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Recurrent uncomplicated lower urinary tract infection — MSRA MCQ

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ModerateUrinary Tract InfectionsRecurrent uncomplicated lower urinary tract infectionMSRA

A 33-year-old non-pregnant woman requests advice about prevention of recurrent urinary tract infection (UTI). She has had four culture-confirmed episodes of Escherichia coli lower UTI in the past 8 months. Each began within 24 hours of vaginal intercourse and resolved with culture-directed treatment. She is currently asymptomatic. She has no fever, loin pain, renal stones, urinary tract abnormality, catheter use, pregnancy plans or symptoms of genitourinary syndrome of menopause. She has tried increasing fluids, avoiding delayed voiding and post-coital voiding without benefit. Her eGFR is 78 mL/minute/1.73 m² and liver function is normal. Previous isolates were susceptible to nitrofurantoin and resistant to trimethoprim. She wishes to minimise total antibiotic exposure. What is the most appropriate prophylactic management now?

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Correct answer: D — Offer a trial of single-dose nitrofurantoin prophylaxis after intercourse

This woman has recurrent UTI, with four culture-confirmed lower UTIs in 8 months, and a clear identifiable trigger: vaginal intercourse. She has already tried behavioural measures, is premenopausal without genitourinary symptoms of menopause, and wishes to minimise antibiotic exposure. NICE recommends considering single-dose antibiotic prophylaxis for non-pregnant women with recurrent UTI when behavioural measures and vaginal oestrogen are ineffective or not appropriate, specifically for use when exposed to an identifiable trigger. Nitrofurantoin is appropriate because prior isolates were susceptible and her renal function is adequate. Daily nitrofurantoin prophylaxis is a later option when appropriate measures, including single-dose prophylaxis or methenamine hippurate where relevant, have not worked. Methenamine hippurate is likewise considered as an alternative to daily antibiotic prophylaxis after other applicable measures, including trigger-based single-dose prophylaxis, have not adequately improved recurrence. A self-start treatment course after intercourse is not equivalent to prophylaxis and risks unnecessary antibiotic use; NICE does not recommend routine stand-by acute-treatment antibiotics for recurrent UTI. Urology referral is not required for recurrent lower UTI in a woman when the cause is apparent and there are no complicating features.

Reference: Urinary tract infection (recurrent): antimicrobial prescribing — Recommendations (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations Urinary tract infection (recurrent): antimicrobial prescribing — Recommendations (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations Urinary tract infection (recurrent): antimicrobial prescribing — Recommendations (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations