff0000">History'''
** '''Characterize current LUTS''' (dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria)
***'''Characterize baseline symptoms between infections'''
**Back or flank pain; catheter usage; vaginal discharge or irritation
**'''UTI history''': frequency of UTI, antimicrobial usage, and documentation of positive cultures and the type of cultured microorganisms, responses to treatment for each episode, the symptoms the patient considers indicative of a UTI, the relationship of acute episode to infectious triggers (e.g. sexual intercourse for post-coital UTIs), relationship of infections to hormonal influences (e.g., menstruation, menopause, exogenous hormone use), results of any prior diagnostic investigations
**'''Bowel symptoms''' such as diarrhea, accidental bowel leakage, or constipation
** '''Menopausal status; contraceptive method; and use of spermicides or estrogen- or progesterone-containing products'''
** '''Risk factors for complicated UTI (see [[Urinary Tract Infections|Urinary Tract Infections Chapter Notes]])'''
** '''Medications''' (immunosuppressive meds, recent use of antibiotics for any medical condition), '''PMHx, PSHx''' (may suggest complicated UTI), '''allergies, travel history'''
* '''<span style="color:#ff0000">Physical Exam'''
** '''<span style="color:#ff0000">Abdominal and pelvic examination'''
***'''Prolapse, urethral tenderness, urethral diverticulum, Skene’s gland cyst, or other enlarged or infected vulvar or vaginal cysts'''
***'''Any other infectious and inflammatory conditions (vaginitis, vulvar dermatitis, and vaginal atrophy''' (genitourinary syndrome of menopause)
***'''Pelvic floor musculature''' for tone, tenderness, and trigger points
** '''Focused neurological exam''' 
***'''May also be considered''' to rule out occult neurologic defects

==== Optional ====
*'''<span style="color:#ff0000">Post-void Residual'''
** '''<span style="color:#ff0000">Indications</span>'''
***'''<span style="color:#ff0000">Can be considered for all patients'''
***'''<span style="color:#ff0000">Should be performed in any patient with suspicion of incomplete emptying, such as those with (4):</span>'''
***# '''<span style="color:#ff0000">Significant anterior vaginal wall prolapse</span>'''
***# '''<span style="color:#ff0000">Underlying neurologic disease</span>'''
***# '''<span style="color:#ff0000">Diabetes</span>'''
***# '''<span style="color:#ff0000">Subjective sensation of incomplete emptying</span>'''.

==== Not recommended (2): ====
*'''Cystoscopy and upper tract imaging'''
** '''Low yield of anatomical abnormalities with cystoscopy and upper tract imaging in patients with uncomplicated rUTI.'''
*** '''However, if a patient does not respond appropriately to treatment of uncomplicated UTI, particularly rapid recurrence with the same organism repeatedly, the patient should be considered to have a complicated UTI, thereby necessitating further investigations of the urinary tract'''
** '''In patients with gross hematuria in the presence of a positive urine culture and no risk factors for urothelial malignancy''' (e.g., age under 40, non-smoker, no environmental risk), '''cystoscopy is not necessary.'''
*** '''If any risk factors are present, cystoscopy should be performed.'''

==== Management ====

===== Conservative =====
*'''<span style="color:#ff0000">Options (2):</span>''' 
*#'''<span style="color:#ff0000">Education</span>'''
*#'''<span style="color:#ff0000">Behavior modification</span>'''

====== Education and Informed Decision Making ======
* '''Discuss the option of delaying antibiotics while awaiting culture results as there is minimal risk of progression to tissue invasion or pyelonephritis for uncomplicated patients with episodes of acute cystitis.'''
** '''Antibiotic treatment for acute cystitis results in mildly faster symptomatic improvement but only modestly decrease the risk of pyelonephritis'''.
** Patients with urosepsis or pyelonephritis often do not have UTI-related symptoms.

====== <span style="color:#ff0000">Behavior modification (2):</span> ======
# '''<span style="color:#ff0000">Changing mode of contraception (avoid barrier contraceptives and spermicidal products</span>''' (has deleterious effect on lactobacillus colonization and/or the vaginal microbiome))
# '''<span style="color:#ff0000">Increasing water intake in those consuming < 1.5L/day</span>'''
#* Unclear if there is a benefit in women that normally consume over this amount

====== '''Changes that DO NOT play a role in rUTI prevention''' ======
# '''Hygiene practices (e.g., front to back wiping)'''
# '''Pre- and post-coital voiding'''
# '''Avoidance of hot tubs'''
# '''Tampon use'''
# '''Douching'''

===== Intervention =====
*'''<span style="color:#ff0000">Options (3):</span>''' 
**'''<span style="color:#ff0000">Antibiotics</span>'''
**'''<span style="color:#ff0000">Non-antibiotic prophylaxis</span>'''
***'''<span style="color:#ff0000">Cranberry</span>'''
***'''<span style="color:#ff0000">Vaginal estrogen (if post-menopausal)</span>'''

====== Antibiotics ======
* '''<span style="color:#ff0000">Acute cystitis episodes in patients with recurrent UTI'''
** '''<span style="color:#ff0000">Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs'''
*** Continued documentation of cultures during symptomatic periods prior to starting antibiotics helps to provide a baseline against which interventions can be evaluated, to determine the appropriate pathway within the treatment algorithm, and to allow for the tailoring of therapy based on bacterial sensitivities.
*** '''In select patients with rUTIs with symptoms of recurrence, presumptive treatment with antibiotics can be initiated prior to finalization of the culture''' based on prior speciation, susceptibilities, and local antibiogram
** '''Use first-line therapy (See [https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti Table 3] (statement 9, no direct link) from Original Guideline) dependent on the local antibiogram for treatment of symptomatic UTIs in women'''
*** <span style="color:#ff0000">'''Options (3):'''</span>
****<span style="color:#ff0000">'''Fosfomycin 3g PO x 1'''</span>
****<span style="color:#ff0000">'''TMP-SMX one tab DS PO BID x 3 days'''</span>
****<span style="color:#ff0000">'''Nitrofurantoin 100mg PO BID x 5 days'''</span>
***A systematic review found no differences between fluoroquinolones, β-lactams (e.g., penicillins and its derivatives, cephalosporins), nitrofurantoin or TMP-SMX in the efficacy or risk of discontinuation due to adverse events
*** TMP-SMX is not recommended for empiric use in areas where local resistance rates > 20%]
***'''Table 3 from guideline suggests that nitrofurantoin does not cover enterococcus but CW11 Table 12-5/CW12 Table 55-6 suggests that it does'''
** '''Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally < 7 days'''
*** '''In patients with rUTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics''', clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than 7 days. '''Many such infections will be caused by organisms producing ESBLs.'''
**** '''Generally, such organisms are susceptible only to carbapenems. However, clinicians should order fosfomycin susceptibility testing, as many MDR uropathogens, including ESBL-producing bacteria, retain susceptibility to Fosfomycin thereby providing an oral option'''.
** '''Do not perform a post-treatment test of cure (urinalysis or urine culture) in asymptomatic patients'''
*** Extrapolating from the asymptomatic bacteruria literature, repeat urine culture after successful UTI treatment may lead to overtreatment
*** '''Omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs.'''
**** While pregnant women and patients undergoing invasive urologic procedures do benefit from treatment, substantial evidence supports that other populations, including women with diabetes mellitus and long-term care facility residents, do not require or benefit from additional evaluation or antibiotic treatment
** '''Repeat urine cultures to guide further management when UTI symptoms persist following antibiotic therapy'''
*** '''After initiating antibiotic therapy for UTI, clinical cure (i.e. UTI symptom resolution) is expected within 3-7 days.''' Although there is no evidence, it is reasonable to '''repeat a urine culture if symptoms persist > 7 days'''
* '''<span style="color:#ff0000">Antibiotics to reduce UTI episodes in patients with rUTI (self-start vs. prophylaxis)</span>'''
*# '''<span style="color:#ff0000">Self-start antibiotics: patient-initiated treatment for acute episodes while awaiting urine cultures.'''</span>
*#* '''For reliable patients, consider shared decision-making with regards to deferring therapy prior to obtaining results from the urine culture.'''
*#* Despite the original concept behind self-start therapy that allowed for women to treat their UTI without obtaining a culture. given more recent goals to reduce overuse of antibiotics and the development of antibacterial resistance, '''obtaining culture data for symptomatic recurrences is recommended''', when feasible.
*# '''<span style="color:#ff0000">Antibiotic prophylaxis (continuous vs. post-coital)</span>'''
*## '''Continuous:''' After discussion of the risks and benefits, clinicians may prescribe continuous antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs.
*##* '''Antibiotic prophylaxis reduces the number of clinical recurrences but increases risk of adverse events. Once the antibiotics are stopped, UTIs recur at the baseline rate.'''
*##* '''The dosing options for continuous prophylaxis include the following:'''
*##** Nitrofurantoin monohydrate/macrocrystals 50mg daily
*##** '''Nitrofurantoin''' monohydrate/macrocrystals '''100mg daily'''
*##** Cephalexin 125mg once daily
*##** '''Cephalexin 250mg once daily'''
*##** TMP 100mg once daily
*##** '''TMP-SMX''' '''40mg/200mg once daily'''
*##** TMP-SMX 40mg/200mg thrice weekly
*##** '''Fosfomycin 3g every 10 days'''
*##* '''Potential adverse effects of gastrointestinal disturbances and skin rash are commonly associated with antibiotics, including TMP, TMP-SMX, cephalexin, and Fosfomycin'''
*##* '''<span style="color:#ff0000">Potentially serious risks with nitrofurantoin include pulmonary and hepatic toxicity.</span>'''
*##** The rate of possible serious pulmonary or hepatic adverse events has been reported to be 0.001% and 0.0003%, respectively.
*##* '''<span style="color:#ff0000">The use of fluoroquinolones (e.g. ciprofloxacin) for prophylactic antibiotic use is not recommended in current clinical practice.</span>'''
*##** '''<span style="color:#ff0000">Fluoroquinolone agents have potentially adverse side effects including QTc prolongation, tendon rupture, and increased risk of aortic rupture</span>'''
*##* '''The duration of prophylaxis can vary from 3-12 months''', with periodic assessment
*## '''Post-coital'''
*##* '''In women with UTIs temporally related to sexual activity, a single dose of antibiotic prophylaxis taken before or after sexual intercourse is effective and safe'''
*##** Options:
*##*** TMP-SMX 40mg/200mg
*##*** TMP-SMX 80mg/400mg
*##*** Nitrofurantoin 50-100mg
*##*** Cephalexin 250mg

====== <span style="color:#ff0000">Non-antibiotic prophylaxis (2):</span> ======
# '''<span style="color:#ff0000">Cranberry prophylaxis</span>'''
#* MOA: thought to be related to proanthocyanidins present in cranberries and their ability to prevent the adhesion of bacteria to the urothelium
#* '''<span style="color:#ff0000">Indications</span>'''
#**'''<span style="color:#ff0000">Can be offered for women with rUTIs</span>'''
#*Oral juice and tablet formulations are available
# '''<span style="color:#ff0000">Vaginal estrogen</span>'''
#* '''<span style="color:#ff0000">Indications</span>'''
#**'''<span style="color:#ff0000">Recommended in peri-and post-menopausal women with rUTIs,</span>''' if there is no contraindication to estrogen.
#*** '''Oral or other formulations of systemic estrogen therapy have not been shown to reduce UTI and are associated with different risks and benefits.'''
#*** Given low systemic absorption, risks generally associated with systemic estrogen (cardiovascular disease, thrombosis, breast cancer) are minimal with vaginal estrogen.
#* '''Patients with rUTI and are already on systemic estrogen therapy should still be placed on vaginal estrogen. There is no substantially increased risk of adverse events.'''
#* '''Vaginal estrogen therapy has not been shown to increase risk of cancer recurrence in women undergoing treatment for or with a personal history of breast cancer'''. Therefore, vaginal estrogen therapy should be considered in prevention of UTI women with a personal history of breast cancer in coordination with the patient’s oncologist.
* '''Lactobacillus is not recommended''' as a prophylactic agent for rUTI given the lack of data

== Questions ==

# What is the definition of recurrent UTIs?
# What is an uncomplicated UTI?
# List 10 factors that classify a UTI as complicated.
# What are the 3 antibiotic regimens to treat recurrent UTIs?
# Urine culture demonstrating growth of which bacteria would be considered contaminant?
# What is the workup of a patient with recurrent UTIs?
# What is the differential diagnosis of a UTI?
# Take a history and describe the physical exam in a patient with recurrent UTI
# What are the indications to treat asymptomatic bacteriuria?
# When should a urine culture be repeated in patients that have started treatment for UTI?
# What conservative recommendations can be made to reduce risk of recurrent UTI?
# Describe 3 first-line antibiotic therapies for uncomplicated symptomatic UTI
# Describe 3 options for continuous antibiotic prophylaxis in the context of recurrent UTI
# What are drug-specific adverse events related to fluoroquinolone use?
# What is the role of cranberry or lactobacillus in the treatment of recurrent UTI?

== Answers ==

# What is the definition of recurrent UTIs?
#* ≥2 UTI within 6 months or ≥3 UTI within 12 months
# What is an uncomplicated UTI?
#* A UTI in a female patient has no known factors that would make her more susceptible to develop a UTI
# List 10 factors that classify a UTI as complicated.
#* UTI with multidrug resistant bacteria
#* Anatomic abnormality: cystocele, diverticulum, fistula
#* Iatrogenic: indwelling catheter, nosocomial infection, surgery
#* Voiding dysfunction: VUR, neurologic disease, pelvic floor dysfunction, high PVR, incontinence
#* Obstruction: Bladder outlet obstruction, ureteral stricture, UPJO
#* Other: pregnant, urolithiasis, diabetes, immunosuppression, UTI in men
# What are the 3 antibiotic regimens to treat recurrent UTIs?
## Self-start
## Prophylaxis
## Post-coital
# Urine culture demonstrating growth of which bacteria would be considered contaminant?
## Lactobacilli
## Corynebacteria
## Group B Streptococci
## Non-saprophyticus coagulase-negative Staphylococci
# What is the workup of a patient with recurrent UTIs?
#* History, physical exam (no role for cystoscopy or imaging in initial workup)
# What is the differential diagnosis of a UTI?
## Interstitial cystitis/bladder pain syndrome
## OAB
## Genitourinary syndrome of menopause
## Urinary calculi
## Infectious bacterial or fungal vaginitis
## Vulvar dermatitis
## Non-infectious vulvovestibulitis
## Vulvodynia
## Hypertonic pelvic floor muscle dysfunction
## CIS of the bladder
# Take a history and describe the physical exam in a patient with recurrent UTI
#* History: characterize LUTS, baseline GU symptoms between infections, UTI history, bowel symptoms, menopausal status, contraceptive method
#* Physical exam: abdominal and pelvic exam, focused neurologic exam, +/- PVR
# What are the indications to treat asymptomatic bacteriuria?
## Pregnant women
## Patient undergoing elective urologic surgery
# When should a urine culture be repeated in patients that have started treatment for UTI?
#* If symptoms persist > 7 days
# What conservative recommendations can be made to reduce risk of recurrent UTI?
## Avoid barrier contraceptives and spermicidal products
## Drink >1.5L water/day
## Changes that DO NOT play a role in rUTI prevention: hygiene practices (e.g., front to back wiping), pre- and post-coital voiding, avoidance of hot tubs, tampon use, and douching
# Describe 3 first-line antibiotic therapies for uncomplicated symptomatic UTI
## Nitrofurantoin 100mg BID x 5 days
## TMP-SMX 1 tab DS BID x 3 days
## Fosfomycin 3g x 1 dose
#* Note that ciprofloxacin is not considered first-line
# Describe 3 options for continuous antibiotic prophylaxis in the context of recurrent UTI
## Nitrofurantoin 100mg daily
## Cephalexin 250mg daily
## Fosfomycin 3g q10days
# What are drug-specific adverse events related to fluoroquinolone use?
## Prolonged QT syndrome
## Aortic rupture
## Tendon rupture
# What is the role of cranberry or lactobacillus in the treatment of recurrent UTI?
#* Cranberry can be offered, lactobacillus is not recommended

== References ==

* [https://pubmed.ncbi.nlm.nih.gov/31042112/ Anger, Jennifer, et al. "Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline." ''The Journal of urology'' 202.2 (2019): 282-289.]