Recurrent UTIs can be frustrating for patients…and challenging for healthcare teams trying to balance effective treatment with antibiotic stewardship.
In this episode, TRC Healthcare Associate Editor and Clinical Pharmacist Don Weinberger, PharmD, PMSP, walks through evidence-based strategies for managing uncomplicated recurrent urinary tract infections, or UTIs, in women. He reviews first-line treatment options such as nitrofurantoin, prevention strategies including hydration and cranberry products, and provides guidance around prophylactic antibiotic use.
This is an excerpt from our June 2026 Pharmacy Essential Updates continuing education webinar series.
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Transcript:
This transcript is automatically generated.
00:00:00 Narrator
When a patient’s third UTI hits in four months, is the antibiotic even the real problem?
00:00:05 Narrator
Why is amoxicillin alone no longer recommended for uncomplicated UTIs?
00:00:15 Narrator
Welcome to Clinical Capsules from TRC Healthcare, your trusted source for practical, evidence-based updates.
00:00:21 Narrator
On this episode, Associate Editor and Clinical Pharmacist Don Weinberger reviews practical treatment and prevention strategies for recurrent, uncomplicated UTIs in women, including first-line antibiotics, non-antibiotic options, and key counseling pearls, in an excerpt from our popular Pharmacy Essential Updates webinar series.
00:00:41 Narrator
This podcast offers continuing education credit for pharmacists and pharmacy technicians.
00:00:45 Narrator
Please log into your pharmacist letter or pharmacy technician’s letter account and look for the title of this podcast in the list of available CE courses.
00:00:53 Narrator
None of the speakers have anything to disclose.
00:00:56 Narrator
Catch new episodes of Clinical Capsules every second and 4th Tuesday, bringing concise, actionable insights from TRC experts straight to your ears.
00:01:04 Narrator
With that, let’s get started.
00:01:11 Don Weinberger
We’re talking about this today because updated guidelines provide tips on how to treat and prevent uncomplicated recurrent urinary tract infections in women.
00:01:22 Don Weinberger
Let’s start off with a case.
00:01:25 Don Weinberger
One of your regular patients comes into your pharmacy picking up another nitrofurantoin prescription for a third urinary tract infection in the past four months.
00:01:35 Don Weinberger
At this point, she wants to know if this med is the right one, since this is the third UTI in a short amount of time.
00:01:42 Don Weinberger
But also, what could she be doing to prevent these from happening over and over?
00:01:48 Don Weinberger
Well, what should she know?
00:01:51 Don Weinberger
Before we talk treatment and prevention, let’s get squared away and ensure we’re all working from the same definition.
00:01:59 Don Weinberger
An uncomplicated recurrent urinary tract infection, sometimes you’ll see it as RUTI, is defined as a bacterial infection of the bladder and/or urethra in female non-pregnant patients.
00:02:13 Don Weinberger
The recurrent part links to the frequency, which in this case would be two or more infections in the past six months or three or more in 12 months.
00:02:24 Don Weinberger
As far as the bacteria is concerned, E. coli is the one driving the majority of these cases.
00:02:30 Don Weinberger
And about 80% of recurrences are actually reinfections.
00:02:35 Don Weinberger
The distinction is that it’s a new infection episode, not a persistent or relapsing one.
00:02:41 Don Weinberger
That distinction matters for patients who assume they never got better from the previous infection.
00:02:46 Don Weinberger
So for some of the increased risks of these type of UTIs, these include patients with cases of UTIs during childhood, menopausal vaginal atrophy or shrinking, or incomplete bladder emptying.
00:03:03 Don Weinberger
So with that foundation set, let’s look at how we approach management.
00:03:10 Don Weinberger
While we’re just talking about uncomplicated urinary tract infections, some of you may be asking about, well, what about complicated urinary tract infections?
00:03:18 Don Weinberger
So let’s go ahead and settle this now.
00:03:21 Don Weinberger
Uncomplicated or complicated, patients will experience classic symptoms like burning or pain with urination, urinary urgency, abdominal discomforts, blood in the urine, or even some urinary discharge.
00:03:35 Don Weinberger
Now, what makes something complicated?
00:03:37 Don Weinberger
Well, if patients report fever, chills, flank or lower back pain, low blood pressure, or signs of a blood infection like sepsis.
00:03:48 Don Weinberger
Well, that is the red flag for a likely complicated UTI.
00:03:53 Don Weinberger
Those symptoms suggest an upper urinary tract involvement, like with the kidneys, or more of a systemic spread, and that patients may need more than a standard UTI treatment plan.
00:04:04 Don Weinberger
Again, we are just going to go over the uncomplicated, but I want to make that distinction known.
00:04:11 Don Weinberger
So with an established bacterial uncomplicated urinary tract infection, we can help guide the proper treatment while also keeping antibiotic stewardship in mind.
00:04:24 Don Weinberger
For uncomplicated UTIs, we have several antibiotic options, so let’s flow through them now.
00:04:31 Don Weinberger
First-line agents include nitrofurantoin, trimethoprim sulfamethoxazole, and fosfomycin.
00:04:38 Don Weinberger
These are preferred for their efficacy, favorable resistant profiles, and targeted activity in the lower urinary tract.
00:04:46 Don Weinberger
Let’s go over where each of these first-line choices fit in.
00:04:51 Don Weinberger
Okay, so trimethoprim sulfamethoxazole is one of the go-to options for uncomplicated UTIs.
00:04:58 Don Weinberger
Typical dose is double strength, which is 160 milligrams per 800 milligrams, twice daily for three days.
00:05:06 Don Weinberger
A couple things to flag, though.
00:05:08 Don Weinberger
If your patient is on an ACE inhibitor like lisinopril or an ARB like losartan, or taking potassium supplements, there’s a risk of potassium levels climbing too high while taking trimethoprim sulfamethoxazole.
00:05:21 Don Weinberger
Also, if they’re on warfarin, this antibiotic can throw off their INR unpredictably.
00:05:26 Don Weinberger
So the warfarin dosing may need to be adjusted.
00:05:29 Don Weinberger
If the patient has severe kidney failure, use with caution or consider a different agent altogether.
00:05:39 Don Weinberger
Okay, so the next one is nitrofurantoin.
00:05:42 Don Weinberger
As everybody knows, it comes in two formulations and they are not interchangeable.
00:05:46 Don Weinberger
First one, brand name is Macrobid, which is the monohydrate macrocrystals form.
00:05:52 Don Weinberger
That one is dosed 100 milligrams twice daily for five days.
00:05:56 Don Weinberger
It’s preferred because that twice daily dosing is easier for patients to stick to versus the next crystal form, which is macrocrystals only, brand name Macrodantin.
00:06:08 Don Weinberger
That one is 50 to 100 milligrams every six hours for five days.
00:06:12 Don Weinberger
Similar drug, more frequent dosing.
00:06:16 Don Weinberger
Always warn patients with auxiliary labels that urine may turn dark yellow or brown.
00:06:22 Don Weinberger
This can catch patients off guard.
00:06:25 Don Weinberger
And mix-ups between these two are common.
00:06:27 Don Weinberger
I admit I have mixed this up before in the past.
00:06:30 Don Weinberger
So use barcode scanning and NDC checks every single time.
00:06:36 Don Weinberger
And also ask about kidney function.
00:06:38 Don Weinberger
This med generally should be avoided if the creatinine clearance is between 30 to 60 mL per minute for fear of increased adverse reactions from drug buildup.
00:06:50 Don Weinberger
When adherence may be a concern, fosfomycin has a key advantage.
00:06:55 Don Weinberger
It’s just one dose.
00:06:57 Don Weinberger
3 grams, one packet, done.
00:07:00 Don Weinberger
Ensure patients take correctly, though.
00:07:01 Don Weinberger
Dissolve the full packet in 3 to 4 ounces of cool or room temperature water and drink it immediately.
00:07:07 Don Weinberger
There is no stability data if hot water is used.
00:07:11 Don Weinberger
Just keep in mind, fosfomycin is usually more costly than the other first-line options, so it’s worth checking coverage before it gets to the patient.
00:07:21 Don Weinberger
Okay, let’s go ahead and go to these other options now, beta-lactams, quinolones, and those newer agents.
00:07:30 Don Weinberger
So 2 common beta-lactam options include amoxicillin clavulanate and cephalexin.
00:07:38 Don Weinberger
So that amoxicillin clavulanate can be dosed, either 500 per 125 every 12 hours, or 250 per 125 every 8 hours, typically three to seven days.
00:07:52 Don Weinberger
Cephalexin runs 250 milligrams every six hours or 500 milligrams every 12 hours for three days.
00:07:58 Don Weinberger
A few things to flag.
00:08:01 Don Weinberger
Amoxicillin alone is no longer recommended.
00:08:05 Don Weinberger
Resistance from E. coli has made it less effective on its own.
00:08:09 Don Weinberger
And as you know, for both drugs, always screen for those penicillin allergies.
00:08:17 Don Weinberger
Urinary quinolones like ciprofloxacin or levofloxacin are reserved as a last resort for UTIs because of resistance and side effects.
00:08:30 Don Weinberger
The dosing, ciprofloxacin 250 milligrams every 12 hours for three days, or levofloxacin 250 milligrams every 24 hours for three days.
00:08:42 Don Weinberger
Patients need to know about the black box warnings like tendon rupture risk, photosensitivity, and QTc prolongation.
00:08:48 Don Weinberger
Those are real concerns.
00:08:50 Don Weinberger
Patients should separate quinolones from dairy, calcium, magnesium, iron elements by at least two to six hours, or the drug won’t absorb properly.
00:08:57 Don Weinberger
All right, so let’s look at those newer agents I mentioned earlier for uncomplicated UTIs.
00:09:07 Don Weinberger
We have gepotidacin, which is a first-in-class triazaacenaphthylene antibiotic dosed twice daily for five days.
00:09:17 Don Weinberger
The key counseling point, it carries a QTc prolongation risk.
00:09:23 Don Weinberger
The next one we have is pivmecillinam, and that’s an extended-spectrum penicillin.
00:09:30 Don Weinberger
Dosed three times daily for three to seven days.
00:09:33 Don Weinberger
Cross-reactivity with penicillin allergies is low, but you still use with caution in patients with that true penicillin allergy.
00:09:43 Don Weinberger
So flag uncomplicated UTI prescriptions running beyond seven days, or if they escalate the dose beyond what was said earlier.
00:09:53 Don Weinberger
Evidence doesn’t support these approaches, and they may drive resistance.
00:09:58 Don Weinberger
So you see it, flag it.
00:10:01 Don Weinberger
And some general counseling points include recommending patients drink enough fluids, help prevent certain meds from sticking to the kidneys, and it’s just good advice for hydration and UTI prevention.
00:10:15 Don Weinberger
And we all know sharing is not caring when it comes to antibiotics.
00:10:20 Don Weinberger
Advise against sharing any antibiotic supply with others since it can increase resistance in the community.
00:10:26 Don Weinberger
Similarly, patients should properly dispose of any remaining antibiotics they have left over after their therapy.
00:10:35 Don Weinberger
Now, here’s where patients can help stop UTIs before they have a chance to start.
00:10:43 Don Weinberger
There are simple lifestyle changes that can make a real difference in preventing recurring UTIs.
00:10:48 Don Weinberger
First, avoid spermicides.
00:10:51 Don Weinberger
They can disrupt vaginal flora and significantly raise UTI risk.
00:10:56 Don Weinberger
Second, stay hydrated.
00:10:58 Don Weinberger
This could be at least 1.5 to 2 liters of water daily.
00:11:02 Don Weinberger
This can help dilute urine and flush out bacteria before they can take hold.
00:11:06 Don Weinberger
And third, don’t hold it.
00:11:08 Don Weinberger
Regular, complete bladder emptying removes bacteria before they have a chance to multiply.
00:11:15 Don Weinberger
Along with lifestyle changes, other measures can be tried.
00:11:18 Don Weinberger
Cranberry is one of the most well-known non-antibiotic options for recurrent UTI prevention.
00:11:24 Don Weinberger
It works by containing compounds called proanthocyanidins, which stop bacteria from sticking to the bladder lining in the 1st place.
00:11:31 Don Weinberger
It could be taken a couple ways, 8 ounces of low sugar or unsweetened juice daily, or a 500 milligram capsule once a day.
00:11:41 Don Weinberger
And overall, cranberry can reduce UTI risk by about 30%.
00:11:45 Don Weinberger
It’s not a treatment, but as a preventative tool, it’s worth recommending.
00:11:52 Don Weinberger
Okay, so the next one is methenamine.
00:11:55 Don Weinberger
And that’s a non-antibiotic option for prevention.
00:11:57 Don Weinberger
And here’s how it works.
00:11:59 Don Weinberger
Once it hits the urine, it converts to formaldehyde, which kills bacteria directly in the bladder.
00:12:05 Don Weinberger
Keep in mind there are two salt forms, the hippurate and the mandelate.
00:12:08 Don Weinberger
The hippurate is the one to point to.
00:12:11 Don Weinberger
It’s dosed 1 gram twice daily, and the mandelate has less data, has to be taken four times daily, and predates modern FDA requirements.
00:12:22 Don Weinberger
So in peri- and post-menopausal women, declining estrogen can lead to vaginal atrophy, and that can lead to loss of protective vaginal flora.
00:12:31 Don Weinberger
And that opens a door for E. coli to move in and trigger recurring UTIs.
00:12:36 Don Weinberger
The good news, vaginal estrogen can help.
00:12:39 Don Weinberger
Meta-analyses showing that vaginal estrogen may lower recurrent UTI risk by about 60% in patients.
00:12:46 Don Weinberger
When it comes to treating vaginal atrophy with estrogen, the ring, cream, or tablet are effective options.
00:12:54 Don Weinberger
But the ring may have a convenient edge, since they’re once every 90 days, and it’s done.
00:13:00 Don Weinberger
But here’s a key difference, looking at the brand names.
00:13:04 Don Weinberger
Estring acts locally. Femring acts systemically.
00:13:08 Don Weinberger
Same dosage form, very different impact.
00:13:10 Don Weinberger
So remember, a ring is bigger than a string, so is its reach.
00:13:15 Don Weinberger
And just set the expectation.
00:13:18 Don Weinberger
It may take up to 12 weeks to see the full preventative benefit for recurrent UTIs with estrogen use.
00:13:27 Don Weinberger
When other preventative strategies haven’t worked, prophylactic antibiotics may be an option, but they come with trade-offs like resistance and side effects, so they’re not a first-line approach.
00:13:40 Don Weinberger
So daily low dose options include trimethoprim sulfamethoxazole 40 milligrams per 200 milligrams, cephalexin 125 or 250 milligrams, or nitrofurantoin 50 to 100 milligrams.
00:13:53 Don Weinberger
Regardless of the approach, courses should be limited to one year or less, again to minimize resistance.
00:14:01 Don Weinberger
And for patients whose UTIs are tied to sexual activity, a single pre- or post-coital antibiotic dose could be an effective targeted option.
00:14:09 Don Weinberger
So let’s bring it on home with some practical pearls specifically for pharmacy teams.
00:14:16 Don Weinberger
First, dig into the patient profile.
00:14:18 Don Weinberger
A history of frequent antibiotic fills, especially for UTIs, is a red flag.
00:14:23 Don Weinberger
It can tell you which antibiotics have already been tried, which to avoid, and whether this patient might benefit from a conversation about prevention.
00:14:32 Don Weinberger
Second, clarify the indication on the Rx.
00:14:35 Don Weinberger
Knowing why an antibiotic is prescribed lets you verify the right drug and the right dose.
00:14:40 Don Weinberger
UTI prescription looks very different from an Rx for a skin infection.
00:14:46 Don Weinberger
Third, double check quantities and durations.
00:14:49 Don Weinberger
A 10-day course of nitrofurantoin for an uncomplicated UTI.
00:14:53 Don Weinberger
That’s worth a flag.
00:14:55 Don Weinberger
If the quantity or duration looks off or longer than expected, loop in the pharmacist before it goes out the door.
00:15:02 Don Weinberger
All right, it’s back to our case.
00:15:07 Don Weinberger
We had this patient picking up nitrofurantoin.
00:15:09 Don Weinberger
Again, it’s her third UTI in the past four months.
00:15:12 Don Weinberger
She’s frustrated, understandably, and she wants to know, is this antibiotic actually working and how does she stop this from happening again?
00:15:22 Don Weinberger
So, antibiotic question, nitrofurantoin, as you know now, is appropriate for uncomplicated UTIs, but three infections in four months tells us treatment alone isn’t the answer.
00:15:34 Don Weinberger
She meets the definition of recurrent UTIs and prevention needs to be part of the conversation.
00:15:39 Don Weinberger
So what should she know?
00:15:42 Don Weinberger
As we establish, most recurring urinary tract infections are a reinfection, not necessarily a resolution from a previous infection.
00:15:52 Don Weinberger
Also, drink up.
00:15:54 Don Weinberger
At least 1.5 to 2 liters of water daily to flush bacteria out before they settle in, and don’t hold it.
00:16:01 Don Weinberger
Regular complete voiding of the bladder cuts off bacteria’s opportunity to grow and ditch the spermicides if she’s using them.
00:16:08 Don Weinberger
They’re likely a contributing factor.
00:16:11 Don Weinberger
Switching contraceptive methods could significantly reduce her risk.
00:16:16 Don Weinberger
Cranberry and methenamine can be tried and prophylactic antibiotics may be something she discusses with her prescriber if all else fails.
00:16:27 Don Weinberger
And I want to highlight a few resources we have available.
00:16:30 Don Weinberger
Use our urinary tract infections chart as a helpful guide for differentiating complicated and uncomplicated UTIs, medication options, dosing, and more.
00:16:40 Don Weinberger
It also covers more treatment options for recurrent UTIs as well as treating asymptomatic bacteriuria in pregnant patients.
00:16:50 Narrator
Thanks for listening.
00:16:51 Narrator
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00:16:56 Narrator
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00:17:00 Narrator
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00:17:07 Narrator
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00:17:12 Narrator
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