Recurrent UTIs in women – a new UK based study to inform our practice.

Recurrent UTIs (rUTIs)– a significant source of problems and distress for patients, and a similar source of repeated appointments for us in general practice. Estimates vary due to study design and definition, but we know between 3-44% of all women suffer from rUTIs at some stage in their adult lives;  are defined as ≥2 UTIs in 6 months, or ≥3 in 12 months – meaning many more patients than you might think fall into this group. The episodes should be symptomatic and confirmed on MSU if an antibiotic is given. We’ve talked about the management of both acute and recurrent UTIs on our courses in the past, and with good reason. After some major shifts in practice over the last decade, and new knowledge around the problems related to long term prophylactic antibiotic use, we are all keen to ensure that patients are put on the correct – and the safest – treatment for this high morbidity condition. 

There has been a gap in the research around who gets a UTI amongst the female population, and working out what happens to these patients in the real-world vs in the guidelines on our computer. This paper published in the BJGP in August is therefore an interesting read, on a condition that is very common and can easily be missed due to a combination of patient under-reporting, self-treatment, and the increased number of places patients can now present for treatment of UTI symptoms. It is a retrospective cross-sectional study carried out in Welsh general practice (Helo cydweithwyr Cymraeg!), looking at women aged ≥18yrs with recurrent UTIs or those using prophylactic antibiotics (2010-2020), and urine culture results (2015-2020). Over 1.5 million patient records were included in the review, via the SAIL Databank, making it highly relevant and applicable for all UK general practice.

The prevalence of rUTIs from the study was 6%, with an increase in those aged 58-67yrs, likely correlating to the reduction in oestrogen related to the menopause and the corresponding increase in vulval atrophy (one reason why NICE recommends all post-menopausal women with recurrent UTIs should receive vaginal oestrogen.) The really fascinating part was looking at the decisions around prophylaxis. In total, 80.8% of women with rUTIs had their urine cultured in the previous 12 months, but only 64.2% had this repeated immediately before starting prophylaxis. This is particularly important as the study found that there was significant resistance to trimethoprim (40.3%), and amoxicillin (57.1%) in those on prophylaxis, both of which feature as first and second line choices in the NICE guideline on recurrent UTIs. 

Nitrofurantoin and cefalexin, the other two recommended antibiotics for prophylaxis, showed much lower resistance, but the long-term complications of nitrofurantoin and the limitations in patients with CKD make it even more important to ensure appropriate culture has been done before starting prophylaxis. This is demonstrated in the research by the 18.5% of women who were prescribed trimethoprim as prophylaxis when they already had evidence of resistance prior to initiation. 

The paper concludes that we should be mindful of the current guidelines around reviewing previous and current MSU results before prescribing, both for acute episodes and as either single dose or long term prophylaxis. The high degree of resistance to two of the four recommended options for longer term prevention also means we should have a good awareness of our local antimicrobial guidelines as well as the individual patient results. Patients on prophylaxis for rUTI should be reviewed every 6 months, and remember to offer treatment with vaginal oestrogen for all post-menopausal women with rUTI, regardless of whether they are also on systemic HRT already (for more on this, join our next womens health course!).