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Table III: Prevention strategies for recurrent acute uncomplicated cystitis.
Behavioral strategiesa
1. Abstinence or reduction in intercourse frequency

Sexual intercourse strongest risk factor for uncomplicated UTI
2. If a spermicide user, recommend consider change to another method for
contraception or infection prevention

Very strong risk factor, including use of spermicide-coated condoms

Causes alteration in vaginal flora favoring uropathogen colonization
3. Change in other behavior: Urinate soon after intercourse; drink fluids liberally; do not
routinely delay urination; wipe front to back after defecation; do not wear tight fitting
underwear; do not douche

Based on potential benefit of reducing level of bacteriuria or vaginal colonization
with uropathogens

None as yet shown to be effective, although none evaluated in prospective trials
Biologic mediator strategiesa
1. Cranberry juice or tablets

Based on inhibition of uropathogen adherence to uroepithelial cells, but welldesigned trials suggest no clinical benefit
2. Topical estrogen (postmenopausal women)

Topical estrogen normalizes estrogen-deficient vaginal flora and reduces risk of
recurrent UTI. Estrogen ring also effective. Oral estrogens not effective
3. Adhesion blockers

Based on finding that E. coli UTI is initiated by adhesion of E. coli to mannosylated
receptors in the uroepithelium via the FimH adhesin located on type 1 pili.
Theoretically, mannosides could block adhesion

D-mannose, a natural sugar available in health-food stores and online, is
occasionally used for preventive therapy, but there are no published clinical trials
with this agent
Antimicrobial strategiesb
1. Self-diagnosis and self-treatment (not preventive)

Based on studies that show that women with previously diagnosed UTI can
accurately self-diagnose >85-95% subsequent UTIs and successfully self-treat

Patient is given a prescription for a first-line antimicrobial regimen (Table I) and
takes it at onset of UTI symptoms

Patients have high patient satisfaction and use less antimicrobial compared with
continuous antimicrobial prophylaxis

Restrict to motivated and compliant women with previous culture-confirmed
cystitis

Advise to call if symptoms are atypical or if treatment response is delayed

Periodically obtain urine culture prior to treatment to ensure presence of UTI and
drug susceptibilities
2. Antimicrobial prophylaxis strategiesc
2a. Post-coital antimicrobial prophylaxissingle dose of antimicrobial soon after
intercourse
Recommended regimens

Nitrofurantoin 50-100mg

TMP-SMX 40mg/200mg or 80mg/400mg

TMP 100mg

Cephalexin 250mg

Ciprofloxacin 125mg
Comments

Reduces recurrences by >90%

Use if UTIs temporally related to coitus

Less exposure to antimicrobials compared with continuous prophylaxis

Counsel women about avoidance of pregnancy if use fluoroquinolones, TMP,
or TMP-SMX
2b. Continuous antimicrobial prophylaxistake daily at bedtime except as noted
Recommended regimens

Nitrofurantoin 50-100mg

TMP-SMX 40mg/200mg (thrice-weekly also effective)

TMP 100mg

Cephalexin 125-250mg

Ciprofloxacin 125mg

Fosfomycin 3g sachet every 10 days
Comments

Reduces recurrences by approximately 95%

Side effects common (e.g., rash, yeast vaginitis)

6-month trial recommended, then stop and observe; approximately 50% revert
to previous pattern of UTI recurrences

If recurrences continue, prophylaxis may be restarted; UTI prophylaxis has
been used for years in some patients with lasting efficacy

Rare toxicities with long-term exposure to nitrofurantoin include pulmonary
hypersensitivity, chronic hepatitis, and peripheral neuropathy

Counsel women about avoidance of pregnancy if use fluoroquinolones, TMP,
or TMP-SMX

Antimicrobial resistance in colonizing strains or breakthrough UTIs reported in
some studies
aCounseling
about the pros and cons of these strategies is appropriate in women who
have one or more recurrent UTIs or who have questions about any of the strategies.
bThe
choice of antimicrobial should be based upon the susceptibility pattern of the
organism causing the patient’s recent UTIs and history of drug allergies. Culture
breakthrough UTIs to assess susceptibility of the infecting uropathogen. Periodic
assessment of patients should be performed to ensure that the antimicrobial strategy in
use remains appropriate and safe.
c
Absence of bacteriuria should first be assured by a negative urine culture at least 1
week after UTI treatment.
SMX, sulfamethoxazole; TMP, trimethoprim; UTI, urinary tract infection.