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uro.recurrent-uti-prophylaxis.v1

Recurrent UTI Prophylaxis & Long-term Management (adult women + postmenopausal + breakthrough)

urologychronicadultgeriatricoutpatienttransition
Start encounter →Print handoutPRODUCTION

shard-3-neuro-sym Phase C wave-11 2026-05-15 — initial author at INTEGRATED with full §5.5 contract depth. 10 prophylaxis phenotypes encoded as severity_triggers covering full recurrent UTI spectrum: postcoital_recurrent_UTI_women_postcoital_prophylaxis_TMP_SMX, recurrent_after_menopause_topical_vaginal_estrogen, recurrent_with_anatomic_abnormality_imaging_eval, recurrent_diabetic_postoperative, recurrent_immunocompromised, CYP_resistant_recurrent (avoid TMP-SMX if local R >20%), methenamine_hippurate_for_prophylaxis, cranberry_extract_low_quality_evidence, pediatric_recurrent_VUR_grade_3_to_5 (routes off to uro.uti.pediatric.v1), chronic_indwelling_catheter (routes off to uro.cauti.v1). 5 setting playbooks centred on home + outpatient (the primary prophylaxis settings); ED / inpatient / icu serve as breakthrough-episode routing to acute engines. AUA/CUA/SUFU 2019 doctrine: recurrent UTI = ≥2 culture-confirmed / 6 mo OR ≥3 / 12 mo. Prophylaxis options — continuous low-dose (TMP-SMX SS qhs or nitrofurantoin 50–100 mg qhs) × 6–12 mo trial; postcoital single dose (TMP-SMX SS or nitrofurantoin 50–100 mg within 2 h post-coital); self-start 3-d course on symptoms; topical vaginal estrogen (postmenopausal first-line adjunct); methenamine hippurate 1 g PO BID (ALTAR-supported); cranberry low-quality; behavioural. AVOID TMP-SMX prophylaxis if local E. coli resistance >20%. AVOID FQ for prophylaxis (FDA Black Box). AVOID continuous abx prophylaxis in chronic indwelling catheter (drives MDR + CDI; routes to uro.cauti.v1). Annual reassessment of continuous prophylaxis mandatory; trial off after 6–12 mo of symptom-free continuous prophylaxis. Sibling pivots: uro.uti.uncomplicated.v1 (acute episode of same patient), uro.uti.complicated.v1 (complicating factor overlay), uro.pyelonephritis.v1 (upper-tract acute), uro.cauti.v1 (chronic catheter routes off — same commit), uro.uti.pediatric.v1 (pediatric routes off — same commit), uro.urinary-incontinence-eval.v1 (dysfunctional voiding overlap) — all resolve to real engines in ALL_DOSSIERS. 2026-05-22 citation remediation — all PMIDs live-verified on PubMed; mis-attributed placeholders replaced with verified anchors; RxCUIs reverse-verified on RxNav. Dossier registered in _registry.ts as part of this commit (Phase C wave-11 commit-race v2; shard-3 explicit scope). Schema-blocked downstream: calc.recurrent_uti_risk_score, protocol.uti_self_start_3d_course, panel.vaginal_microbiome, workup.imaging_eval_recurrent_uti — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §10.

Entry points (8)

  • history
    ≥2 culture-confirmed UTI in 6 mo OR ≥3 in 12 mo (AUA/CUA/SUFU 2019 definition)
    recurrent_uti_2_in_6mo_or_3_in_12mo
  • history
    Recurrent UTI within days of intercourse — honeymoon pattern; postcoital prophylaxis candidate
    postcoital_uti_pattern
  • history
    Postmenopausal woman with recurrent UTI → topical vaginal estrogen first-line adjunct
    postmenopausal_with_recurrent_uti
  • history
    Breakthrough UTI on continuous or postcoital prophylaxis → switch agent + urology referral
    breakthrough_uti_on_prophylaxis
  • history
    Recurrent UTI in DM / postoperative state → glycemic control + reassess prophylaxis
    diabetic_or_postoperative_recurrent_uti
  • history
    Recurrent UTI in SOT, hematologic malignancy, HIV with low CD4, chronic steroid → ID consult + tailored prophylaxis
    immunocompromised_recurrent_uti
  • history
    Pediatric recurrent UTI with VUR grade III–V — routes off to uro.uti.pediatric.v1 (RIVUR / PRIVENT)
    pediatric_recurrent_uti_VUR_present
  • history
    Chronic indwelling catheter + recurrent UTI — routes off to uro.cauti.v1 (do NOT prophylax routinely)
    chronic_indwelling_catheter_recurrent_uti

Required inputs (20)

  • uti_episode_historyrequired
    history • used at CONTEXT
    Establish recurrent definition (≥2/6mo or ≥3/12mo culture-confirmed) and pattern (postcoital, sporadic, breakthrough) (AUA/CUA/SUFU 2019)
  • sexrequired
    demographic • used at FRAME
    Engine scope is adult women; men with recurrent UTI route to uro.uti.complicated.v1 for obstruction / prostatitis workup
  • agerequired
    demographic • used at CONTEXT
    Postmenopausal age tier → topical vaginal estrogen first-line adjunct; geriatric → atypical presentation considerations
  • menopause_statusrequired
    history • used at CONTEXT
    Postmenopausal women benefit from topical vaginal estrogen — modifies vaginal microbiome (AUA 2019 PMID 31042112)
  • sexual_activity_pattern
    history • used at CONTEXT
    Postcoital pattern → postcoital single-dose prophylaxis candidate (AUA 2019)
  • pregnancy_statusrequired
    history • used at FRAME
    Pregnancy modifies prophylaxis: AVOID nitrofurantoin near term + sulfa near term + FQ throughout; treat ASB (USPSTF 2019)
  • diabetes_controlrequired
    history • used at CONTEXT
    Poorly controlled DM → emphysematous pyelo risk; glycemic optimisation reduces recurrence
  • immunosuppressionrequired
    history • used at CONTEXT
    SOT / hematologic malignancy / HIV / chronic steroid → broader empirics on breakthrough; ID consult
  • anatomic_abnormality_or_stonesrequired
    history • used at CONTEXT
    Recurrent UTI + structural anomaly → urology imaging eval (renal US / CT) (AUA 2019)
  • current_prophylaxis_status
    history • used at CONTEXT
    On continuous, postcoital, vaginal estrogen, methenamine, cranberry — drives next-step decision
  • recent_antibioticsrequired
    history • used at CONTEXT
    Recent exposure drives resistance pattern; avoid prior agent
  • local_antibiogram_TMP_SMX_resistancerequired
    history • used at CONTEXT
    AVOID TMP-SMX prophylaxis if local E. coli resistance >20% (IDSA 2010; AUA 2019)
  • allergies_and_intolerancesrequired
    history • used at CONTEXT
    Sulfa allergy, nitrofurantoin pulmonary intolerance, etc.
  • urologic_procedure_history
    history • used at CONTEXT
    Recent instrumentation / stent / nephrolithotomy → post-procedural recurrence pattern
  • catheter_statusrequired
    history • used at FRAME
    Chronic indwelling catheter → route off to uro.cauti.v1; do NOT prophylax routinely (drives MDR + CDI)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    UA on each acute episode + post-prophylaxis baseline (AUA 2019)
  • urine_culture_each_episoderequired
    lab • used at INITIAL_WORKUP
    Culture-confirmed recurrence is the definition; not symptom-defined (AUA 2019)
  • creatininerequired
    lab • used at TREATMENT
    Dose adjustment for renal-cleared prophylaxis agents — nitrofurantoin AVOID if CrCl <30; methenamine AVOID in renal / hepatic impairment
  • renal_us_or_ct_if_anatomic_concern
    imaging • used at BRANCHING_WORKUP
    Imaging eval if recurrent + anatomic concern / breakthrough / unusual organism (AUA 2019)
  • current_medsrequired
    medication • used at TREATMENT
    Anticoagulant + TMP-SMX → INR rise; methotrexate + sulfa toxicity; methenamine + sulfa precipitation; topical estrogen + breast Ca history

12-phase flow (12)

  1. 1FRAME
    Adult woman with recurrent UTI (≥2/6mo or ≥3/12mo culture-confirmed) → prophylaxis pathway. Pivot: chronic indwelling catheter → uro.cauti.v1; pediatric → uro.uti.pediatric.v1; men → uro.uti.complicated.v1 for obstruction / prostatitis workup; pregnancy → modified pathway (AUA/CUA/SUFU 2019)
    inputs: sex, pregnancy_status, catheter_status
    advance: engine scope confirmed
  2. 2ENTRY
    Recurrent UTI pattern documented (≥2/6mo or ≥3/12mo) OR postcoital pattern OR postmenopausal + recurrent OR breakthrough on prophylaxis (AUA 2019)
    inputs: uti_episode_history
    advance: entry captured
  3. 3CONTEXT
    Age, menopause status, sexual activity pattern, pregnancy, DM control, immunocompromise, anatomic anomaly, current prophylaxis, recent abx, local antibiogram, allergies, urologic procedure history (AUA/CUA/SUFU 2019; IDSA 2010)
    inputs: age, menopause_status, sexual_activity_pattern, diabetes_control, immunosuppression, anatomic_abnormality_or_stones, current_prophylaxis_status, recent_antibiotics, local_antibiogram_TMP_SMX_resistance, allergies_and_intolerances, urologic_procedure_history, current_meds
    advance: context complete
  4. 4RED_FLAGS
    Breakthrough UTI episode with sepsis features (fever, flank pain, hypotension) → route to acute pathway (uro.uti.complicated.v1 / uro.pyelonephritis.v1 / id.sepsis.core.v1); pregnancy + recurrent → OB co-management
    advance: no red flags OR routes engaged
  5. 5INITIAL_WORKUP
    UA + urine culture on each acute episode (AUA 2019); baseline creatinine for dose adjustment; pregnancy test in reproductive-age women (USPSTF 2019)
    inputs: urinalysis, urine_culture_each_episode, creatinine
    actions: panel.ua, panel.renal
    advance: workup complete
  6. 6BRANCHING_WORKUP
    Imaging eval (renal US / CT) if recurrent + anatomic concern / breakthrough on prophylaxis / unusual organism / hematuria persistent; urology referral if breakthrough or anatomic anomaly (AUA 2019)
    inputs: renal_us_or_ct_if_anatomic_concern
    advance: imaging plan documented
  7. 7DIFFERENTIAL
    Recurrent UTI vs interstitial cystitis vs pelvic floor dysfunction vs vulvovaginitis vs urethritis (STI) vs anatomic anomaly vs chronic prostatitis (men) vs interstitial cystitis (AUA 2019)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    Pattern (postcoital vs sporadic vs breakthrough), comorbidity tier (DM, IC, anatomic), menopause status, resistance pattern → drives prophylaxis selection (AUA 2019)
    advance: tier selected
  9. 9TREATMENT
    STEP 1 acute episode — culture-directed treatment per uro.uti.uncomplicated.v1 (NOT this engine); STEP 2 prophylaxis selection — continuous low-dose (TMP-SMX SS qhs OR nitrofurantoin 50–100 mg qhs × 6–12 mo) OR postcoital single dose OR self-start 3-d course OR vaginal estrogen (postmenopausal) OR methenamine 1 g PO BID OR cranberry low-evidence OR behavioural; STEP 3 AVOID FQ prophylaxis (FDA Black Box) + AVOID TMP-SMX if local R >20% + AVOID continuous prophylaxis in chronic catheter (AUA 2019)
    inputs: creatinine, current_meds
    advance: prophylaxis selected + counselled
  10. 10DISPOSITION
    Outpatient primary care + urology referral if breakthrough / anatomic / male / pediatric; acute episode disposition per uro.uti.uncomplicated.v1 pathway
    advance: disposition documented
  11. 11MONITORING
    Symptom diary; culture each acute episode; annual reassessment of prophylaxis; resistance surveillance; LFTs / pulmonary review for long-term nitrofurantoin; QTc / LFTs for fluconazole if used (AUA 2019)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Annual reassessment of continuous prophylaxis; trial off after 6–12 mo; urology referral if breakthrough; postmenopausal vaginal estrogen ongoing; methenamine adherence; behavioural reinforcement (AUA 2019)
    advance: follow-up + reassessment cadence documented