This document provides information on recurrent urinary tract infections (UTIs) including definitions, risk factors, pathogenesis, clinical presentation, diagnostic evaluation, treatment and prevention strategies. It notes that Escherichia coli is the most common cause of UTIs and discusses approaches to treatment including antibiotic prophylaxis and self-initiated antibiotic therapy. Imaging may be used to identify structural abnormalities and treatment is tailored based on causative organism and severity of infection. Lifestyle changes and non-antibiotic approaches like oestrogen therapy can also help in prevention of recurrent UTIs.

1. Recurrent U.T.I.
Recent Updates
Dr. Shashwat K. Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : drshashwatjani@gmail.com

2. • Urinary tract infection (UTI)
is one of the commonest
bacterial infections globally
encountered by women.
• The risk of women
acquiring a UTI in their lifetime
has been estimated to be over
50 %, with about 25 % having a
recurrence.
4/5/2017
Dr Shashwat Jani.
99099 44160.
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3. R.U.T.I.
 Symptomatic infections that follow complete
resolution of a previous UTI.
 In a primary care setting, 53% of women
above the age of 55 years & 36% of younger
women report a recurrence within 1 year.
 Hence, its management and prevention is
of utmost significance for all clinicians including
non-specialists and those in the primary care
setting.
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Dr Shashwat Jani.
99099 44160.
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4. Imp. Definitions
• UTI can manifest as either cystitis (lower UTI)
OR pyelonephritis (upper UTI).
• Complicated UTI :
associated with a structural or
functional urinary tract abnormality or an
underlying pathology, both of which can
subsequently increase risks of acquiring an
infection or failure of therapy.
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Dr Shashwat Jani.
99099 44160.
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5. • Uncomplicated UTI :
Sporadic, community acquired episodes
of cystitis and pyelonephritis in otherwise healthy
individuals, but could lead to more serious
outcomes and thus require additional attention.
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Dr Shashwat Jani.
99099 44160.
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6. Recurrent UTI
Defined as …
> 2 episodes of uncomplicated UTI in the last 6
months
OR
> 3 episodes in the last 12 months,
documented by culture.
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Dr Shashwat Jani.
99099 44160.
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7. Relapse Vs. Reinfection
• Relapse :
Caused by the same bacterial strain
implicated in a previous UTI within 2 weeks of the
completion of treatment for the original infection.
• Reinfection :
A recurrent UTI arising for > 2 weeks after
treatment or after sterile intervening culture is
considered to be a reinfection, even if the infecting
pathogen is the same as the original.
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Dr Shashwat Jani.
99099 44160.
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8. Factors predisposing to
treatment failure:
Recent antibiotic treatment
Hospital acquired infection
Renal or bladder calculi
Obstructive uropathy
Renal cysts
Renal diseases such as reflux nephropathy,
chronic interstitial nephropathy, analgesic
nephropathy, diabetic nephropathy, sickle cell
nephropathy, immunosuppression.4/5/2017 8

9. Pathogenesis
• Bacterial strains are uniquely equipped
with specialised virulence factors,
e.g. different types of pili, which facilitate
the ascent of bacteria from the faecal flora,
vaginal introitus or periurethral area up the
urethra into the bladder, or less frequently,
allow the organisms to reach the kidneys .
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Dr Shashwat Jani.
99099 44160.
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10. In Premenopausal Women :
• Vaginal colonisation by lactobacilli, promoted
by estrogens. This results in the production of
lactic acid, maintaining a low pH that inhibits
growth of many pathogenic bacteria.
In Postmenopausal Women :
• lactobacilli are not present and the vagina
becomes primarily colonised with enterobacteria,
in particular E. coli.
• This is a major factor leading to increased
susceptibility to clinically significant UTI.
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Dr Shashwat Jani.
99099 44160.
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11. 4/5/2017
Dr Shashwat Jani.
99099 44160.
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12. Commonest Organisms
• Escherichia coli is the predominant
uropathogen responsible for both sporadic
and recurrent UTI, seen in 70–85%of cases.
• Other causative organisms include
Staphylococcus saprophyticus (10–15 % of
cases), Klebsiella pneumoniae and Proteus
mirabilis.
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Dr Shashwat Jani.
99099 44160.
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13. 4/5/2017
Dr Shashwat Jani.
99099 44160.
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14. • Fungi (Candida and Cryptococcus spp.) and
• Parasites (Trichomonas and Schistosoma)
• Klebsiella and group B streptococcus infections
are relatively more common in patients with
diabetes.
• Pseudomonas infections are relatively more
common in patients with chronic catheterization.
• Proteus mirabilis is a common uropathogen in
patients with indwelling catheters, spinal cord
injuries, or structural abnormalities of the urinary
tract.
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Dr Shashwat Jani.
99099 44160.
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15. 4/5/2017
Dr Shashwat Jani.
99099 44160.
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16. Clinical Presentation
ANY 3 OUT OF 5 :
1. Frequency,
2. Polyuria,
3. Dysuria,
4. Suprapubic tenderness
5. Haematuria
• Unpleasant odour
• Cloudy.
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Dr Shashwat Jani.
99099 44160.
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17. Clinical manifestations depending on
site of infection
• Urethritis:
 Discomfort in voiding
 Dysuria
 Urgency
 frequency
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Dr Shashwat Jani.
99099 44160.
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18. • Cystitis:
 dysuria, urgency and frequent
urination
 Pelvic discomfort
 Abdominal pain
 Pyuria
• Hemorrhagic cystitis:
 Visible blood in urine.
 Irritating voiding symptoms
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Dr Shashwat Jani.
99099 44160.
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19. • Pyelonephritis:
 Invasive nature
 Suprapubic tenderness
 Fever and chills
 White blood cell casts in
urine
 Back pain
 Nausea and vomiting
Complications include sepsis, septic shock and
death.
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Dr Shashwat Jani.
99099 44160.
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20. Stepwise Mx Of RUTI
1. History - appropriate for recurrent UTI.
2. Confirm bacteriological evidence of infection.
3. Exclude underlying anatomical or functional
abnormality using appropriate imaging and
endoscopic evaluation.
4. Advise on prophylactic lifestyle changes.
5. Consider a prophylactic antibiotic regimen.
6. Consider alternative strategies.
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Dr Shashwat Jani.
99099 44160.
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21. Imp. History Points
Age of first UTI
No. of previous UTI episodes Ix & Rx taken
Lower or Upper UTI symptoms
Sexual & contraceptive history
Past Med. History : DM , neurological dis., any
previous urolithiasis, previous Sx,
Instrumentation in urinary tract.
Any medications
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Dr Shashwat Jani.
99099 44160.
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22. Differentiation by History
 Lower UTI- frequency, urgency,
dysuria, haematuria.
 Upper UTI - fever, rigor and lion
pain and symptoms of lower UTI.
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Dr Shashwat Jani.
99099 44160.
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23. Assessment
General & Neurological examination
Renal size & tenderness
Is the bladder palpable?
Vaginal examination : local cause or
prolapse
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Dr Shashwat Jani.
99099 44160.
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24. Investigations
Routine :
1. Urine Dip stick Test
2. Urine for microscopic examination
3. Urine for culture & sensitivity
If systemic involvement is suspected :
4. USG
5. IVP
6. CT / MRI
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Dr Shashwat Jani.
99099 44160.
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25. 1. Urine Dip stick
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99099 44160.
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26. Urine Dip stick
• A leucocyte and nitrite positive urine dipstick
has been considered a highly sensitive test in
predicting a UTI.
• However, since some bacteria, such as S.
saprophyticus, lack the enzymes to reduce
nitrates into nitrites, false-positive results are
fairly common.
• So, not much reliable test to rule out UTI.
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Dr Shashwat Jani.
99099 44160.
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27. 2. Urine Microscopy
Rapid & reliable test
Presence of pus, white blood cells, red blood cells
Bacterial count > 105 /ml – significant bacteriuria
 Presence of Cast , Epithelial cells
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Dr Shashwat Jani.
99099 44160.
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28. 3. Urine Culture
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Dr Shashwat Jani.
99099 44160.
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29. Ideally obtained before and without delaying
antibiotics is recommended in patients with Recurrent
UTI.
Recommended in…
• Pregnant women,
• Patients with immunosuppression
• Urinary tract malformations,
• Urinary tract stones,
• Recent urologic instrumentation,
• Indwelling catheters,
• Neurogenic bladder,
• Kidney transplant
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Dr Shashwat Jani.
99099 44160.
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30. Also helpful, while starting empiric
therapy, in patients with …
• Previous history of known resistant
infections,
• Failure of empiric antibiotics,
• Multiple recurrent UTIs.
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Dr Shashwat Jani.
99099 44160.
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31. Specimen Collection
• The urine collected in a
wide mouthed container
from patients
• A mid stream specimen is
the most ideal for
processing
• Patients passes urine
with a labia separated
and mid stream sample is
collected
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Dr Shashwat Jani.
99099 44160.
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32. Transport of Urine for Culturing Urine
• All collected specimens
of urine to be transported
to laboratory with out
delay
• Delay of 1 – 2 hour deter
the quality of diagnostic
evaluations.
• If the delay is anticipated
the specimens are at
preserved at 40c
• In field conditions Boric
acid can be added at a
concentration of 1.8 %
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Dr Shashwat Jani.
99099 44160.
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33. Following bacterial counts are clinically relevant:
 > 103 cfu/mL of uropathogens in a mid-stream sample of urine
(MSU) in acute uncomplicated cystitis in women.
 > 104cfu/mL of uropathogens in an MSU in acute uncomplicated
pyelonephritis in women.
 > 105 cfu/mL of uropathogens in an MSU in women, or in straight
catheter urine in women, in a complicated UTI.
 In a suprapubic bladder puncture specimen, any count of bacteria
is relevant
Culture in UTI
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Dr Shashwat Jani.
99099 44160.
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34. Imaging studies
Indicated in :
Pts. With Urinary outflow
obstruction
Systemic involvement with
fever
Fail to respond to
antimicrobial therapy of 72
hours.
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Dr Shashwat Jani.
99099 44160.
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35. 1. X - RAY KUB
2. USG KUB
3. Unenhanced helical CT
4. MRI
5. Dimercaptosuccinic acid (DMSA) scanning
6. Excretory urography / IVP
7. Voiding cystourethrography
8. Cystoscopy
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Dr Shashwat Jani.
99099 44160.
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36. Intravenous pyelography /
excretory urography
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Dr Shashwat Jani.
99099 44160.
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37. • Voiding cystourethrography
• Cystoscopy
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Dr Shashwat Jani.
99099 44160.
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38. TREATMENT
 Continuous antibiotic prophylaxis
 Postcoital antibiotic prophylaxis
 Self-start antibiotic therapy
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Dr Shashwat Jani.
99099 44160.
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Antibiotic Prophylaxis

39. Ideal antibiotic for UTI :
Adequate coverage over E.coli
Concentration in urine
Duration of therapy
Low resistance
Cost
Low adverse effect profile
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Dr Shashwat Jani.
99099 44160.
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40. Continuous antibiotic prophylaxis
• TMP/SMX (40 mg/200 mg daily or thrice weekly)
• Trimethoprim (100 mg daily)
• Ciprofloxacin (125 mg daily)
• Cephalexin (125 mg to 250 mg daily)
• Nitrofurantoin (50 mg to 100 mg daily)
• Norfloxacin (200 mg daily)
• Fosfomycin (3 gm every 10 days)
4/5/2017
Dr Shashwat Jani.
99099 44160.
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41. Post Coital Prophylaxis
( Within 2 hours of Coitus )
• TMP/SMX (40 mg/200 mg to 80 mg/400 mg )
• Ciprofloxacin (125 mg)
• Cephalexin (250 mg)
• Nitrofurantoin (50 mg–100 mg daily)
• Norfloxacin (200 mg)
• Ofloxacin (100 mg )
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Dr Shashwat Jani.
99099 44160.
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42. Self-start antibiotic therapy
 Ideal for women who are not suitable
candidates for long-term prophylaxis.
 Additional option for women with the and
start antibiotics.
 Pt. is given Prescription for 3 day course of
Antibiotics.
 Patients are advised to contact doctor, if
symptoms do not resolve within 48 hours, for
treatment based on culture and sensitivity.
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Dr Shashwat Jani.
99099 44160.
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43. The Infectious Diseases Society of America
and the European Society for Microbiology
and Infectious Diseases recommends…
Nitrofurantoin = 100 mg, twice daily for 5 days,
TMP-SMX = 160/800 mg twice daily for 3 days,
Fosfomycin = 3 gm , single dose.
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Dr Shashwat Jani.
99099 44160.
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44. For Severe Cases of RUTI
Pathogen Treatment options
Escherichia coli Ceftriaxone 50mg/kg i.v
/I.M Qday
Pseudomonas
aeroginosa
Gentamycin 6-7.5mg /kg
i.v Q8hr / Qday
Klebsiella sps
Enterobacter sps
Proteus sps
Ceftadizine 100-
150mg/kg/day i.v Q8hr
Enterococcus sps Ampicillin 100-
200mg/kg/day Q6hr
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Dr Shashwat Jani.
99099 44160.
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45. Non-antibiotic prevention strategies
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99099 44160.
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46. Oestrogen therapy
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Dr Shashwat Jani.
99099 44160.
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47. Oestrogen therapy
• A 2008 Cochrane review demonstrated vaginal
oestrogen to be an effective prophylaxis in the
prevention of recurrent UTIs.
• Oestriol cream :
0.5 mg Vaginally every night for 2 weeks,
and then twice a week for 8 months.
• Oral Oestrogen tabs are ineffective and also
causes breast tenderness & Vaginal bleeding.
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Dr Shashwat Jani.
99099 44160.
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48. Cranberry
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99099 44160.
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49. Cranberry - Controversial
 A Cochrane review of 24 studies, with a
total of 4,473 subjects, revealed that cranberry
products were of no benefit compared to
placebo in most populations.
 A recent retrospective review concluded
that clinical studies on cranberry products
strongly support their prophylactic use in young
and middle-aged women but that evidence
among other patients remains controversial.
4/5/2017
Micali S, Isgro G, Bianchi G,Miceli N, Calapai G, NavarraM(2014)
Cranberry and recurrent cystitis:more thanmarketing? Crit Rev Food
Sci Nutr 54(8):1063–1075

50. Ascorbic Acid ( Vit – C )
• Often recommended as a supplement that can
prevent recurrent UTIs by acidification of the
urine.
• Weak association.
• 100 mg / day.
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Dr Shashwat Jani.
99099 44160.
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51. Methenamine salts
• Hydrolyzed to ammonia and formaldehyde
when in acidic urine, which act as a bactericide
to some strains of bacteria.
• Less side effects
• A Cochrane review on the use of methenamine
hippurate concluded that short-term use is
effective in preventing RUTI.
4/5/2017
Lee BB, Simpson JM, Craig JC, Bhuta T (2007) Methenamine
hippurate for preventing urinary tract infections. Cochrane Database
Syst Rev 4:CD003265
Dr Shashwat Jani.
99099 44160.
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52. Emerging Therapies
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53. D - Mannose
• Inhibits bacterial adherence to urothelial cells.
• Weak recommendations.
• Need further clinical trials to prove its efficacy.
• Recommended for prevention prophylaxis
only.
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Dr Shashwat Jani.
99099 44160.
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54. Lactobacillus (probiotics)
• A recent phase 2 trial has found that
treatment with probiotics following UTI is
associated with a decrease in recurrent UTIs.
• Still strong validation is required.
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Dr Shashwat Jani.
99099 44160.
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Restore the vaginal lactobacilli
Compete with urogenital pathogens
Prevent bacterial vaginosis, a condition that
increases the risk of UTI

55. Vaccination
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Dr Shashwat Jani.
99099 44160.
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56. • Uro-Vaxom is an oral capsular vaccine
comprising 18 heat killed E. coli strains. It has
been found to be an effective prophylaxis for
prevention of UTI.
• A meta-analysis of four studies comprising 891
patients demonstrated that Uro- Vaxom
significantly reduced the risk for development of
UTI.
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Dr Shashwat Jani.
99099 44160.
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57. Uro Vaxom
• Preventive treatment and/or consolidation
therapy: 1 capsule daily on an empty stomach,
for 3 consecutive months.
• Treatment during acute episodes: 1 capsule
daily on an empty stomach as comedication to
conventional antimicrobial therapy, until
disappearance of the symptoms but for at
least 10 consecutive days.
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Dr Shashwat Jani.
99099 44160.
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58. • Urovac :
Vaginal suppository vaccine comprises 10
uropathogenic strains of bacteria ( six E. coli strains
and one strain each of Proteus, Mirabilis,
Morganella morganii, K.pneumoniae and
Enterococcus faecalis).
Currently this vaccine has successfully
completed a phase 2 trial.
• Intranasal vaccines :
Currently under research.
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Dr Shashwat Jani.
99099 44160.
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59. RUTI in Pregnancy
Nitrofurantoin 100 mg q12 h, 3-5 days (Avoid
in G6PD deficiency)
Amoxicillin 500 mg q8 h, 3-5 days
Co-amoxicillin/clavulanate 500 mg q12 h, 3-5
days
Cephalexin 500 mg q8 h, 3-5 days
Trimethoprim q12 h, 3-5 days.
Avoid trimethoprim in first trimester/term
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Dr Shashwat Jani.
99099 44160.
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60. Pregnancy & RUTI.
• With symptomatic or asymptomatic
bacteriuria, the risk of a preterm delivery and
low birth weight infant is significantly increased.
• A follow-up culture for test of cure a week after
completion of Rx and monthly follow-up until
the completion of the pregnancy.
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Dr Shashwat Jani.
99099 44160.
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61. Prophylactic Measures to prevent
RUTI
• Avoid long intervals between urination.
• Have at least eight to ten drinks (mug-size) daily.
These could be water or sugar free cranberry
juice, squash or other fluids. Caffeinated drinks
are best avoided.
• Shower instead of taking a bath. Avoid using
bubble bath or other cosmetic bath products.
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Dr Shashwat Jani.
99099 44160.
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62. • Avoid using any feminine hygiene sprays
and scented douches.
• Avoid using a vaginal diaphragm for birth
control.
• Empty the bladder after sexual
intercourse, as sexual relations can often
trigger UTIs.
• After urination, wipe from front to back.
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99099 44160.
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63. 5-Apr-17 63
Dr Shashwat Jani.
+91 9909944160