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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 prophylaxissingle 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 prophylaxistake 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.