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Recurrent uncomplicated lower urinary tract infection — MSRA MCQ

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ModerateUrologyRecurrent uncomplicated lower urinary tract infectionMSRA

A 61-year-old woman requests advice about preventing further urinary tract infections. Over the past 9 months she has had four culture-confirmed episodes of acute cystitis, each growing Escherichia coli susceptible to nitrofurantoin and resistant to trimethoprim. Symptoms resolved fully after treatment on each occasion. All episodes developed within 24 hours of vaginal intercourse. She is currently asymptomatic, is not pregnant, has an eGFR of 74 mL/min/1.73 m², and has no haematuria between infections, fever, loin pain, urinary tract abnormality or catheter. She has already tried behavioural measures and has used vaginal oestrogen for 4 months without reducing episodes. She wishes to avoid continuous antibiotics if possible. What is the most appropriate next preventative management strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Offer single-dose antibiotic prophylaxis after intercourse, selected using previous urine culture susceptibilities

Explanation lettering: E = shown as A · A = shown as B · B = shown as D · D = shown as E

This is recurrent uncomplicated lower UTI with a clear, identifiable trigger: every culture-confirmed episode follows intercourse. She has no current infection, has already had appropriate behavioural measures and vaginal oestrogen, and wishes to avoid continuous antibiotic exposure. NICE recommends considering single-dose antibiotic prophylaxis when recurrent UTI is associated with an identifiable trigger, after any current infection has been adequately treated. Antibiotic selection should reflect previous culture and susceptibility results; here, nitrofurantoin would be appropriate if otherwise clinically suitable. A is insufficient because these measures have already been tried without benefit. B is not the next step in a woman with recurrent uncomplicated lower UTIs and no features suggesting upper tract infection, obstruction, malignancy or another structural cause. C is plausible because methenamine hippurate can be an alternative to daily antibiotic prophylaxis, but NICE places it after behavioural measures, vaginal oestrogen and single-dose prophylaxis where these are appropriate. D is also reasonable later, but daily prophylaxis is generally considered when single-dose prophylaxis, methenamine hippurate or other applicable measures have not improved recurrence.

Reference: NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Recommendations (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Methenamine hippurate and daily antibiotic prophylaxis (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Choice of antibiotic or antiseptic prophylaxis (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations