Recurrent Uncomplicated Urinary Tract Infections in Women

Publication Date: May 1, 2019
Last Updated: March 14, 2022

Guideline Statements


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, C)
6. Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures. (Moderate, C)

Asymptomatic Bacteriuria

7. Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. (Moderate, C)
8. Clinicians should not treat ASB in patients. (Strong, 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, 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, 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. (Moderate, B)

Non–Antibiotic Prophylaxis

13. Clinicians may offer cranberry prophylaxis for women with rUTIs. (Conditional, 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 , )


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, B)

Recommendation Grading



Recurrent Uncomplicated Urinary Tract Infections in Women

Authoring Organizations

Publication Month/Year

May 1, 2019

Last Updated Month/Year

June 12, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

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.

Inclusion Criteria

Female, Adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Prevention, Treatment

Diseases/Conditions (MeSH)

D014552 - Urinary Tract Infections


bacteriuria, urinary tract infection (UTI), urinary tract infection, Acute bacterial cystitis

Supplemental Methodology Resources

Methodology Supplement