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Recurrent uncomplicated lower urinary tract infection in a postmenopausal woman — MSRA MCQ

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HardUrologyRecurrent uncomplicated lower urinary tract infection in a postmenopausal womanMSRA

A 62-year-old postmenopausal woman requests prevention treatment for recurrent urinary tract infection (UTI). She has had 4 culture-confirmed uncomplicated lower UTIs in 9 months, each caused by Escherichia coli and occurring within 48 hours of vaginal intercourse. Her most recent isolate was susceptible to nitrofurantoin and resistant to trimethoprim. She is currently asymptomatic and her urine culture 2 weeks ago was negative. She has already implemented behavioural measures and has used vaginal oestrogen for 6 months, but has had 2 further culture-confirmed UTIs. Her eGFR is 68 mL/minute/1.73 m². She is not pregnant and has no history of pyelonephritis, urinary tract abnormality, catheterisation or renal stones. What is the most appropriate next management plan?

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Correct answer: D — Offer nitrofurantoin 100 mg as a single dose when exposed to the identifiable trigger, with review within 6 months

This woman has recurrent uncomplicated lower UTI with a clear, reproducible precipitant: vaginal intercourse. She is currently infection-free, has already had appropriate behavioural measures and vaginal oestrogen, and her recent organism is susceptible to nitrofurantoin. Her renal function is also adequate for nitrofurantoin prophylaxis. NICE therefore recommends considering single-dose antibiotic prophylaxis when there is exposure to an identifiable trigger; nitrofurantoin 100 mg as a single dose is a listed regimen. It should be reviewed within 6 months. Methenamine hippurate is an alternative to daily antibiotic prophylaxis, but is considered after inadequate improvement with behavioural measures, vaginal oestrogen and single-dose prophylaxis where these are applicable. Continuous nightly nitrofurantoin is a later option if appropriate preceding measures have not worked, and exposes her to unnecessary continuous antibiotic selection pressure and longer-term toxicity risk. A 3-day treatment course after intercourse is neither the recommended single-dose prophylactic regimen nor an appropriate self-start treatment strategy in this situation. Systemic HRT should not be offered specifically to reduce recurrent UTI risk; this differs from locally acting vaginal oestrogen.

Reference: Urinary tract infection (recurrent): antimicrobial prescribing (NG112) – Recommendations (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations Urinary tract infection (recurrent): antimicrobial prescribing (NG112) – Recommendations (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations Nitrofurantoin 50 mg Tablets – Summary of Product Characteristics (Updated 2024) — https://www.medicines.org.uk/emc/product/3601/smpc