Adult

Recurrent UTIs

This guidance applies to recurrent UTI in women, or trans men or non-binary people with a female urinary system, who are not pregnant.

For recurrent UTI in pregnant women see HERE

Background:

  • Recurrent UTIs: 2 or more UTIs in the past 6 months or more than 3 UTIs in the past 12 months.
  • Investigate the cause, e.g. with ultrasound, in the following patient groups:
    • female patients with recurrent lower UTI without a known trigger,
    • male patients with recurrent lower UTI
    • recurrent upper UTI (both male and female)
  • See NICE guidelines for investigating and managing recurrent UTIs. 
  • A current episode of UTI should be treated before offering preventative treatment. See UTI, lower (female, not pregnant, non-severe), UTI, lower (male) and symptomatic catheter-associated UTI

Antibiotic avoidance strategies (also known as self-care strategies)

  • Hydration (1.6L/day) and ibuprofen for symptom relief
  • Some women, trans men and non-binary people with a female urinary system, who have recurrent UTI and are not pregnant may wish to try:
    • D-mannose. These are not on OUH formulary so will need to be purchased by the patient
    • Cranberry products. They may reduce the recurrence rate of cystitis. NICE state that the evidence is uncertain. Cranberry products should not be taken if warfarin is being used.
    • Advise people taking cranberry products or D-mannose about the sugar content of these products

Management if self-care strategies are not effective or not appropriate

First line:

  • Consider Vaginal oestrogen if the patient is experiencing/already experienced perimenopause/menopause AND person hygiene measure are not effective or not appropriate:
    • Take account of severity and frequency of previous symptoms, risk of complications from recurrent UTIs, benefits for other symptoms (vaginal dryness), possible adverse effects (breast tenderness and vaginal bleeding), unknown long-term endometrial safety and patient’s preferences for treatment option.
    • Review treatment with vaginal oestrogen within 12 months.

OR

  • If Vaginal oestrogen not appropriate or effective and trigger identified: trimethoprim 200mg po single dose when exposed to trigger
    • Review treatment at 6 months.

 

Second line:

If recurrent UTI has not been adequately improved by first line options consider: methenamine hippurate 1g po BD (if eGFR more than 10ml/min/1.73m2).

  • Review use of methenamine hippurate within 6 months, and then at least every 12 months
  • Can be prescribed by Primary care: See CCG formulary

 

Third line:

Antibiotic prophylaxis. See section below.

Combination of methenamine hippurate and antibiotic prophylaxis is not recommended.

Antibiotic prophylaxis

If decision is made to treat with a trial of antibiotics consider the following:  

  • severity and frequency of symptoms,
  • risk of complications and long-term antibiotic use,
  • previous urine culture and susceptibility results,
  • previous antibiotic use,
  • allergy and tolerance to antimicrobials,
  • renal and hepatic function
  • local antimicrobial resistance, and
  • preferences for treatment.

 

Preferred

trimethoprim 100mg po at night

 

Alternatives

If urine cultures are resistant to trimethoprim or trimethoprim otherwise contraindicated: Speak to Micro/ID. Antibiotics such as nitrofurantoin, amoxicillin or cefalexin may be suggested by Micro/ID.

 

Duration

Review antibiotic prophylaxis for recurrent UTI at least every 6 months, with the review to include:

  • Assessing the success of prophylaxis,
  • Discussion of continuing, stopping or changing prophylaxis (taking into account the person's preferences for antibiotic use and the risk of antimicrobial resistance),
  • A reminder about behavioural and personal hygiene measures and self-care treatments.

If antibiotic prophylaxis is stopped, ensure that people have rapid access to treatment if they have an acute UTI.

If the patient develops a UTI whilst receiving prophylactic antibiotics

If the patient develops a UTI whilst receiving prophylactic antibiotics

  • Ensure any current UTI is treated,
  • Omit the prophylactic antibiotic,
  • Once UTI is treated, review antibiotics used for prophylaxis and adjust as appropriate taking account of factors discussed above related to antibiotic choice.

Additional Information

Editorial Information

Last reviewed: 03 Mar 2025

Author(s): AMST.

Approved By: MMTC