American Urogynecologic Society Best-Practice Statement: Recurrent Urinary Tract Infection in Adult Women: [WITHDRAWN]

Female pelvic medicine and reconstructive surgery (FPMRS) specialists provide care for women with recurrent urinary tract infection (rUTI). In a study of more than 1100 urogynecologic patients, investigators reported a patient-reported rUTI prevalence of 19%.1 However, clinical care varies because of a lack of evidence and best practices. In addition, variable rUTI definitions exacerbate the gap in our understanding of this common clinical problem. In the context of evolving evidence and reviews on rUTI, this document summarizes current best practice for rUTI diagnosis and management in women. These best practices do not apply to women who are pregnant, are immunosuppressed, have surgically altered urinary tracts (not including typical surgery for stress urinary incontinence or pelvic organ prolapse), or regularly use urinary catheters except where specified. In addition, this document does not cover diagnosis or treatment of asymptomatic bacteriuria. Terminology and Definitions A commonly used definition describes urinary tract infection (UTI) as an infection of the lower and/or upper genitourinary tract which is diagnosed based on the presence of a pathogen in the urinary tract and associated symptoms.2 This definition assumes that the symptoms are caused by the detected uropathogens. However, neither the uropathogen detection method nor any specific symptoms are inherent in this UTI definition. Although the umbrella term UTI formally includes both upper and lower urinary tracts, the term UTI is often used interchangeably with cystitis (more accurately bacterial cystitis). There is limited evidence to support any “gold standard” UTI definition for epidemiologic or clinical research. There are multiple definitions for rUTI. This best-practice statement endorses a clinically useful, culture-based definition: at least 2 culture-proven episodes in 6 months, or at least 3 in 1 year.3 It is assumed that these episodes are separate events; however, there is no consensus as to diagnostic requirements to document resolution of any episode, such as a posttreatment culture. Diagnosis and care of rUTI patients does not require use of the various terms proposed to further subtype frequent UTI, although the presence of persistent organisms may alter the diagnostic and/or treatment approach (eg, earlier search for foreign body or urinary stone). Relapse indicates that the same uropathogen causes UTI symptoms within 2 weeks of completing appropriate antibiotic therapy. Recurrence specifically applies to situations in which there is evidence that the subsequent UTI occurred beyond the initial 2 weeks or with a different uropathogen.4 Epidemiology Estimates of UTI incidence vary based on the research definition of UTI being used and the likely overuse of UTI codes before a completed diagnostic evaluation. Commonly cited references suggest that more than 8 million ambulatory visits (84% women) in the United States in 2007 were due to UTI; 21% were emergency department visits.5,6 Using a woman's report of a physician diagnosis of UTI, the National Health and Nutrition Examination Survey data reported a 12.6% annual incidence of UTI in women 18 years or older.7 In a mixed-sex population of more than 30,000 patients whose UTI diagnosis had urine culture confirmation, Canadian investigators reported the annual UTI incidence in women aged 20 to 79 years as 3% to 5% and those aged 80 to 89 years as 12%. Two percent of these women had at least 6 UTIs in 2 years.8 After a single UTI, 30% to 44% of women will have a recurrent UTI; 50% will have a third episode if they have had 2 UTIs in 6 months.3 In a study of college women with a UTI, 19% experienced recurrence within 6 months.9 In a recent study, Suskind et al,10 using a database of health care claims, studied women aged 18 to 64 years who had an evaluation and management visit associated with an International Classification of Disease, Ninth Revision code for UTI and an antibiotic prescription within 14 days of that visit. They reported an overall rate of incident rUTI cases of 102 per 100,000 women per year, with the highest rates in women 18 to 34 years old and 55 to 66 years old. Pathophysiology Adjacent pelvic microbial niches serve as reservoirs for uropathogens that can lead to UTI/rUTI.11 Currently, the majority of evidence for uropathogens in the urine comes from standard urine culture techniques, which have been refined to detect Escherichia coli. Standard cultures also detect other common pathogens including Klebsiella species, Staphylococcus saprophyticus, Enterococcus faecalis, and Streptococcus agalactiae. Culture-independent techniques, such as polymerase chain reaction testing and sequencing, confirm that standard urine cultures do not detect all uropathogens or other resident microbes of the urinary microbiota.11 Enhanced culture techniques complement culture-independent methods to advance our understanding of UTI and rUTI prevention, pathogenesis, treatment, and recovery but are not yet widely available for clinical use. Current evidence, based on standard cultures, indicates that E. coli causes most (70%–95%) community-acquired UTIs. Studies in older women suggest that E. coli accounts for more than half of UTIs, whereas other common organisms are Klebsiella pneumoniae, Proteus mirabilis, and E. faecalis. E. coli is also the most common cause of rUTI (66%). The uropathogens associated with rUTI are the same microbes associated with episodic (non-rUTI) UTI episodes. However, non–E. coli pathogens and resistant organisms are more likely to be associated with UTI episodes in women with rUTI.3,7,12 E. coli has multiple strains and virulence factors.13 Uropathogenic E. coli (UPEC) has been widely studied in murine models, and some findings have been verified in human studies.14,15 Uropathogenic E. coli have special features that facilitate urothelial attachment, allowing the microbe to take up residence within the bladder.14,15 Uropathogenic E. coli can form intracellular bacterial communities that act like a biofilm, allowing bacteria to persist in quiescent intracellular reservoirs, acting as a source of recurrent infection.16,17 Episodes of rUTIs are often associated with the same bacterial strain; this has important implications for treatment, highlighting the need for careful antimicrobial sensitivity testing and treatment selection. In addition to bacterial factors, host factors, including hormonal status, anatomy, functional, and behavioral variables, and genetic factors likely modulate UTI and rUTI susceptibility.3,14,18 For example, E. coli has an increased ability to adhere to the urothelium in women who are nonsecretors of certain blood group antigens.3,19 Individual factors, such as pre-UTI microbiota/microbiome health, degree of inflammation, and urothelial exfoliation from an infection, may affect response to UTI, recovery from UTI, and susceptibility to future UTI.13,14 Risk Factors Many commonly recommended behaviors have not been established as reducing risk for rUTI (wiping away from the urethra; voiding before and after intercourse; increasing frequency of voiding; wearing certain types of underwear; avoiding douching; or avoiding hot tubs, bubble bath, or tampons).3 Physicians should consider the contribution of gross fecal soilage, as in women with fecal incontinence. A personal history of UTI before age 15 years and maternal UTI history are rUTI risk factors.3,20 A case-control study of more than 400 women reported an increased risk of rUTIs in women having a first-degree female relatives with a history of at least 5 UTIs.21 Sexual risk factors, such as a new sexual partner, intercourse frequency, and spermicide use, are more common in premenopausal women.21 Women with pelvic floor disorders are at increased risk for rUTIs, especially postmenopausal women with urinary incontinence. Some investigators suggest an association between postvoid residual of at leasy 50 mL and rUTI.19 The association with prolapse is unclear.22 There is a risk of rUTI after surgery for stress urinary incontinence. The early postoperative period is associated with a transient increased rUTI risk (11%) after retropubic tension-free vaginal tape with or without concomitant prolapse repair.23 Beyond the first 6 postoperative weeks, investigators reported rUTI in 2.3% to 2.4% of participants in 2 randomized surgical trials (Stress Incontinence Surgical Treatment Efficacy trial and Trial of Mid-Urethral Slings).24 Between 2 and 12 months, women who had a midurethral sling had a postoperative rUTI rate of 2.3%.25 No cases of rUTI were reported during a recent 10-year follow-up of 71 women who had transobturator midurethral slings.26 DIAGNOSIS Women with frequent UTI may experience diagnostic delay if clinicians do not review the UTI history; clinicians should order pretreatment urine cultures to document rUTI (culture-proven UTI ≥2 in 6 months or ≥3 in 12 months).3 Although infrequent UTI can be assessed with less rigor and treated empirically, women with frequent UTI who are being formally assessed for rUTI should have detailed symptom and pretreatment urine culture and is a symptom of bacterial and are of and and and should of In there is a of a UTI and frequency in the of vaginal or The of history and for UTI diagnosis in women an increased UTI with frequency and The of UTI diagnosis is with a history of vaginal or vaginal symptoms associated with a UTI may be less a frequency or has been to with UTI, and urinary incontinence should evaluation for such as urinary or urinary may be for urogynecologic patients to care for Women with may have may health care to in or which may UTI, although this is a diagnostic the common clinical of incontinence or other urinary symptoms are not associated with There is symptom between UTI and urogynecologic including urinary and Currently, our understanding of appropriate symptom in this population is The urine has to than UTI in patients with lower of women with rUTI do not have a of UTI, testing is not and pretreatment urine culture is Beyond the standard for testing in women with rUTI can confirm least blood per The of for women with rUTI because of a lack of in urogynecologic the of alter the treatment the should a The for UTI diagnosis by urine culture varies and has not been in any urogynecologic The standard urine culture with has been used as a standard for A culture is by of at least although to the of a of in patients is for The of and of clinical practice that 102 is in the of UTI should have a understanding of clinical as certain may report or less as practices for posttreatment of urine culture vary and are based on on resolution the ability to detect of uropathogen or The Canadian suggest a urine culture 1 to 2 weeks after treatment to for A urine culture may for detection of of uropathogen or recurrence that may provide the or A posttreatment urine culture evidence of In the of a posttreatment urine is that 2 or 3 UTI episodes are to a single persistent However, clinicians a the posttreatment culture is and the UTI symptoms have Some who that women with an diagnosis of rUTI can also a diagnosis of asymptomatic posttreatment testing to the risk of asymptomatic and antibiotic women with asymptomatic in a randomized trial who were treated were more likely to subsequent at a rate than those who were not treated and more likely to Examination Although a may not be before treatment for a with infrequent UTI, an should as of the rUTI evaluation to detect an and findings of upper tract In addition to an of the status, should for and The pelvic including can for and/or in pelvic floor or vaginal and pelvic In addition, detection of pelvic organ presence of a foreign body such as a or or will the treatment These should be with initial evaluation of a with rUTI and as on including new or risk A postvoid residual should be to that there is no urinary This can be at the of the and There are no specific for for women with rUTI. for in women with UTI persistent symptoms after of appropriate antibiotic recurrence after appropriate treatment, or and women with who are at risk for such as and should be if a is at risk for foreign body within the or although the of in evaluation of rUTI has not been study reported that of the participants had specific findings on that not with should be there is clinical for or for urinary tract can be with the clinical more of the upper tracts, or should be In a which is with and without is the of in patients of having and and This can also a source of infection such as or and Women who the for rUTI should have this diagnosis to to other to the recurrent of the UTIs and to that best practices are for evaluation and In addition, methods to UTIs antibiotic can be in or in the use of International Classification of Disease, is important for of patients for clinical diagnosis and population of rUTI. 1 describes of the codes associated with lower The code of urine can be used of UTI or asymptomatic a urine culture is but the clinical are not for a for example, if a is asymptomatic and a culture is before treatment or the is on but the rUTI diagnosis with history of rUTI after 1 of the no being treated for rUTI and not the for the diagnosis of UTI Treatment for rUTIs can be by such as genitourinary anatomy, and are have on or antibiotic whereas data on and are is used to and future the treatment and will vary based on the clinical and should be for antibiotic treatment have been for patients with recurrent These can be treatment of an episode or or further rUTI patients should have a culture before can be before urine culture if clinically as history of or should be to the and and and to should be with the in communities which is available any clinical should be altered if based on the urine culture Treatment of UTI in Women UTI Treatment for UTI in women with rUTI have been from UTI treatment in women without rUTI. treatment and antibiotic are the 2 treatment with evidence of in bacterial treatment, a is used for or patients are up without any form of is if symptoms or do not in a clinically treatment has not been studied in women older than years or with rUTI. trials in women than years have resolution rates of to without antibiotic However, study a rate of in the group at to are treatment of bacterial cystitis in women with In women with rUTI, treatment can be by a or at the of symptom of UTI treatment were not in women with rUTI or other pelvic floor for of for a UTI, the should review and may have reported and/or to recommended UTI patients can be further to they have reaction a reaction should not an antibiotic in patients with such as for of the may be for patients with microbial is associated with a in the rate and this the and of that are such as as UTI with rate are more likely to experience treatment due to is because of urine in patients with a of less than should be with antibiotic of and specific for if Although more than of at least years old have an rate of less than in microbial or based on age are not has been based on although support use in but The has to the for using from to based on 2 the antibiotic in older women and women with rUTI. In the of for premenopausal 3 for UTI treatment are and are from these for use in rUTI, older and women with urogynecologic for UTI Treatment in Women is and in the lower urinary It is E. coli and with of However, is other uropathogens including some Proteus and some strains of and The of treatment is to A recent of of women from 12 to years old with variable that are as although this is not to women with rUTI. The clinical practice for the treatment of cystitis in a of is a antibiotic that bacteria including Staphylococcus and most there is than E. coli to an treatment should be of treatment has from 3 to 14 with the being to have to to of the form of is in a single which is in the urine in urine that persist for to has both and including and has of a of in with In addition, is an important for treatment of E. coli are not available or be because of or or bacterial and can be as and have in most uropathogens except trial evidence that the of or is at have a lower rate than and like can also be used if are for any Although (eg, and are they are not because of increasing and as in a and there is evidence of sensitivity to certain including and these should be used because of to be due in to the lack of in the of The for the of bacterial cystitis treatment in women with rUTI is not evidence based and is from women without some use in rUTI women. Although not specifically women with rUTI, in a review and of 15 randomized trials of women antibiotic for treatment of UTI, the that the standard for with to 14 The review also reported that associated with a rate of persistent UTI with the 15 in this 2 studied This document the practice of using standard and treatment as clinically The of of and has and and is widely for UTI treatment in the of These are as for as to and have and lower rates of The of 5 days of is to 3 days of days of has than a of to can be associated with physician for urine culture before after treatment, to diagnostic For women who are or to a urine episodes of without culture are with is associated with a rate of infection UTI per UTI per is an for women with the ability to UTI symptoms and who are not for or who do not to take For clinicians the appropriate and of an antibiotic that will cover the most likely uropathogen based on the history that can treatment based on Women who use the should be of if symptoms or to within 3 the recommended with are recommended to and and are not for because of risk of and use of other UTI Factors Women with rUTI who have factors, such as genitourinary anatomy, and require in diagnosis and treatment because bacterial are more likely to be resistant to various of an UTI with factors is treatment should be urine culture and sensitivity are The initial of should the uropathogen current treatment (eg, if on UTI and response to clinically antimicrobial should be culture and susceptibility antimicrobial treatment can be based on the uropathogen 5 the recommended for of UTI with for of UTI in Women with UTI are not recommended for treatment, including and is not recommended for treatment because of rates of 6 the recommended treatment should be refined the urine culture are Treatment and Treatment Treatment may be used as an for symptoms of bacterial However, in women with rUTI, there is no evidence that should be used in of an antibiotic on There is evidence to medicine as rUTI The used in to have in for rUTI treatment and clinical in A review of and The review limited by a of study and an overall these the of the review that may be for rUTI treatment during an episode as an or as an and may rUTI for up to 6 months after of the for and/or treatment some and These to the of infection and of tract which and such as has been the antibiotic most studied for There have been no randomized trials to and all have been in with UTIs. have findings from in and human have with from with 50 mL of to mL with at least a or have been No were and all reported a in UTIs were may use this in patients, the lack of evidence from current evidence the of is a that the of to increased and et reported use in 3 different patients with The treatment 100,000 in 50 mL 3 for for days and 2 days 3 patients were Although there are not data to this treatment, may be in a who has limited treatment The of is to or subsequent Although this is most commonly with as the of and the of and of a urine culture before recommended and antibiotic should be to women who have UTIs to sexual These women will take a single of an antimicrobial after recurrence rates with and as as This has likely and risk of antibiotic a a antibiotic with by up to The of these from 6 months on that UTIs to and within 3 to at least 2 have been to 5 years in some A review of for of rUTI in women that for 6 to 12 months were more than in rUTI Although with may of bacteria on this may not the antibiotic is have that 50% to of women within 3 months of due in to bacterial may the risk of bacterial This document of antibiotic at 3 months to the and is beyond 6 months, although may have to be if UTIs should be used in women with rUTI because UTI In a trial of postmenopausal women to in vaginal for 2 weeks, by for 8 UTI incidence in the treatment group episodes per In addition, after 1 of treatment, in of the group and of the In randomized trial of postmenopausal women with rUTI randomized to vaginal 1 for 12 weeks, for a of the vaginal UTI and the to A review of these that vaginal may be more than the vaginal although in these of A review of vaginal treatment of evidence of UTI risk in women with vaginal using vaginal Studies vaginal and are has not been to be and should not be used for rUTI A review reported evidence that may be for UTI, specifically used for are in the urine to and is and does not In addition, has an with reported There is no evidence the of in rUTI The organisms used in from which antimicrobial that A review of 5 on premenopausal women with current UTI or history of UTI that using strains that vaginal A review that with variable in premenopausal and postmenopausal women no in rUTI in the However, findings from this study were because the data were from and and of are in patients with rUTI using The of evidence does not support use of in the care of women with rUTI. in of of E. coli to The in reviews of are limited by lack of in and lack of rates in suggest an review of trials or to or in that risk of UTI in various including women with A review of and trials using various in and with a history of at least 2 UTIs in the 12 months not a in UTI except in A more recent clinical trial of women randomized to to 20 of no in the study not to detect in and There is limited evidence use of the in women with rUTI. available the of 1 bacteria in UTI In a recent randomized clinical trial of women with UTIs and history of rUTI in which women were first treated for UTI and randomized to 2 of for 6 months, 50 of or no the rate of rUTI and The group had and Although has a based on of there is evidence to support use for UTI in women with rUTI. The 2 that have the of had including and are however, they do not yet have clinical evidence for The the use of and is that to the of the urothelium is to a in and are likely to a future in rUTI prevention, although there is evidence to clinical use at this is an from 18 different In a review of there a in the of UTI by half in the treatment with with a rate of is a vaginal that 6 of 1 of Proteus pneumoniae, and E. faecalis. from 3 suggest a in rUTI but in the that after the in have a in the care of women with rUTI. research on and best practices to our understanding of rUTI, these best practices will be for current care are in diagnosis with use of and use of appropriate and are to the best-practice The of these best Diagnosis for rUTI diagnosis are at least 2 in 6 months or at least 3 in 12 culture before antibiotic is recommended to document rUTI episodes and culture after appropriate may episodes. should take specific factors factors, and uropathogen For cystitis in women with rUTI, is a is may need to sensitivity can also be used if is less than in the and are not treatment of cystitis without antibiotic is in women with rUTI. antibiotic is in women with rUTI. are of vaginal in and

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.