Recurrent Uncomplicated Urinary Tract Infections in Women
Posted on August 25, 2025
Source:
American Urological Association
Purpose
Over the past few decades, our ability to diagnose, treat, and manage recurrent urinary tract infection (rUTI) long-term has evolved due to additional insights into the pathophysiology of rUTI, a new appreciation for the adverse effects of repetitive antimicrobial therapy (“collateral damage”), rising rates of bacterial antimicrobial resistance, and better reporting of the natural history and clinical outcomes of acute cystitis and rUTI. For the purposes of this guideline, the Panel considers only recurrent episodes of uncomplicated cystitis in women. This guideline does not apply to pregnant women, patients who are immunocompromised, those with anatomic or functional abnormalities of the urinary tract, women with rUTIs due to self-catheterization or indwelling catheters or those exhibiting signs or symptoms of systemic bacteremia, such as fever and flank pain. This guideline also excludes those seeking prevention of urinary tract infections (UTIs) in the operative or procedural setting. In this document, the term UTI will refer to acute bacterial cystitis unless otherwise specified. This document seeks to establish guidance for the evaluation and management of patients with rUTIs to prevent inappropriate use of antibiotics, decrease the risk of antibiotic resistance, reduce adverse effects of antibiotic use, provide guidance on antibiotic and non-antibiotic strategies for prevention, and improve clinical outcomes and quality of life for women with rUTIs by reducing recurrence of UTI events.
Methodology
The systematic review utilized to inform this guideline was conducted by a methodology team at the Pacific Northwest Evidence–based Practice Center (EPC). Scoping of the report and review of the final systematic review to inform guideline statements was conducted in conjunction with the rUTI Panel. A research librarian conducted searches in Ovid MEDLINE (1946 to January Week 1 2018), Cochrane Central Register of Controlled Trials (through December 2017) and Embase (through January 16, 2018). Searches of electronic databases were supplemented by reviewing reference lists of relevant articles. An updated literature search was conducted on September 20, 2018. In 2022, the EPC conducted an update review assessing abstracts from new studies published since the publication of the 2019 Guideline. The AUA asked the EPC to further assess a subset of studies included in the update report, to support potential changes to the 2019 guideline.
Guideline Statements
Evaluation
1. Clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs. (Clinical Principle)
2. To make a diagnosis of rUTI, clinicians must document positive urine cultures associated with prior symptomatic episodes. (Clinical Principle)
3. Clinicians should obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen. (Clinical Principle)
4. Cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with a rUTI. (Expert Opinion)
5. Clinicians should obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs. (Moderate Recommendation; Evidence Level: Grade C)
6. Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures. (Moderate Recommendation; Evidence Level: Grade C)
Asymptomatic Bacteriuria
7. Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. (Moderate Recommendation; Evidence Level: Grade C)
8. Clinicians should not treat ASB in patients. (Strong Recommendation; Evidence Level: Grade B)
Antibiotic Treatment
9. Clinicians should use first-line therapy (i.e., nitrofurantoin, TMP-SMX, fosfomycin) dependent on the local antibiogram for the treatment of symptomatic UTIs in women. (Strong Recommendation; Evidence Level: Grade B)
10. Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days. (Moderate Recommendation; Evidence Level: Grade B)
11. In patients with rUTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics, clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than seven days. (Expert Opinion)
Antibiotic Prophylaxis
12. Following discussion of the risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs. (Conditional Recommendation; Evidence Level: Grade B)
Non–Antibiotic Prophylaxis
13. Clinicians may offer cranberry prophylaxis for women with rUTIs. (Conditional Recommendation; Evidence Level: Grade C)
Follow–up Evaluation
14. Clinicians should not perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients. (Expert Opinion)
15. Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy. (Expert Opinion)
Estrogen
16. In peri– and post–menopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication to estrogen therapy. (Moderate Recommendation; Evidence Level: Grade B)
Introduction
Purpose
rUTI is a highly prevalent, costly, and burdensome condition affecting women of all ages, races, and ethnicities without regard for socioeconomic status, or educational level.2 The incidence and prevalence of rUTI depend on the definition used. Approximately 60% of women will experience symptomatic acute bacterial cystitis in their lifetime.3 An estimated 20-40% of women who have had one previous cystitis episode are likely to experience an additional episode, 25-50% of whom will experience multiple recurrent episodes.4,5 The exact numbers are unclear, as most epidemiologic studies utilize diagnosis codes that may overestimate true numbers due to overuse of UTI and rUTI codes in patients who have not yet undergone culture or evaluation.3 Regardless of the definition, the evaluation and treatment of UTI costs several billion dollars globally per year, reaching approximately $2 billion per year in the United States alone.6
Terminology and Definitions
For the purposes of this guideline, the Panel considers only recurrent episodes of uncomplicated cystitis in women. “Uncomplicated” means that the patient has no known factors that would make her more susceptible to develop a UTI, while “complicated” indicates that other complicating factors may put one at higher risk for UTI and decreased treatment efficacy. Such complicating factors may include an anatomic or functional abnormality of the urinary tract (e.g., stone disease, diverticulum, neurogenic bladder), an immunocompromised host, or infection with multi-drug resistant (MDR) bacteria. In this guideline, the term UTI will refer to culture-proven acute bacterial cystitis and associated symptoms unless otherwise specified. While most providers have confidence in making a diagnosis of acute cystitis, diagnostic criteria are imprecise and vary considerably. Strong evidence suggest that the diagnosis of acute cystitis should include the combination of laboratory confirmation of significant bacteriuria with endorsement of acute-onset symptoms referable to the urinary tract.7,8 Without symptoms, bacteriuria of any magnitude is considered asymptomatic bacteriuria (ASB).
While there are multiple definitions for rUTI,9 this Guideline endorses the two most commonly used definitions of two episodes of acute bacterial cystitis within six months or three episodes within one year. These definitions typically consider these episodes to be separate infections with the resolution of symptoms between episodes, and do not include those who require more than one treatment or multiple antibiotic courses for symptomatic resolution, as can occur with inappropriate initial or empiric treatment. Any patient experiencing episodes of symptomatic acute cystitis after previous resolution of similar symptoms meets the criteria for rUTI. However, it should be noted that those patients initially treated for uncomplicated bacterial cystitis who recur rapidly (i.e. within two weeks of initial treatment) after symptom resolution or display bacterial persistence without symptom resolution may be reclassified as complicated and require imaging, cystoscopy, or other further investigation for bacterial reservoirs.
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