Females, Frequent

≥ 3 episodes/year or ≥ 2 episodes in 6 months

Pre treatment urine cultures recommended.

• Isolation of certain organisms such as Proteus, Morganella, Providencia species, Corynebacterium urealyticum, Actinobaculum spp, and Actinomyces turicensis in non-catheterized patients may indicate structural abnormality and warrant investigation, especially if repeat isolation.

• If culture negative or isolation of an organism that is not a usual uropathogen, consider other causes of dysuria, e.g. vaginitis.

• Consultation with microbiologist or Infectious Diseases physician recommended for culture negative recurrent UTIs.

- Postmenopausal women with new onset recurrent UTI should be investigated for impaired voiding.

- Post treatment cultures not recommended unless symptoms persist or recur.

Prevention:

- Avoid the use of spermicides or spermicide-coated condoms as these alter vaginal flora and favor colonization of uropathogens.

- No evidence for specific instructions regarding urinary hygiene (wiping patterns, douching, postcoital voiding, hot tub use, bubble baths, tampon use, wearing of pantyhose/tight clothing), voiding frequency, or body mass index.

- Use of ascorbic acid (vitamin C), D-mannose, or probiotics are not recommended.

- Methenamine has a limited role in recurrent cystitis as it can only be given for a maximum of 1 week and not if the recurrent UTIs are due to the following organisms:

• Proteus spp

• Providencia spp

• Morganella spp

• Pseudomonas spp.

- For premenopausal women with recurrent UTIs, the following prophylaxis can be considered:

• cranberry products – conflicting evidence of efficacy but little harm

• pericoital or daily antibiotic prophylaxis – see below. NB: Need to confirm eradication of UTI with a negative urine culture 1-2 weeks post treatment before starting prophylaxis.

- For postmenopausal women with recurrent UTIs, the following prophylaxis can be considered:

• topical vaginal estrogen therapy. NB: Oral estrogen therapy NOT recommended.

• pericoital or daily antimicrobial prophylaxis – see below. NB: Need to confirm eradication of UTI with a negative urine culture 1-2 weeks post treatment before starting prophylaxis.