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How to manage recurrent urinary tract infections?

Q: My daughter is suffering Recurrent Urinary Tract Infections. She is 7 years old and weighs 33 kg. Since the last 3 and half years she is suffering the same problem (UTI). When she got this for the first time, we consulted the doctor who gave antibiotic (Septran) for 5 days and that time did not do the urine culture and did only urine analysis and found there are pus cells. After taking the antibiotic (septran), she was OK. Then she was OK for one year. After one year, she got again the same thing and we consulted the urologist and advised for septran again. Again after 5 months she got the same problem and took Septran again. We never got her urine culture test done. Only U/A was done and there was infection. Later she got the same problem frequently (in 1 or 2 months) and we consulted urologist and advised the urine culture and understood that she has “E. coli” bacteria and the septran was not sensitive for it and advised to take nitrofurantoin tablet 100 mg TIDx10 days, then ODx45 days given. Then sent her urine for culture and there was no bacterial growth. Then the medicine was stopped. When she stopped medicine/ nitrofurantoin, she got the same problem again, (after 5 days). Then again started nitrofurantoin. Also, doctor advised to do MCUG and found it was normal (no reflux), ultra sound is normal, KUB is normal and IVP also normal. Nitrofurantoin took almost 5 months! When the problem starts, there is frequent urination and then later pain also starts when urinating! In urine analysis, pus cells are found and in culture report may have organisms, usually E. coli. During these times she never get fever or abdominal pain or shivering. After 3 or 4 hours later the urination and pain may stop. Now last 2 weeks ago, she got again same problem and found in culture that there is E. coli bacteria and doctor suggested to give antibiotic/augmentin 312 mg Q8H (every 8 hourly for 5 days given) now she is taking 312mg OD. Because when she took nitrofurantoin she had vomiting and epigastric irritation. E. coli is sensitive to Augmentin. Recent abdomen ultra sound shows normal. No stone, kidney and bladder OK. No residual urine in the bladder. The urologist advised to repeat MCUG and do urodynamic study and keep on prophylaxis antibiotic Augmentin 312 mg OD. Kindly go through above and give your suggestion.

A:The investigations carried out appear to be adequate. There is no need for carrying out the tests such as MCUG and urodynamic study. The urologist has rightly suggested to keep the child on antibiotic prophylaxis. The followings are suggested for antibiotics prophylaxis: Please repeat the urine culture and sensitivity testing. If it is sterile then the antibiotics of choice for prophylaxis will be Septran single strength once a day or nitrofurantoin 50 mg once a day. Cap. cephalexin 250 mg once a day can be also given, which is the next drug of choice. Antibiotics prophylaxis can be safely given even for 2 years. I would not recommend Augmentin for antibiotic prophylaxis. It is necessary to pay attention to consumption of lot of fluids and also the voiding habit. So take lot of fluids and pass urine as and when required. The objectives behind consuming large volume of water is that this will prevent the colonisation of bacteria in the urinary bladder. Most of the bacteria in the urinary bladder will be flushed out in the urine. Hence she should be encouraged to drink water as frequently as possible. Barley water can be taken frequently as it is a diuretic. The child should not hold back from voiding urine.

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