The AUA/CUA/SUFU guideline includes 16 recommendations that cover evaluation, testing, treatment, and follow-up of women experiencing recurrent urinary tract infections. Preventing inappropriate use of antibiotics, decreasing the risk of antibiotic resistance and improving clinical outcomes are the main goals of this guideline.

Evolving insights into the pathophysiology of recurrent urinary tract infections (rUTI), antimicrobial resistance and adverse effects of repetitive therapy have led to improvements in the management strategies for this bothersome condition. The American Urological Association (AUA)/Canadian Urological Association (CUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) guideline includes 16 recommendations that cover evaluation, testing, treatment, and follow-up of women experiencing recurrent urinary tract infections. In this guideline, the term UTI refers to acute bacterial cystitis.

---

Following are the main goals of this document:

• Prevent inappropriate use of antibiotics
• Decrease the risk of antibiotic resistance
• Reduce adverse effects of antibiotic use
• Provide guidance on antibiotic and non-antibiotic strategies for prevention
• Improve clinical outcomes and quality of life for women with rUTIs by reducing recurrence of UTI events

This guideline is not applicable to pregnant women, immunocompromised patients, patients with anatomic or functional abnormalities of the urinary tract, women with rUTIs due to self-catheterization or indwelling catheters, patients exhibiting signs or symptoms of systemic bacteremia (fever and flank pain) and those seeking prevention of urinary tract infections in the operative or procedural setting

---

Evaluation

1. Clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs

Complete history along with lower urinary tract symptoms (LUTS) should be obtained. Information such as history of bowel symptoms, recent use of antibiotics and antibiotic-related problems, back or flank pain; catheter usage; vaginal discharge or irritation; menopausal status; post-coital UTIs; contraceptive method should be noted.

Details of prior urinary tract or pelvic surgery and baseline genitourinary symptoms are also important. Patients should also be queried regarding their travel history.

A physical examination including an abdominal and detailed pelvic examination should be performed to look for any structural or functional abnormalities. Neurological exam should be carried out to rule out occult neurologic defects.

---

2. To make a diagnosis of rUTI, clinicians must document positive urine cultures associated with prior symptomatic episodes

As per the panel, microbial confirmation at the time of acute-onset urinary tract-associated symptoms and signs is a critical component to establish a diagnosis of rUTI. rUTI is defined as at least two culture-proven symptomatic uncomplicated acute cystitis episodes in six months or three within one year in which symptom resolution occurred between culture-proven events.

Continued documentation of cultures during symptomatic periods prior to instituting antimicrobial therapy helps to provide a baseline against which interventions can be evaluated. It also helps to determine the appropriate pathway within the treatment algorithm, and to allow for the tailoring of therapy based on bacterial antimicrobial sensitivities.

When there is a lack of correlation between the microbiological data and symptomatic episodes, alternative or comorbid diagnoses should be considered.

---

3. Clinicians should obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen

Contamination of urine specimens leads to suboptimal or unnecessary treatment, which results in poor patient outcomes and higher health care costs.

Contamination should be suspected when the specimen exhibits growth of normal vaginal flora, mixed cultures containing more than one organism, or even low quantities (<103 CFU/mL) of a pathogenic organism in an asymptomatic patient. In cases with high contamination, catheterized specimen should be taken for further evaluation prior to treatment.

A mid-stream voided specimen provides less rates of contamination. Urine should not sit at room temperature for more than 30 minutes; samples should either be transported to the lab in urine transport media in vacuum-filled tubes or refrigerated (2°C to 10°C) immediately to reduce artifactual bacterial proliferation. Bringing samples from home should also be discouraged.

---

4. Cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with rUTI

Cystoscopy and upper tract imaging are not always required in patients with uncomplicated rUTI due to low yield of anatomical abnormalities. However, in cases where the patient does not respond appropriately to treatment of uncomplicated UTI, the patient should be considered to have a complicated UTI and evaluation of the urinary tract via cystoscopy and upper tract imaging should be carried out.

---

5. Clinicians should obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs

Urinalysis can determine the presence of epithelial cells suggesting contamination.

As per the panel, presumptive treatment with antibiotics can be initiated in selected patients with symptoms of recurrence, based on prior speciation, susceptibilities, and local antibiogram.

Acute cystitis may in some cases progress to pyelonephritis, hence, non-antibiotic treatments such as urinary analgesics can be considered in selected patients while awaiting urine culture results.

The panel does not recommend the use of point of care dipstick or home dipstick to diagnose rUTI or guide treatment decisions due to the poor sensitivity and specificity of these modalities.

---

6. Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures

The panel favours self-start treatment, at the discretion of the patient, for acute symptomatic episodes in patients with diagnosis of rUTI. However, culture data for symptomatic recurrences should be obtained when feasible. Empiric therapy may be allowed in select circumstances when the clinician deems the patients reliable with communication and self-assessment of symptoms.

---

Asymptomatic Bacteriuria

1. Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs.

Without symptoms, bacteriuria of any magnitude is considered asymptomatic bacteriuria (ASB). In women with rUTIs, identification of ASB between UTI episodes does not provide any useful prognostic information. Identification of ASB by surveillance testing would not result in improved clinical outcomes, unless an alternative effective treatment exists.

---

2. Clinicians should not treat ASB in patients

Evaluation and treatment of rUTIs should be performed only when acute cystitis symptoms are present. In women with rUTIs, there is no evidence that treatment of ASB results in improved clinical outcomes; in fact there is clear evidence that these practices can cause harm such as antibiotic side effects, development of opportunistic infections and antibiotic resistance.

In 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.

---

Antibiotic Treatment

1. Clinicians should use first-line therapy (i.e., nitrofurantoin, TMP-SMX, fosfomycin) dependent on the local antibiogram for the treatment of symptomatic UTIs in women

As per the IDSA guidelines, in vitro resistance prevalence and ecological adverse effects of antimicrobial therapy or collateral damage are key considerations while choosing UTI treatments.

Nitrofurantoin, TMP-SMX and fosfomycin are the three first-line agents effective in treating UTI; they are less likely to produce collateral damage than second-line agents.

Second-line or alternate therapies include β-lactam agents or fluoroquinolones and are generally chosen because of resistance patterns and/or allergy considerations.

Single-dose antibiotics (except fosfomycin) should not be used in the treatment of patients with rUTI.

---

2. Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days

There is lack of evidence on the length of antibiotic therapies for complete resolution of UTI symptoms. Generally, all antibiotics have risks; stewardship should be exercised to balance symptom resolution with reduction in risk of recurrence. Clinicians should treat rUTI patients with as short duration of antibiotics as possible - generally no longer than seven days.

---

3. 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 seven days

Such infections are usually caused by organisms producing extended spectrum beta-lactamases - ESBLs. Such organisms are susceptible only to carbapenems. However, before considering intravenous antimicrobials, clinicians should order fosfomycin susceptibility testing, as many multi drug resistant uropathogens, retain susceptibility to fosfomycin and/or nitrofurantoin. Consultation with an infectious diseases specialist is also recommended.

---

Antibiotic Prophylaxis

Following discussion of the risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs

Antibiotic prophylaxis can reduce the number of clinical recurrences in women with rUTIs. There is little evidence on the benefits of rotating antibiotics used for prophylaxis.

Nitrofurantoin has been shown to be effective as a prophylactic antibiotic for UTI prevention. Risk assessment, shared decision-making, and clinical monitoring are important prior to prescribing nitrofurantoin for prophylaxis, to avoid the potential adverse events associated with nitrofurantoin. The potential of acquiring an antibiotic resistant infection should also be considered.

The duration of antibiotic prophylaxis can be variable, from three to six months to one year, and, periodic assessment and monitoring is required during this phase.

 

---

Non-Antibiotic Prophylaxis

Clinicians may offer cranberry prophylaxis for women with rUTIs

Non-antibiotic modalities in the prevention of rUTI include the use of probiotics and the consumption of cranberry products.

Proanthocyanidins present in cranberries have the ability to prevent the adhesion of bacteria to the urothelium. Cranberry may be offered as prophylaxis in the form of oral juice or tablet; there is lack of evidence to support one formulation over another when considering this food-based supplement.

The panel does not recommend the use of lactobacillus as a prophylactic agent for rUTI given the current lack of data indicating benefit in comparison to other available agents.

---

Follow-up Evaluation

1. Clinicians should not perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients.

The Panel does not recommend microbiological reassessment after successful UTI treatment as this may lead to overtreatment. However, in clinical scenarios, such as planned surgical intervention in which mucosal bleeding is anticipated, screening may be required.

2. Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy.

A repeat urine culture is reasonable if UTI symptoms persist beyond 7 days. A second antibiotic can be given empirically (after a urine sample is obtained for culture). This strategy will minimize unnecessary treatment of patients with persistent UTI/pain symptoms who are culture-negative.

---

Estrogen

In peri- and post-menopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication to estrogen therapy

Vaginal estrogen therapy should be prescribed to all peri- and post-menopausal women with rUTI to reduce the risk of rUTI. The formulation of vaginal estrogen that is preferred by the patient should be recommended. Systemic estrogen therapy is not recommended for treatment of rUTI.

Vaginal estrogen therapy can be considered in women with a history of breast cancer, after consulting the patient’s oncologist.