How should relapsing UTIs be treated?
Relapse of UTI caused by the same pathogenic microbe would be expected to occur shortly after cessation of antimicrobial therapy.
Therefore, the results of a urinalysis and culture should be re-evaluated approximately seven to 10 days following the discontinuation
of therapy to detect recurrent relapses at a subclinical stage. Recovery of the same organism from urine that was sterile
during anti-microbial therapy is presumptive evidence that antimicrobial therapy failed to eradicate the infection from adjacent
tissue, and suggests lack of compliance with treatment recommendations, or deep-seated infection (Tables 2 and 4). If diagnostic
efforts to find a predisposing cause have not yet been performed, they should be considered as essential at this time (Table
Table 4. Checklist of compliance problems and solutions
If the relapse occurred following a brief period of therapy, continue treatment for a longer period. If the relapse occurred
10 or more days following therapy, repeat therapy with a different antimicrobial agent selected on the basis of susceptibility
tests. Then, continue therapy for a longer period (three to four weeks). The procedures to evaluate treatment efficacy described
above should be repeated.
Caveat: Relapses are indicative of antimicrobic treatment failure, and are of considerable significance in terms of potential morbidity.
Special consideration should be given to the likelihood that the drug selected will reach therapeutic concentrations at the
site of infection in the urinary tract.
How should UTIs caused by reinfection be treated?
Provided the urinary tract has had sufficient time to repair damaged tissues, reinfection caused by different pathogenic microbes
would be expected to occur later following discontinuation of treatment than a relapse (Table 1). Therefore the results of
a urinalysis and culture should be re-evaluated approximately two to three weeks after cessation of antimicrobial therapy.
Detection of frequent reinfection following antimicrobial therapy warrants evaluation of the patient for one or more predisposing
causes (Table 3). The goal is to correct the predisposing cause. reinfection should be managed by choosing antimicrobial agents
on the basis of antimicrobial susceptibility tests. Each product should be used for a sufficient period of time (three to
five days) to evaluate its effectiveness in sterilizing urine.
Caveat: Elimination of bacterial pathogens associated with reinfection may require therapy of shorter duration (10 to 14 days) than
recurrences associated with relapses. In fact, treatment of reinfection with therapeutic doses of antibiotics for long periods
is usually not warranted. Why? Because, when recurrences due to reinfection occur the antimicrobial drugs are effectively
eradicating bacterial pathogens. Infrequent reinfection (two or three times per year) may be treated as single episodes (i.e.
short course of a suitable antimicrobial agent).
How can frequent reinfection be minimized?
In some patients with recurrent UTIs, it may be impossible to identify and/or correct underlying disorders in host defenses
that permit bacteria to infect the urinary tract (Table 3). The result is often frequent reinfection. In such cases it may
be helpful to provide low-dose (so-called preventative) antibacterial therapy for six months or more with bacteriocidal drugs
primarily eliminated in urine.
Drugs that have been used for this purpose include amoxicillin, ampicillin cephalexin and trimethoprim-sulfadiazine. Consider
selection of drugs to use for preventative therapy on the basis of results of the most recent antimicrobial susceptibility
test. Reduced dosages (about one-third to one-half of the therapeutic dosage) of drugs excreted in high concentration in urine
may be used provided there has been complete eradication of bacterial pathogens by therapeutic dosages of appropriate drugs.
Logically, low-dose preventive antimicrobial therapy would be inappropriate for management of patients with recurrent bacterial
UTI due to relapses, since they have persistent infection.
It is best to give one daily preventive dose of the antibiotic at a time when the drug is likely to be retained in the urinary
tract for six to eight hours (for example, prior to bedtime). Even though this preventive dosage regimen does not result in
MICs throughout the day, low concentrations of some drugs augment innate host defenses.
In some patients, this strategy appears to interfere with production of fimbriae by some uropathogens. This in turn interferes
with the ability of potential pathogens to adhere to and colonize uroepithial cells.