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REVIEW PAPER
DOI: https://doi.org/10.5114/pm.2021.105382
Menopause Rev 2021; 20(1): 40-47
Introduction
Urinary tract infections (UTIs) in women are one of
the most prevalent infections occurring at various stag-
es of life. Women are much more prone to UTIs than
men, mainly due to the female lower urinary tract ana-
tomy and its proximity to the reproductive organs. The
female urethra is relatively short, reducing the distance
for bacterial ingress. Furthermore, it opens into the vul-
var vestibule, i.e. astructure that is also quite prone
to infections, given the prevalence of vulvar vestibu-
litis and vaginitis. In this case, sexual activity as well
excessive use of intimate hygiene products interfering
with natural vaginal microbiome are often to blame.
On the other hand, the proximity of the anus facili-
tates the colonization of both the reproductive organs
and distal parts of the urinary tract by Escherichia coli,
Enterococcus fecalis, and the Streptococcus species. Preg-
nancy and the perinatal period are other characteristic
timepoints marked by frequent urinary tract infections.
The increasing number of caesarean sections and perio-
perative catheterizations are yet another risk factor. In
the post-menopausal period falling oestrogen levels
interfere with the vaginal epithelium, contributing to
its gradual atrophy, while glycogen deficiency reduces
the lactic acid bacteria counts. As aresult, post-meno-
pausal vaginas are often colonized by other bacteria,
mainly Escherichia coli, which may spread and infect
the urinary tract. Pelvic organ prolapse and urinary in-
Urinary tract infection in women
Krzysztof Czajkowski1, Magdalena Broś-Konopielko1, Justyna Teliga-Czajkowska2
1II Faculty and Clinic of Obstetrics and Gynaecology, Medical University of Warsaw, Warsaw, Poland
2Department of Obstetrics and Gynaecology Didactics, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
Abstract
Urinary tract infection (UTI) is one of the most common infections afflicting women. UTI often accompanies
vaginal infections and is frequently caused by pathogens originating in the digestive tract. The paper discusses
the prevalence of UTI in various patient populations, including postmenopausal, pregnant, diabetic, epileptic,
and perioperative female patients. Current UTI treatment and prevention guidelines both for primary and recur-
ring UTIs were reviewed. Antibiotic treatment duration should be minimized, with the exact dosage and time
schedule depending on the type of infection. Asymptomatic bacteriuria does not always require antibiotic treat-
ment, because their excessive use may lead to the emergence of antibiotic resistant strains. The role of non-
antibiotic prophylaxis of recurrent infections involving immunomodulants (OM-89), probiotics, and behavioural
interventions was underlined.
Key words: urinary tract infections, menopause, pregnancy, prevention, treatment.
continence also contribute to frequent UTIs. These are
believed to affect between 30% and 50% of women
above the age of 50 years. It is estimated that every
other woman will have had at least one UTI during
her lifetime [1, 2], with 10–60% of all women having
asymptomatic UTI at least once in their lives [3, 4]. The
infection risk increases with age [5].
Recurring UTIs in women are defined as at least
2 UTIs occurring within a6-month period or at least
3 UTIs in a12-month period. The prevalence of re-
curring UTIs in women is estimated at 25–50% of all
infections [6–9].
Diagnosis
All UTI cases can be classified as either asympto-
matic or symptomatic. An asymptomatic UTI is diag-
nosed based on urinalysis results. Careful sample col-
lection is crucial given the external urethral opening
position in women. The number of leukocytes is the key
criterion utilized in UTI diagnosis; acount > 10 leuko-
cytes/mm3 suggests an infection. In pregnant patients
the cut-off is higher, at > 20 leukocytes/mm3. Sample
contamination by vaginal secretions containing mucus
and lactic acid bacteria may result in erroneous diagno-
sis of multiple mucus threads and abundant bacterial
growth in urine sediment. Sometimes the mucus even
Corresponding author:
dr n. med. Justyna Teliga-Czajkowska, II Katedra iKlinika Położnictwa iGinekologii, Warszawski
Uniwersytet Medyczny, ul. Karowa 2, 00-315 Warszawa, e-mail: jtckcac@gmail.com
Submitted: 19.03.2021
Accepted: 26.03.2021
M R/P M 20(1) 2021
41
yields amistaken diagnosis of proteinuria. Period, post-
partum bleeding, or any other uterine bleeding may
result in sample contamination with red blood cells.
In such cases, adetailed history and abetter-prepared
repeat analysis is necessary. Urinalysis results not ac-
companied by the patient’s symptoms are not suffi-
cient to initiate treatment. Aurine culture can be used
to confirm or disprove ahypothesis of an UTI. The cul-
ture sample should be collected in asterile container
to avoid contamination, preferably from first morning
urine. The presence of ≥ 105 colony forming units per
millilitre (CFU/mL) confirms an infection, while an an-
tibiogram will help verify the efficacy of agiven treat-
ment.
In the case of elevated leukocyte values in urine
sediment combined with clinical symptoms, treatment
should be initiated. When dealing with pregnant pa-
tients, it is recommended to take aculture sample at
the start of treatment due to increased risk of prema-
ture birth associated with urinary tract infections as
well as limited antibiotic treatment options compatible
with pregnancy. Typical symptoms will still indicate the
need for treatment. In the absence of abnormal vaginal
discharge and burning sensation in the vulvar vesti-
bule, typical UTI symptoms lead to infection confirma-
tion in as many as 90% of young women [10, 11]. In 15%
of cases, urine cultures are positive in spite of elevated
leukocyte count in the urinalysis [3].
Characteristic patient groups
The main reasons behind the increased prevalence
of urinary tract infections in peri- and postmenopausal
women include hormonal changes (oestrogen insuf-
ficiency) and connective tissue aging (urinary incon-
tinence, pelvic organ prolapse). Factors conducive to
UTIs in the perimenopausal period include urinary in-
continence (impeding proper hygiene), atrophy of vag-
inal mucous membranes (increasing the risk of vaginal
infections that may spread into the urinary tract), and
anterior vaginal prolapse (precluding complete voiding
of the bladder). Prevalence of asymptomatic bacteri-
uria increases in the peri- and postmenopausal period,
reaching levels of 4–19% as compared to 1.5% in pre-
menopausal women [12]. In peri- and postmenopausal
women, oestrogen deficiency may be conducive to both
urinary incontinence and urinary tract infections. Topi-
cal vaginal (but not systemic) application of oestrogens
was proven to significantly reduce the risk of bacte-
riuria (OR = 0.3; 95% CI: 0.13–0.68) [13]. The recom-
mendation of topical oestrogen use in peri- and post-
menopausal patients to prevent UTIs is also included in
guidelines published by research associations [14].
Diabetes constitutes asignificant UTI risk factor for
postmenopausal women [15, 16]. Studies involving ato-
tal of 256,725 females with type 2 diabetes showed sig-
nificantly more prevalent UTI diagnoses starting from
ages 45–49 years onward, with the difference as high
as 100% in the said age range and yet another 80% for
those aged 50–54 years [16]. Another study compared
2 groups of women aged 55–75 years diagnosed with
acute UTI – 901 diabetic patients and 913 controls [15].
Diabetes in postmenopausal women turned out to in-
crease UTI risk twofold (OR = 2.2; 95% CI: 1.5–3.1). Sig-
nificant factors included oral pharmacotherapy or in-
sulin treatment (OR 2.8 and 2.7, respectively) and type
2 diabetes (OR = 2.2). Disease duration and glycaemia
control assessed by glycated haemoglobin HbA1c levels
turned out not to be significant. In patients 57 years
and older, undergoing surgical treatment constitutes
yet another risk factor for UTIs [17].
Diabetes mellitus, uncontrolled in particular, is arisk
factor for both urinary and reproductive tract infections
(involving the vulva, vulvar vestibule, and/or vagina).
Fourteen per cent of women with type 1 diabetes and
23% of women with type 2 diabetes are diagnosed with
UTIs [18]. The most significant risk factors in this group
include glycaemia control and glycosuria. Infections are
also more prevalent in perimenopausal patients with
longer disease duration. In awell-documented trial in-
volving 1357 female patients with type 1 diabetes, in-
creased prevalence was observed for the following: acute
cystitis (OR = 1.46; 95% CI: 1.10–1.95; p = 0.001), acute
vaginitis (OR = 1.20; 95% CI: 1.01–1.42; p = 0.044), and
acute vulvitis (OR = 2.12; 95% CI: 1.56–2.90; p < 0.001)
[10]. In agroup of 241 women with type 1 diabetes, the
most significant risk factors for symptomatic infections
included sexual intercourse, use of oral contraceptives,
and microangiopathy [18]. Urinary incontinence, more
prevalent in diabetic females than in the general pop-
ulation, may be another contributing factor (OR = 1.64;
95% CI: 1.19–2.26; p = 0.001) [10]. In type 2 diabetes,
asymptomatic bacteriuria is more frequent than in
healthy controls (17.5% vs. 10%, p = 0.015). Asympto-
matic bacteriuria may progress to symptomatic UTI in
20% of patients during 6 months [19, 20]. In another
study of 348 women with type 2 diabetes, asympto-
matic bacteriuria also constituted the primary risk fac-
tor for developing asymptomatic infection [18]. It may
also lead to decreased renal function [21]. The available
data suggest that periodic urine cultures in diabetic pa-
tients, in particular those with type 2 diabetes, should
be recommended.
Epileptic patients were also recognized as requiring
more frequent UTI treatment than the general popula-
tion [22], with the problem affecting around 58% wo-
men and 42% diagnosed with epilepsy (p < 0.0001). An
analysis of reasons revealed that the most significant
cause underlying the increased UTI prevalence in this
population were anti-epileptic drugs. Urinary tract in-
fections occurred more frequently in patients using
phenytoin (OR = 1.78; 95% CI: 1.24–2.55; p = 0.001),
M R/P M 20(1) 2021
42
primidone (OR = 1.73; 95% CI: 1.21–2.49; p = 0.002), car-
bamazepine (OR = 1.61; 95% CI: 1.33–1.96; p < 0.0001),
and valproate (OR = 1.52; 95% CI: 1.28–1.82; p < 0.0001),
probably due to their immunomodulating properties.
The said studies suggest the need to carefully plan
thera pies for epileptic patients with recurrent urinary
tract infections.
Another group with elevated UTI risk are patients
with indwelling urinary catheter or those requiring in-
termittent self-catheterization [23]. UTIs occur more
than once a year in 15.4% to 86.6% patients in that
group, with antiseptic product use probably reducing
the risk.
The perioperative period may also be conducive to
urinary tract infections [17]. Age above 57–60 years, dia-
betes, immunosuppressant therapy, obesity, and blood
transfusions due to iatrogenic all constitute additio-
nal risk factors in this case. Preventative administration
of antibiotics to patients catheterized for surgery with
diagnosed asymptomatic bacteriuria significantly re-
duces the risk of progression to symptomatic infection
(RR = 0.20; 95% CI: 0.13–0.31) [24]. Female patients
are catheterized for avast majority of surgeries due to
their reproductive anatomy. In the case of caesarean
sections, the catheter may stay in for afew hours af-
ter block anaesthesia, while with gynaecological proce-
dures it typically stays in for around 24 hours. Surgical
repairs of pelvic organ prolapse are an exception, how-
ever, requiring catheterization for 2–3 days at times.
Pregnancy is accompanied by a series of factors
conducive to urinary tract infections – the urine is
more basic in pregnant women, urine flow obstruction
is more common (especially towards the end of preg-
nancy), as is proteinuria, diabetes, and anaemia. Taking
aurinalysis sample is more difficult, in particular in the
3rd trimester, resulting in protein and bacteria detected
in the samples that do not always signify an infection
– typically these result from sample contamination by
vaginal secretions. Protein may originate from mucus
contamination, but in hypertensive patients it suggests
proteinuria characteristic of preeclampsia. Multiple
bacteria in the field of view when analysing urine se-
diment are typically lactic acid bacteria if the reading
is not accompanied by elevated leukocyte count, with
the latter constituting akey factor for differential diag-
nosis against UTI in apregnant patient. Asymptomatic
urinary tract infections affect 2–8% of pregnant wom-
en [25]. According to other sources, UTIs constitute the
most common infections of pregnancy, diagnosed in as
many as 50–60% of all pregnant women [26]. Research
results suggest an increased prevalence of preterm
birth associated with asymptomatic bacteriuria [27].
UTI is diagnosed more frequently in women with ges-
tation-induced hypertension, and as such it is linked
to increased risk of intrauterine growth restriction,
premature birth, and caesarean section [28]. It must
be remembered, however, that aUTI diagnosis in itself
does not necessitate any specific obstetric intervention.
Recurrent urinary tract infections affect 1 in 4 pregnant
women diagnosed with UTI and lead to pyelonephritis
in 4–5% of cases [25]. UTI in apregnant woman was
also found to constitute asignificant risk factor with
regard to the child’s UTI, at 30% vs. 6.8% (OR = 5.9 at
95% CI: 1.9–18.3; p = 0.001) [29].
Bacteria identification key to therapy
selection
Studies analysing the typology of pathogens cau-
sing urinary tract infections in non-diabetic patients
quote Escherichia coli (69%), Enterococcus sp. (10%),
Klebsiella sp. (4%), Pseudomonas aeruginosa (4%), Pro-
teus sp. (4%), and Staphylococcus sp. (2%) as the most
prevalent bacteria [30, 31]. For diabetic patients, the
most typical pathogens observed were Escherichia coli
(71%), Klebsiella spp (6%), Staphylococcus spp (5%), and
Enterococcus spp (4%) [31]. In pregnant women, urinary
tract infections are usually caused by Escherichia coli
(30.8–90%), bacteria from the Staphylococcus genus
(4.3–32%), Proteus mirabilis (10.2%), Enterococcus fae-
calis (1–8.1%), and Klebsiella pneumoniae (6.1–9.1%)
[25, 26, 32]. In infants, the most common pathogens
included Escherichia coli (65.9%), Klebsiella (14.6%), and
Staphylococci (9.8%) [29].
Antibiotic treatment
French guidelines issued by the French Language
Infectious Pathology Society recommend sequential ad-
ministration of fosfomycin, nitrofurantoin, and quinolo-
nes to treat cystitis, and third-generation cephalospo-
rins to treat pyelonephritis [33].
Antibiotic dosages proposed by international asso-
ciations are included in the Table 1 [14].
Any treatment of pregnant patients with asymp-
tomatic bacteriuria should be targeted, requiring
a urine culture antibiogram prior to treatment initia-
tion. In acute cases treatment should be initiated while
waiting for culture results. Cephalosporins are the drug
of choice in pregnant patients. Kashif et al. [25] suggest
particular caution when treating pregnant women with
nitrofurantoin (because it may cause haemolytic dis-
ease of the foetus), augmentin (necrotizing enterocoli-
tis was observed in foetuses in the 3rd trimester), and
trimethoprim (folic acid antagonist). Between 7 and
10 days after treatment course completion a repeat
urine culture should be taken to confirm treatment ef-
ficacy. Single-dose fosfomycin can be agood treatment
alternative. Ameta-analysis published in 2020 showed
its efficacy to match that of other antibiotics while
M R/P M 20(1) 2021
43
maintaining high safety levels both in pregnant and
non-pregnant patients [34].
Studies by Malmartel et al. [31] analysed the preva-
lence of antibiotic-resistant bacteria causing urinary
tract infections. Resistance to ofloxacin and cefixime
was slightly higher in diabetic patients, see data in
Table 2.
Non-antibiotic prophylactic treatment –
immunomodulation
OM-89 is an immunomodulatory drug [11, 36]. It is
effective against Escherichia coli infections, constitu-
ting 70–80% of all urinary tract infections. Women with
recurring urinary tract infections treated with OM-89
for 6 months had atwofold reduced further recurrence
rate (67.3% vs. 32.7%) [37]. Uncontrolled diabetes sig-
nificantly reduced the treatment efficacy, however. In
Table 1. Proposed antibiotic dosage (based on guidelines published by the American Urological Association, Canadian Urological
Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, and the European Urological Society)
Indication Antibiotic Dosage Treatment duration
Prophylaxis in asymptomatic
bacteriuria; continuous
treatment
Trimethoprim 100 mg 1× aday
Trimethoprim + sulfamethoxazole 40–200 mg 1× aday
40–200 mg 3× aweek
Nitrofurantoin 50–100 mg aday
Cephalexin 125–250 mg 1x aday
Fosfomycin 3 g every 10 days
Prophylaxis in asymptomatic
bacteriuria; periodic treatment
Trimethoprim + sulfamethoxazole 40/200 mg
80/400 mg
Nitrofurantoin 50–100 mg
Cephalexin 250 mg
Uncomplicated cystitis Fosfomycin 3 g For 1 day
Nitrofurantoin 50–100 mg aday For 5 days
Extended-release nitrofurantoin 100 mg 2× aday For 5 days
Pivampicillin 400 mg 3× aday For 3–5 days
Cephalosporins 500 mg 2× aday For 3 days
Trimethoprim + sulfamethoxazole 80/400 mg 2× aday For 3 days
Trimethoprim 100 mg 2× aday For 3–5 days
Complicated cystitis Ciprofloxacin 500–750 mg 2× aday For 7 days
Levofloxacin 750 mg aday For 5 days
Trimethoprim + sulfamethoxazole 160/800 mg 2× aday For 14 days
Cefpodoxime 200 mg 2× aday For 10 days
Ceftibuten 400 mg aday For 10 days
Pyelonephritis, parenteral
therapy
1st line of treatment
Ciprofloxacin 400 mg 2× aday
Levofloxacin 750 mg aday
Cefotaxime 2 g 3x aday
Ceftriaxone 1–2 g aday
Pyelonephritis, parenteral
therapy
2nd line of treatment
Cefepime 1–2 g 2× aday
Piperacillin/tazobactam 2.5–4.5 g 3× aday
Gentamycin 5 mg/kg aday
Amikacin 15 mg/kg aday
Not all antibiotics are available in Poland.
Table 2. Percentage of strains resistant to selected antibiotics
Antibiotic Percentage of resistant strains
In study by
Malmartel [31]
According to
NICE guidelines [23]
Ofloxacin 10.8%
Cefixime 3.8% 9.9%
Trimethoprim,
sulfamethoxazole
16.8% 30.3%
Nitrofurantoin 4.05% 2.5%
Fosfomycin 3.2%
Pivampicillin 7.5%
NICE – National Institute for Health and Care Excellence
amulti-centre double blind study involving 453 women,
a34% reduction of urinary tract infections was observed
after 3 months of initial treatment and a10-day boos-
ter course of OM-89 [30]. The same treatment structure
M R/P M 20(1) 2021
44
was utilized in aretrospective study of 79 patients, with
Escherichia coli identified as the main pathogen in 49%
of the population [11]. Sixty-three per cent of those in-
fected with Escherichia coli and 53% of the whole popu-
lation had apositive response to treatment.
OM-89 efficacy was also confirmed in a study in-
volving menopausal women. Aclinical trial was carried
out with a group of patients aged 66 years on aver-
age. The number of recurrent infections in the group
dropped from 3.4 to 1.8 (areduction of 65%) after the
immunomodulatory treatment [38].
OM-89 oral immunomodulatory treatment for the
prevention of recurring UTIs is recommended both by the
European Association of Urology (EAU) in uncomplicated
UTIs in women (strong evidence, highest recommenda-
tion level, 1a) [12] and by the Polish Association of Urolo-
gy in prevention of recurring urinary tract infections. The
treatment helps reduce the frequency of recurring infec-
tions, patients’ symptoms, antibiotic prescriptions, and
the risk of antibiotic resistance [39]. To prevent recurring
UTIs, OM-89 is administered once aday before ameal,
for atotal of 90 days. The drug can be used in parallel
with antibiotic treatment during the acute phase of an
infection, without prior urine culture results, because it
induces astrong immune response not only to E. coli, but
also to other pathogens causing UTIs.
OM-89 is characterized by the highest level of
evidence of all non-antibiotic methods of UTI preven-
tion [12].
Other non-antibiotic methods
of prevention
In accordance with the 2017 Cochrane database
analysis [40], the impact of probiotics on reducing uri-
nary tract infections in patients with bladder function
disorders requires further research.
In vitro studies have shown that cranberry juice re-
duces adherence of Escherichia coli bacteria to the uri-
nary tract and vaginal epithelium [41, 42]. As aresult,
patients’ symptoms associated with bacterial irritation
should be relieved. Reduced symptom levels, however,
are not equivalent to infection eradication. Prospec-
tive randomized trials with women aged 18–45 years
did not detect any statistically significant difference in
UTI prevalence diagnosed by urine cultures between
groups drinking cranberry juice and those drinking pla-
cebo [43]. Similar conclusions were presented in aCo-
chrane analysis published in 2012 [44].
Treatment of chronic urinary tract infections and
preventing further recurrences is yet another challenge.
D-mannose was found to be efficient in preventing re-
curring UTIs by reducing bacterial adherence to urinary
tract epithelium. Ameta-analysis published in 2020 in-
cluded 8 papers overall, but the final results were based
on data from merely 163 patients [35]. The results are
promising, but further research is necessary to deter-
mine the optimum dosage and treatment duration.
Antibiotic prophylaxis
Some doctors recommend long-term prophylactic
use of antibiotics in women with recurring urinary tract
infections. ACochrane meta-analysis indicated positive
outcomes of prophylactic use of antibiotics in young
women with recurring UTIs [45]. Results published by
Ahmed et al. [46], however, show that long-term antibio-
tic prophylaxis had positive outcomes in patients aged
65 years and above only when continued for more than
2 years. The patients received nitrofurantoin, cephale-
xin, or trimethoprim. The treatment reduced the fre-
quency of recurring symptomatic urinary tract infections
(OR = 0.57; 95% CI: 0.55–0.59) and the need for ad-
ditional antibiotic prescriptions (OR = 0.61; 95% CI:
0.59–0.62). At the same time, asmall but statistically
significant increase of hospitalizations due to UTIs was
observed (OR = 1.16; 95% CI: 1.05–1.28).
According to EAU guidelines, antibiotic prophylaxis
should be introduced when neither behavioural inter-
ventions nor non-antibiotic prevention is successful.
International and domestic
recommendations
According to American Urological Association (AUA),
Canadian Urological Association (CUA), and Society of
Urodynamics (SUFU), Female Pelvic Medicine, and Uro-
genital Reconstruction guidelines, most recommenda-
tions are classified as level B or C [14]. Diagnosis of recur-
ring UTI should always be confirmed by aurine culture.
Prior to treatment initiation, the practitioner should re-
view urinalysis and urine culture results. In case of very
severe symptoms, however, antibiotic treatment may
be initiated while waiting for laboratory test results. As-
ymptomatic bacteriuria should not be treated; it does
not necessitate urinalyses or urine cultures, either. Anti-
biotic treatment of symptomatic UTI (with nitrofuranto-
in, trimethoprim-sulfamethoxazole, and fosfomycin as
the first line of treatment) should follow the results of
an antibiogram. Antibiotic treatment should not exceed
7 days, and it may be administered parenterally when-
ever required. If symptoms recede, no post-treatment
laboratory tests are required. If symptoms persist, are-
peat urine culture should be carried out to guide further
treatment. Topical vaginal administration of oestrogens
is recommended in post- and perimenopausal women
(unless there are contraindications). In accordance with
the WHO plan to counteract inducing excessive antibi-
otic resistance, the aforementioned research associa-
tions permit prophylactic use of cranberry and other
alternative therapies.
M R/P M 20(1) 2021
45
European Association of Urology guidelines are com-
plete with anote providing acurrent literature review
[12]. The strength levels of the recommendations were
also provided. The authors recommend not diagnosing
or treating asymptomatic bacteriuria with the exception
of pregnant patients (weak recommendation) and pa-
tients with discontinuity of mucous membranes of the
bladder (strong recommendation). When considering
an uncomplicated urinary tract infection, the diagnosis
should be based on clinical symptoms in the absence of
vaginal infection. Urinary culture is recommended only
when considering adiagnosis of acute pyelonephritis,
dealing with pregnant patients, and women with uncon-
ventional presentation of symptoms or symptoms not
receding within four weeks after treatment completion.
The first line of treatment should include fosfomycin,
pivampicillin, or nitrofurantoin. Treatment of uncompli-
cated cystitis with aminopenicillins or fluoroquinolones
is not recommended (strong recommendation). The
authors indicated that using test strips to diagnose un-
complicated cystitis carried low strength of evidence.
Diagnosis of recurring UTI must be confirmed by urine
culture with antibiogram. Non-antibiotic prevention of
recurring infections should involve, as the first line of
treatment, behavioural interventions and OM-89 im-
mune system stimulation.
Antibiotic prophylaxis is only recommended in the
case of UTI recurring in spite of non-antibiotic preven-
tion – antibacterial prophylaxis after sexual intercourse,
periodic short-term antibacterial treatment in women
for whom the treatment was successful (strong recom-
mendation). At the same time, the recommendation
to treat postmenopausal women with oestrogens and
introduce behavioural modifications, and the wide use
of imaging technologies in women with uncomplica-
ted cystitis was classified as weak in terms of evidence.
Urinalysis (laboratory based or strip test), urine culture,
and imaging are recommended in all cases of pyelo-
nephritis. The authors of the guidelines recommend
treatment of uncomplicated pyelonephritis with short
courses of fluoroquinolones and hospitalization only in
the case of parenteral antibiotic administration, until
the patient can be converted to an oral route. At the
same time, treatment with nitrofurantoin, fosfomycin,
or pivampicillin is not recommended (strong recom-
mendation). In the case of complicated recurring pyelo-
nephritis, aminoglycosides combined with amoxicillin
or second-generation cephalosporin is recommended.
Another option is intravenous treatment with third-gen-
eration cephalosporin in the case of generalized symp-
toms emerging. Ciprofloxacin is only recommended
for oral treatment of cases that do not require hospi-
talization, or for patients with known allergies to the
other available antibiotics. Ciprofloxacin and other flu-
oroquinolones are contraindicated if the patient has
received them in the past 6 months (strong recommen-
dation). The authors do not recommend routine antibio-
tic treatment in patients after catheter removal.
The British committee National Institute for Health
and Care Excellence guidelines published in 2020 dis-
cuss treatment of lower urinary tract infections [47].
Outside of pregnancy, a3-day treatment course is as ef-
fective as 5-day or 10-day courses. In older women, the
treatment may continue for 3 to 6 days. Nitrofurantoin
or trimethoprim is the recommended first-line treat-
ment, with fosfomycin or pivampicillin constituting the
second line of treatment. Pregnant patients should be
treated for 7 days, making sure that, prior to treatment
initiation, no antibiotic resistance to the selected drug
has been observed in the past. Drugs recommended in
cases of asymptomatic bacteriuria include nitrofuran-
toin, amoxicillin, and cefalexin, and in the case of symp-
tomatic infections – amoxicillin or cefalexin.
Polish guidelines for the diagnosis, treatment and
prevention of urinary tract infections in adults were de-
veloped in 2015 under the National Antibiotic Protec-
tion Program [48]. Asymptomatic bacteriuria requires
treatment with antibiotics only during and before sur-
gery of the urinary system. Treatment of acute uncom-
plicated cystitis in young women can be undertaken
based on clinical symptoms. In such cases the diagnosis
does not require laboratory test results, such as urine
sediment test or urine culture. Most patients may re-
ceive outpatient treatment. According to the guidelines,
evidence-based treatment of uncomplicated cystitis
should not involve fluoroquinolones. These should be
limited to treatment of complicated or severe cases. In
the case of recurrence, aurine culture should be taken
together with evidence-based antibiotic treatment ini-
tiated while waiting for laboratory test results. In the
case of complicated UTIs, the following tests should
be carried out: urinalysis, blood panel, CRP, creatinine
concentration, GRF, and urine culture. Treatment should
be modified in line with antibiogram results. Acute py-
elonephritis diagnosed based on clinical presentation
should always be confirmed by aurine culture, accom-
panied by a blood culture for more severe cases. Ini-
tial evidence-based treatment should be modified to
account for culture results. For pregnant patients, the
authors recommend aurine culture in the first trimes-
ter of pregnancy, to prevent pyelonephritis and prema-
ture birth risk. In the case of cystitis in the patient’s
history, repeat urine cultures should be taken every
1–2 months. Fluoroquinolones are contraindicated
throughout the pregnancy, and co-trimoxazole should
not be used in the first trimester.
Conclusions
Urinary tract infection is one of the most common
infections afflicting women. UTI occurs in females at
any age, with the highest prevalence in pregnant and
M R/P M 20(1) 2021
46
postmenopausal patients. UTI often accompanies vagi-
nal infections and is frequently caused by pathogens
originating in the final section of the digestive tract. An-
tibiotic treatment duration should be minimized, with
the exact dosage and time schedule depending on the
type of infection.
Asymptomatic bacteriuria does not always require
antibiotic treatment, because their excessive use may
lead to the emergence of antibiotic resistant strains.
When dealing with chronic infections and asympto-
matic bacteriuria, alternative treatment to reduce the
risk of recurrence should always be considered.
For recurrent urinary tract infections, non-antibiotic
prevention is recommended as the first line of treat-
ment, based on behavioural interventions and immune
system modulation.
Disclosure
The authors report no conflict of interest.
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