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Practice Uncertainties

Non-antibiotic options for recurrent urinary tract infections in women

BMJ 2017; 359 doi: (Published 23 November 2017) Cite this as: BMJ 2017;359:j5193
  1. Jonathan Barclay, specialty trainee in urology,
  2. Rajan Veeratterapillay, consultant urological surgeon,
  3. Chris Harding, consultant urological surgeon
  1. Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
  1. Correspondence to C Harding: chris.harding{at}

What you need to know

  • After treating the acute infection, low dose antibiotics given for 6-12 months are the most evidence based preventive measure for recurrent urinary tract infections (UTIs) in women, and are recommended by national and international guidelines as the standard of care

  • There is evidence of antimicrobial resistance development with prolonged low dose antibiotics and this has led to the investigation of non-antibiotic alternatives to prevent UTIs

  • Evidence for non-antibiotic treatments is variable: vaginal oestrogens, D-mannose, immunotherapy, and methenamine look most promising

Recurrent urinary tract infection in women is a common problem. There is no universally accepted definition, but most clinicians would classify recurrent UTI as being two episodes of infection in six months, or three episodes in one year.1 The annual incidence of a single UTI is 30 per 1000 women,2 with 44% experiencing recurrence within 12 months.3

When to investigate further

Most women presenting with recurrent UTI have uncomplicated infections (defined as no structural or functional urinary tract abnormalities).1 Current international guidelines do not recommend routine investigations of women with recurrent UTI because of their low diagnostic yield.1 Symptoms such as persistent loin pain, haematuria, or the presence of atypical infection would necessitate referral to secondary care, where further tests (renal tract ultrasound/computed tomography, flexible cystoscopy, and urine flow studies/post-void urine estimation) can be carried out.

Guidelines from the Scottish Intercollegiate Guidelines Network4 and the European Association of Urology1 recommend the use of low dose prophylactic antibiotics for preventive treatment of recurrent UTI. The largest systematic review and meta-analysis of the effect of prophylactic antibiotics on recurrence rates includes 19 randomised controlled trials with data from 1120 women5 and reports an 85% reduction in the incidence of symptomatic UTI compared with placebo (relative risk 0.15, 95% confidence interval 0.08 to 0.28). This review examined data from …

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