American Journal of Epidemiology [626261]

American Journal of Epidemiology
Copyright O 2000 by The Johns Hopkins University School of Hygiene and Pubflc Health
All rights reservedvol. 151, No. 12
Printed in U.S.A.
Risk Factors for Second Urinary Tract Infection among College Women
Betsy Foxman,1 Brenda Gillespie,2 James Koopman,1 Lixin Zhang,1 Karen Palin,3 Patricia Tallman,1 Jane V.
Marsh,1 Scott Spear,4 Jack D. Sobel,6 M. Joan Marty,1 and Carl F. Marrs1
To better understand the etiology of recurrent urinary tract infection (UTI), the authors followed a cohort of 285
female college students with first UTI for 6 months or until second UTI. A first UTI due to Escherichia coli was
followed by a second UTI three times more often than was a non-E. coli first UTI (24 vs. 8%; p = 0.02). In a
logistic regression analysis limited to the 224 women from the University of Michigan Health Service and the
University of Texas at Austin Health Service from September 1992 to December 1994, with a first UTI due to E.
coli, vaginal intercourse increased the risk of a second UTI with both a different (odds ratio (OR) = 1.60, 95%
confidence interval (Cl): 1.19, 2.15) and the same (OR = 1.37, 95% Cl: 0.91, 2.07) uropathogen, as did using a
diaphragm, cervical cap, and/or spermicide (same uropathogen: OR = 1.53, 95% Cl: 0.95, 2.47; different
uropathogen: OR = 1.77, 95% Cl: 1.22, 2.58). Condom use decreased the risk of a second UTI caused by a
different uropathogen (OR = 0.68, 95% Cl: 0.48, 0.99) but had no effect on a second UTI caused by the same
E. coli (OR = 0.99; 95% Cl: 0.66, 1.50). Type or duration of treatment was not associated with a second UTI.
Although the risk of second UTI is strongly influenced by sexual behavior, women with a first UTI caused by E.
coli are more likely than are those with a non-E. coli first UTI to have a second UTI within 6 months. Am J
Epidemiol 2000;151:1194-1205.
Escherichia coir, recurrence; risk factors; sex behavior; urinary tract infections; women
Each year, approximately 7.3 million women visit a
clinician for urinary tract infections (UTI) (National
Center for Health Statistics, unpublished data, 1995).
Half of all women will have at least one UTI by age 30
years (1), an estimated 20-30 percent of women with
a first UTI will have two or more episodes (2), and 5
percent will have chronic recurring infections (3). The
relative roles of host and bacterial factors on risk of
second or repeated UTI are not well understood.
Most studies of UTI pathogenesis include women
with culture-confirmed, symptomatic infections
regardless of the number of prior UTI. History of
prior UTI is a strong predictor of acquiring subse-
quent infection (4, 5): the 6-month risk of second UTI
is an order of magnitude greater than the risk of UTI
Received for publication March 16, 1999, and accepted for publi-
cation August 5, 1999.
Abbreviations: Cl, confidence interval; OR, odds ratio; RR, rate
ratio; UTI, urinary tract Infection.
1 Department of Epidemiology, University of Michigan School of
Public Hearth, Ann Arbor, Ml.
2 Center for Statistical Consultation and Research, University of
Michigan, Ann Arbor, Ml.
3 Department of Biology, Bates College, Lewiston, ME.
4 Department of Pediatrics, University of Wisconsin, Madison, Wl.
5 Division of Infectious Diseases, Wayne State University, Detroit,
Ml.
Reprint requests to Dr. Betsy Foxman, Department of
Epidemiology, 109 Observatory Street Ann A/bor, Ml 48109-2029
(e-mail: bfoxman®umich.edu).in the general population (2). One third (5) to one half
of recurring UTI are due to the previous infecting
organism (6), making it difficult to separate risk fac-
tors for acquiring new uropathogens (that lead to
symptoms) from risk factors for developing symp-
toms from an existing colonization. Although the
number of prior UTI can be adjusted for in the analy-
sis, statistical adjustment summarizes overall cate-
gories of other variables, potentially obscuring
important effects. For example, a risk factor for colo-
nization with a uropathogen—a crucial first step that
might be subject to intervention—may have little or
no effect on risk of recurrent symptomatic infection.
The effects of this factor would remain undetected if
first UTI were not examined separately.
Combining first and subsequent UTI is especially
problematic when addressing bacterial virulence fac-
tors. A bacterial virulence factor may be associated
with risk of first UTI but be associated with decreased
risk of second or multiple UTI (6). Virulence factors
leading to first UTI may protect against second UTI by
stimulating host response to those factors, or chronic,
recurring infection due to the same bacteria may signal
a failure in host response. One third of the women with
community-acquired Escherichia coli UTI have subse-
quent UTI caused by the same strain (5). Among
women with recurring UTI, 68 percent may have a
recurrence caused by the same strain (7).
1194
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Risk Factors for Second Urinary Tract Infection 1195
To understand better the pathogenesis of UTI, we
followed a cohort of 285 women with first UTI for 6
months or until the second UTI. This standardized
prior history of UTI and allowed us to determine
whether the behavioral factors for the first and second
UTI were the same. Moreover, we were able to esti-
mate the risk of second UTI associated with first infec-
tion due to a particular uropathogen. We have previ-
ously reported the retrospectively determined patterns
of first UTI (8, 9) and have described the frequency of
E. coli virulence characteristics (6, 10) among E. coli
isolated from this cohort.
MATERIALS AND METHODS
Study protocol
Study participants were recruited at the University
of Michigan Health Service and the University of
Texas at Austin Health Service from September 1992
through December 1994. At the University of
Michigan, enrollment was offered to all female stu-
dents referred to the University of Michigan
Laboratory for urinalysis who had one or more urinary
symptoms (frequency, urgency, dysuria, hematuria,
nocturia, fever, or back or flank pain), had no UTI his-
tory, were aged 18-39 years, and stated that they
intended to stay in the same geographic area over the
next 6 months. At the University of Texas, female stu-
dents aged 18-39 years who intended to stay in the
same geographic area over the next 6 months and who
had clinically diagnosed UTI and no history of UTI
were referred to a research nurse for further eligibility
screening and an invitation to enroll in the study. At
both sites, all consenting women with a urine culture
positive for a uropathogen who had a clinical diagno-
sis of UTI (but not pyelonephritis) who were not cur-
rently pregnant, married, diabetic, or recently catheter-
ized were accepted into the study. Treatment of the
UTI was decided by the patient's clinician.
Participants were asked to return for a follow-up urine
culture after completion of their medication.
Laboratory personnel at both sites actively moni-
tored all incoming urine specimens for potential sec-
ond UTI among study participants. Medical records
were reviewed at the time of enrollment to confirm eli-
gibility and obtain the treatment prescribed; records
were reviewed again at the end of the follow-up period
to check for missed recurrences. We also ascertained
recurrence by self-report of clinician diagnosis.
At the University of Michigan, a study representa-
tive screened for eligibility 1,342 women referred for
urinalysis. We eliminated 827 (62 percent) because
they had a history of UTI, were pregnant, were older
than age 39 years, were not available for follow-up, orrefused to hear more about the study (n = 211). The
most common reason for refusal was "too busy." After
screening, the remaining 515 potentially eligible
women were offered enrollment, and 304 (59 percent)
consented. Those who refused were similar to those
who consented with respect to age and racial group. Of
those who consented, 141 (46 percent) had a positive
urine culture, one or more UTI symptoms, clinician
diagnosis of UTI, and no history of UTI or other exclu-
sionary criteria noted in their medical record. The
major reason for exclusion was a negative urine cul-
ture. At the University of Texas, potentially eligible
cases were referred to the study nurse by their clini-
cian. The tracking of referrals was unreliable, so we
have no good estimate of the consent rate.
Nevertheless, the study nurse reported that most
women who met with her participated. Of the 172
potential cases enrolled at the University of Texas, 16
were ineligible because they were married, one was
not a student, and 11 had missing data for one or more
eligibility criteria, leaving 144 cases (84 percent).
Measuring Instruments
Study participants completed a self-administered
questionnaire at enrollment and 2, 4, and 6 months
after enrollment and/or at the time of recurrence. The
questionnaire asked about sociodemographic vari-
ables; medical and sexual histories; and sexual behav-
ior, birth control methods, and diet during the previous
2 weeks. This time period was chosen both because
recent exposures are most pertinent for UTI risk and to
minimize problems of recall. Questionnaires were
mailed 1 week before the due date; participants were
telephoned 1 week after the follow-up due date to
remind them and/or to complete the questionnaire by
telephone.
Sample collection
Clean-voided urine specimens were obtained from
potential study participants at time of UTI diagnosis
and were cultured and identified as described previ-
ously (6).
Definitions
A UTI was defined as a clinically diagnosed UTI,
with one or more urinary symptoms and 1,000 or more
cfu/ml urine of a known uropathogen, consistent with
published guidelines for diagnosis of acute uncompli-
cated cystitis in clinical trials (11). Women with a clin-
ical diagnosis of pyelonephritis were excluded. A
woman was considered to have a first UTI if she
reported no history of a previous UTI and no history of
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1196 Foxman et al.
a previous UTI was documented in her university med-
ical record. We considered the woman cured if a urine
culture after completion of antimicrobial therapy and
resolution of symptoms had no growth or symptoms
resolved and the urine culture yielded a genotypically
different E. coli than that which caused the first UTI
(based on DNA hybridization if both isolates were E.
coli). If a woman had a positive urine culture (>l,000
cfu/ml urine of a known uropathogen) at follow-up,
she was asked to return for an additional urine culture.
Treatment after a positive follow-up culture was left to
the discretion of her treating clinician.
Because a follow-up culture after the first UTI and
culture results for the second UTI were not always
available, we used two alternative definitions for sec-
ond UTI. In conjunction with a clinician diagnosis, a
second UTI was defined as 1) urinary symptoms with
a urine culture positive for any known uropathogen
after a negative follow-up culture or a symptomatic
infection with a genotypically different organism with-
out a negative follow-up culture. These are designated
"culture-confirmed symptomatic episodes" (n = 40);
or 2) urinary symptoms after initial UTI. These are
designated as "symptomatic episodes" (n = 53).
Symptomatic episodes include all culture-confirmed
symptomatic episodes.
Bacterial strains, plasmids, and labeling DNA
probes
E. coli strains used as controls for hybridization
studies, the plasmids used as sources, and genes and
fragment size used as probes were described previ-
ously (6, 10). All genes were originally isolated from
E. coli. Since the pap gene probe can strongly
hybridize to both pap and prs genes, we use the system
of Blum et al. (12) and call pap-hybridizing sequences
prf for P-related fimbriae. Similarly, as pIL14
hybridizes to AFAI-IV and F1845 pili, we call
sequences hybridizing this probe drb, for Dr-binding
adhesins. We determined Dr subtypes as previously
described (13). The kpsMI gene probe is specific to
group II E. coli capsule genes and does not hybridize
to strains containing either group I or group HI capsule
genes (14). Preparation of DNA for use as probes has
been described previously (6, 10).
Total DNA Isolation, dot blots, and Southern blots
We performed crude DNA isolations for dot blots as
described previously (6, 10). For Southern blots, larger
amounts of purified total DNA were prepared, and the
DNA was digested and transferred as described previ-
ously (6, 10). We performed dot blots in duplicate for
each probe, and films were read independently by tworeaders. Blots that were questionable on both films
were retested (6, 10). Each E. coli strain was assigned
a nine-digit binary code in which each digit corre-
sponded to the presence or absence of a virulence char-
acteristic. We refer to these dot blot hybridization pat-
terns as signatures. Signatures do not identify clonal
groupings (10). When first and second E. coli isolates
from one individual have the same signature, they
have so far always had identical pulsed-field gel elec-
trophoresis patterns (6); thus, for the analysis in this
paper, we considered E. coli from second UTI with the
same signature as the first UTI to be the same strain.
Data entry and statistical analysis
All data were coded and entered twice by different
individuals. The files were compared, and descrepan-
cies were checked against the original questionnaire
for accuracy.
Each participant had baseline information (e.g.,
race, virulence characteristics of first UTI isolate) and
up to three follow-up records, one for each 2-month
interval describing their behavior during the 2 weeks
prior to completing the questionnaire. Information
from all questionnaires prior to recurrence or until the
end of follow-up were included in the analysis.
Participants with a second UTI in the first or second
interval had only one or two follow-up records, respec-
tively, because participation was terminated after a
second UTI. Recurrence information was linked to the
appropriate questionnaire data for each 2-month inter-
val after enrollment. We calculated the rate of second
UTI as the number of UTI per person-months exposed.
Associations between exposure variables and the
rate of second UTI were very similar regardless of
whether we used culture-confirmed symptomatic or all
symptomatic episodes. We present the results using all
symptomatic episodes as the outcome, but numbers of
culture-confirmed, symptomatic episodes are included
in the tables for comparison.
We describe associations between exposures and
rate of second UTI with rate ratios and their approxi-
mate 95 percent confidence intervals (15). We tested
differences between groups for categorical variables
with chi-square tests and for continuous variables with
Student's t tests with a significance level of a = 0.05.
We stratified all sexually related behaviors by fre-
quency of vaginal intercourse and calculated Mantel-
Haenszel summary rate ratios and approximate 95 per-
cent confidence intervals using dEPID (16).
We examined the effects of multiple concurrent
variables on the rate of second UTI after first UTI
caused by E. coli by using three different outcomes: 1)
all second UTI together; 2) second UTI caused by the
same E. coli; and 3) second UTI caused by a different
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Risk Factors for Second Urinary Tract Infection 1197
uropathogen. For each outcome, we performed dis-
crete-time survival analyses with 2-month intervals
using logistic regression (17). The model for all second
UTI included frequency of vaginal intercourse, con-
dom and other birth control method use during the 2
weeks prior to the questionnaire, an indicator of
whether no birth control method was used, time since
first engaged in sexual activity with the current sex
partner (partnership <4 months, 4 to <8 months, 8 to
<12 months, and a year or more), and an indicator for
months 3—4 and 5-6 since first UTI (to model changes
in risk over time). Oral contraceptives were the refer-
ent group for birth control method because the num-
bers of women using no method were small. Cutpoints
for time engaged in sexual activity with the current sex
partner were determined by using quartiles of the dis-
tribution (considering data from all 2-month intervals
together) and then rounding each quartile to the near-
est month for ease of interpretation. A subset of these
variables was used for the other two models. We used
the log(* +1) transformation of the variables measur-
ing frequency during the previous 2 weeks of vaginal
intercourse, condom use, and all other birth control
methods. The log(;c +1) transformation improved the
fit of the model over a linear relation for all three vari-
ables. Other variables were added individually to the
base model. We compared the effect of each individual
E. coli virulence factor with that of E. coli containing
only type I pili by using two dummy variables: an indi-
cator of the presence of the bacterial virulence factor
of interest and an indicator for the presence of all other
non-type I factors. If a woman was infected with two
different E. coli, one was chosen at random for inclu-
sion in this analysis. Women infected with an E. coli
and a non-£. coli were considered to have E. coli UTI.
All adjusted analyses were performed using SAS for
Windows 6.10 (18).
RESULTS
Study population characteristics
We enrolled 285 eligible women with first UTI; 263
(92 percent) completed at least one follow-up ques-
tionnaire, and 211 (74 percent) were followed for 6
months or until their second UTI. There were 53 symp-
tomatic second UTI, of which 40 were confirmed by
culture. Six symptomatic second UTI were identified
by self-report of clinician diagnosis only. The majority
(85 percent) of first UTI were caused by E. coli, and
the remainder by Staphylococcus saprophyticus (5 per-
cent), Proteus (3 percent), and Klebsiella (3 percent),
with Enterobacter, Citrobacter, Group B streptococ-
cus, and other staphylococcal species making up the
remainder. Although we defined a UTI as 1,000 ormore cfu/ml urine of a single uropathogen in the pres-
ence of one or more urinary symptoms, 76 percent of
women had 100,000 or more cfu/ml. The majority (86
percent) of second UTI were also caused by E. coli and
the remainder by S. saprophyticus (7 percent), Proteus
(5 percent), and Klebsiella (2 percent).
When compared by site of enrollment, study partic-
ipants did not differ with respect to rate of second UTI,
frequency of vaginal intercourse, condom use, or
length of relation. However, more participants from
Michigan than from Texas were Black (15 vs. 5 per-
cent), and fewer were Hispanic (2 vs. 11 percent) (p =
0.001). As behavioral variables did not differ within
racial groups across sites, all participants were com-
bined for presentation.
The most common first UTI symptoms reported by
women with E. coli compared with all other
uropathogens were frequency (93 and 95 percent),
urgency (92 and 83 percent), dysuria (88 and 88 per-
cent), suprapubic pressure (72 and 66 percent), noc-
turia (57 and 60 percent), and gross hematuria (51 and
39 percent), respectively. Back pain (28 and 31 per-
cent), flank pain (16 and 17 percent), fever (19 and 12
percent), and chills (24 and 5 percent) were less com-
mon in both groups. Only five women (2 percent) had
an objectively measured temperature greater than
99.9° F.
Treatment was decided by the treating clinician. The
majority (63 percent) were treated with trimethoprim-
sulfa for 1-15 days. Twenty-six percent were treated with
nitrofurantoin for 3-14 days, and the remainder were
treated with some other antimicrobial. Ten percent were
treated with trimethoprim-sulfa for 1 or 2 days. Choice of
V)
2 3 4
Month
FIGURE 1. Monthly incidence of second UTI among women from
the University of Michigan Health Science Service and the University
of Texas at Austin Health Science Service from September 1992 to
December 1994 with first UTI due to E. coli by whether recurrence
was with the same or a different bacteria (n = 224 women). The aver-
age standard error for recurrence with the same bacteria was
0.0054; for recurrence with a different bacteria, it was 0.0087.
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1198 Foxmanetal.
TABLE 1. Rate of second urinary tract Infection (UTI) by age at enrollment and race and sexual
behavior reported bimonthly between first and second UTIs In 224 college women with first UTI
caused by Escherichla coll (total person-months of exposure = 1,140), University of Michigan
Health Service and University of Texas at Austin Health Service, 1992-1994*
Characteristic
Age (years)
18-19
20-21
22-23
24-39
Race
White
Black
Other
Lifetime no. of sex partners
1
2-3
4-7
£8
Vaginal intercourse in previous
2 weeks
None
1-5
26
Digital stimulation in previous
2 weeks
0-1
2-7
28Person-
months
of
exposure
262
448
280
150
850
88
202
252
402
304
174
312
522
304
336
588
212No. with second UTI
Culture-
confirmed
symptomatic
episodes
2
21
8
9
29
1
10
9
16
9
6
4
16
20
7
20
13All
symptomatic
episodes
6
25
12
10
36
2
15
15
19
12
7
6
21
26
9
27
17Rate of
o/v^nH 1 111StJCOOU U 1 1
(all
symptomatic
episodes)
per 100
person-
months
2.29
5.58
4.29
6.67
4.24
2.27
7.43
5.95
4.73
3.95
4.02
1.92
4.02
8.55
2.68
4.59
8.02RRt
1.00
2.44
1.87
2.91
1.00
0.54
1.75
1.00
0.79
0.39
0.68
1.00
2.09
4.45
1.00
0.92
0.9595% Clf
1.00,5.94
0.70, 4.99
1.06,8.01
0.13,2.23
0.96, 3.20
0.40,1.56
0.31,1.42
0.28, 1.66
0.84, 5.18
1.83,10.81
0.34, 2.50
0.21,4.25
Table continues
treatment regimen was very similar for women with
non-£. coli and E. coli UTI, with most treated with
trimethoprim-sulfa (69 percent non-£. coli vs. 62 per-
cent E. coli; p = 0.56). The average duration of treat-
ment did not differ by infecting bacteria (p = 0.69).
Risk of second UTI by initial infecting organism
Among the 224 women with first UTI caused by E.
coli who completed at least one follow-up, 53 (24 per-
cent) had a symptomatic episode, and 42 (19 percent)
had a culture-confirmed symptomatic episode after
culture-confirmed cure within 6 months. Thirty-nine
women with non-E. coli first UTI completed at least
one follow-up; three (8 percent) had a symptomatic
episode, and two (5 percent) had a culture-confirmed
symptomatic episode after a negative follow-up urine
culture within 6 months. Risk of a second sympto-matic UTI was significantly higher among women
whose first UTI was caused by E. coli (53 of 224 vs.
three of 39, p — 0.02). When the analysis was limited
to the 27 women with non-£. coli UTI and 137 women
with E. coli UTI who were treated with trimethoprim-
sulfa, women with non-E. coli UTI still had a second
infection at significantly lower rates (two of 27 vs. 34
of 137, p = 0.045).
For women with first UTI caused by E. coli, risk of
a second UTI within 6 months was 25 percent among
women treated with trimethoprim-sulfa (34 of 137) or
nitofurantoin (15 of 61) and 14 percent (three of 22)
among those treated with other regimens (14 percent),
but the differences between the three groups were not
statistically significant (chi-square p = 0.51) (treat-
ment was unknown for four individuals). The rates of
second UTI after non-£. coli first UTI were similar by
treatment: 7 percent (two of 27) for trimethoprim-
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Risk Factors for Second Urinary Tract Infection 1199
TABLE 1. Continued
Characteristic
Receptive oral sex in previous
2 weeks:):
None
1-2
£3
Length of current partnership
(months):):
£12
No current partner
<4
4 to <8
8to<12
New sex partner since
enrollments
No
Yes
Birth control method}:,§
Oral contraceptives
None
Condoms
Oral contraceptives and
condoms
Diaphragm or cap (alone or
with any other method)
Spermicide without condoms
(includes other methods
or alone)
Some other methodPerson-
mofrths
of
exposure
608
334
192
306
212
242
242
136
992
146
436
202
242
194
20
18
8No. with second UT1
Cuitu re-
confirmed
symptomatic
episodes
14
18
8
9
2
15
11
3
32
8
16
1
9
7
4
2
0A1J
symptomatic
episodes
22
21
10
15
4
17
13
4
10
43
22
2
13
8
5
2
0Rate of
second UTI
(all
symptomatic
episodes)
per 100
person-
months
3.62
6.29
5.21
4.90
1.89
7.02
5.37
2.94
1.01
29.45
5.05
0.99
5.37
4.12
25.00
11.11
0.00RR
1.00
1.20
0.73
1.00
0.42
1.57
0.98
0.57
1.00
1.65
1.00
0.20
1.12
0.89
3.56
2.4095% Cl
0.64, 2.26
0.31,1.69
0.23, 7.89
0.79, 3.10
0.48, 2.00
0.21, 1.54
0.83, 3.30
0.05, 0.83H
0.55, 2.29
0.39, 2.01
1.32,9.60
0.55, 10.44
* Rate ratios and 95% confidence intervals for other sexual behaviors and birth control method are adjusted
for frequency of vaginal intercourse. Person-months may not total 1,140 because of missing exposure information.
Exposure information was missing for no more than 2% for any one variable.
t RR, rate ratio; Cl, confidence interval.
t Mantel-Haenszel rate ratio adjusted for frequency of vaginal intercourse. Missing data for 2 person-months
on frequency of vaginal intercourse.
§ Mutually exclusive categories.
1) Crude RR, since there were no cases of second UTI in two of three strata.
sulfa and 10 percent (one of 10) for nitofurantoin (chi-
square p = 0.88). We observed no recurrences among
the two women with first UTI caused by non-£. coli
who were treated with some other regimen. Average
duration of treatment was not associated with recur-
rence for E. coli or non-£. coli UTI (p = 0.3).
Age, race, length of relationship, condom use, and
frequency of engaging in oral sex or digital stimulation
were similar among women with first UTI caused by
E. coli and those whose first UTI was caused by some
other uropathogen (data not shown). However,
women with first UTI caused by E. coli were signifi-
cantly more likely than were those with non-£. colifirst UTI to have engaged in vaginal intercourse during
the 2 weeks prior to their first UTI ( 96 vs. 86 percent,
p = 0.03). Because of the small number of second UTI
among women infected with non-£. coli, the remain-
der of the analyses are limited to women with first UTI
caused by E. coli.
Second UTI caused by a different uropathogen
occurred twice as frequently as recurrence with the
same E. coli (16 vs. 8 percent). Second UTI caused by
a genetically different E. coli or other uropathogen
were spread fairly evenly throughout the follow-up
period; by contrast, most (89 percent) of second UTI
caused by the identical E. coli occurred within the 3
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1200 Foxmanetal.
months after first UTI (figure 1). Patterns were similar
for culture-confirmed and symptomatic episodes.
Host characteristics and behaviors
Rate of second UTI was lowest among those aged
18-19 years and was fairly constant in the older age
groups (table 1). We observed few second UTI among
Black participants. The highest rate of second UTI
was among women who self-identified as "other"
race, but the numbers are small and the differences are
not statistically significant.
Women who reported a history of eight or more life-
time sex partners had a lower rate of second UTI, but
the differences were not statistically significant (table
1). Recent and more frequent sexual activity increased
the rate of second UTI. Oral contraceptives were the
most popular birth control method, although they were
often used with condoms, spermicides, condoms and
spermicides, or a diaphragm or cervical cap. However,
only women who used diaphragms or cervical caps
had a significantly higher incidence of second UTI
than did women who used oral contraceptives. Women
who used no contraceptive method had the lowest
risk.
We examined the associations of several health
behaviors with rate of second UTI. Regularly drinking
cranberry juice was associated with a slightly, but
not significantly, lower rate of second UTI (rate ratio
(RR) = 0.78,95 percent confidence interval (CI): 0.42,
1.44) (data not shown). Women who regularly took vit-
amin C compared with those who did not were equally
likely to have a second UTI (RR = 1.18,95 percent CI:
0.64, 2.19). More frequent consumption of carbonated
beverages was associated with significantly lower rates
of second UTI (daily vs. never, RR = 0.33, 95 percent
CI: 0.12, 0.90). The type of menstrual protection used
did not appear to be associated with rate of second
UTI. There was no clear pattern with voiding habits,
and the associations are not statistically significant.
Only women who reported wiping in either direction
after urination had an increased rate of second UTI
(RR = 1.76, 95 percent CI: 0.91, 3.43); wiping back-
to-front as opposed to front-to-back had no impact on
the rate of second UTI (RR = 0.91, 95 percent CI:
0.45,1.85). There was no association with cigarette use
(RR = 1.08, 95 percent CI: 0.59, 1.99). However,
women who reported taking antibiotics during the 2
weeks prior to the follow-up survey had a higher rate
of second UTI (RR = 1.75, 95 percent CI: 0.94, 3.27).
Bacterial virulence characteristics
We probed all E. coli isolates for the presence of
nine different virulence characteristics either knownor hypothesized to be associated with risk of acquiring
UTI. Results of a preliminary analysis of this set has
been presented previously (6). None of the virulence
characteristics individually or in the most commonly
occurring groups of virulence factors were associated
with increased risk of second UTI, although several
factors seemed protective (data not shown).
Second UTI caused by the same versus a
different uropathogen
To explore the factors associated with a second UTI
caused by the same or a different uropathogen, we
analyzed the data by using two additional outcomes:
second UTI caused by the same E. coli {n = 18) and
second UTI caused by a different uropathogen (n =
35). In both of these analyses, the most important fac-
tor was frequency of vaginal intercourse (table 2).
Having a new sex partner was associated with
increased rate of second UTI with the same E. coli but
not a different uropathogen. Diaphragm use increased
the risk of a second UTI with either the same E. coli
or a different uropathogen. Wiping in either direction
after urination was associated with recurrence with a
different uropathogen, but not with the same E. coli.
The effects of bacterial characteristics on risk of sec-
ond UTI with the same or a different uropathogen are
difficult to interpret because of small sample sizes
(data not shown). Compared with the overall risk of
second UTI with the same E. coli, the point estimates
for the presence of P pili (RR = 0.44, 95 percent CI:
0.15, 1.29), cytotoxic necrotizing factor I (RR = 0.43,
95 percent CI: 0.10, 1.78), hemolysin (RR = 0.44, 95
percent CI: 0.13, 1.44), and S fimbrial adhesin (RR =
0.61, 95 percent CI: 0.19, 1.98) in the initial isolate are
negatively associated with risk of a second UTI, but
the confidence intervals are wide. None of these fac-
tors were associated with risk of second UTI caused by
a different uropathogen (P pili, RR = 0.97, 95 percent
CI: 0.58, 1.68; cytotoxic necrotizing factor I, RR =
1.03,95 percent CI: 0.55, 1.96; hemolysin, RR = 0.81,
95 percent CI: 0.43, 1.51; S fimbrial adhesin, RR =
0.91, 95 percent CI: 0.47, 1.79). Presence of one Dr
subtype, AFAV, in the initial isolate, was positively
associated with second UTI caused by the same E. coli
(RR = 2.10, 95 percent CI: 0.70, 6.33) but was nega-
tively associated with a second UTI caused by a differ-
ent uropathogen (RR = 0.45, 95 percent CI: 0.07,
3.05), and neither result was statistically significant.
Multivariate analyses
We included frequency of vaginal intercourse,
diaphragm use, cervical cap or spermicide use, con-
dom use, and starting a new sexual partnership since
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Risk Factors for Second Urinary Tract Infection 1201
TABLE 2. Rate of second urinary tract infection (UTI) with the same or a different uropathogen than the Eacherlchla coll that
caused the first UTI, by selected behavioral variables In 224 college women with first UTI caused by E. coll (total person-months
of exposure = 1,140), University of Michigan Health Service and University of Texas at Austin Hearth Service, 1992-1994*
Characteristic
Vaginal intercourse in previous
2 weeks
None
1-5
£6
Lifetime no. of sex partners}:
1
2-3
4-7
^8
New sex partner since
enrollment!:
No
Yes
Birth control method§
Oral contraceptives
None
Condoms
Oral contraceptives and
condoms
Diaphragm or cap (alone or
with any other method)
Spermicide without condoms
(includes other methods
or alone)
Some other method
Wipe after urination
Front to back
Back to front
Either direction
Other
Antibiotic use In previous 2
weeks
No
YesPerson-
months
of
exposure
312
522
304
252
402
304
174
994
146
436
202
242
194
20
18
8
614
284
174
62
892
216Rate with
second UTI
due to the
same E.
coll (per
100 person-
months)
0.64
1.72
2.30
1.59
1.74
1.97
0.57
1.21
4.11
1.61
0.50
2.89
1.03
5.00
0.00
0.00
1.63
1.41
1.72
1.61
1.12
2.31RRt
1.00
2.69
3.59
1.00
1.10
1.24
0.36
1.00
3.40
1.00
0.31
1.80
0.64
3.11
1.00
0.86
1.06
0.99
1.00
2.0695% Clt
0.58, 12.45
0.75, 17.29
0.32, 3.74
0.35, 4.40
0.04, 3.23
1.28, 9.07
0.04, 2.51
0.63, 5.13
0.13, 3.09
0.38, 25.31
0.27, 2.76
0.29, 3.85
0.13, 7.73
0.71,6.04Rate wttti
second UTI
due to a
different
uropathogen
(per 100
person-
months)
1.28
2.30
6.25
4.37
2.99
1.97
3.45
3.12
2.74
3.44
0.50
2.48
3.09
20.00
11.11
0.00
2.61
2.46
5.75
1.61
2.58
4.17RR
1.00
1.79
4.88
1.00
0.68
0.45
0.79
1.00
0.88
1.00
0.14
0.72
0.90
5.81
3.23
1.00
0.95
2.21
0.62
1.00
1.6295% Cl
0.58, 5.56
1.66, 14.33
0.30, 1.55
0.17, 1.22
0.29, 2.13
0.31, 2.49
0.02, 1.09
0.28, 1.86
0.35, 2.32
1.93, 17.52
0.74, 14.12
0.39, 2.30
1.00,4.86
0.08, 4.67
0.75, 3.49
* Person-months may not total to 1,140 because of missing exposure information. Exposure information was missing for no more than 3%
for any one variable.
t RR, rate ratio; Cl, confidence interval.
% One woman reported no sex partners.
§ Mutually exclusive categories.
first UTI as independent variables in two discrete-time
survival models, one with recurrence caused by the
same E. coli as the dependent variable and the other
with recurrence caused by a different uropathogen as
the dependent variable (see Materials and Methods).
After adjustment for other variables, the results aresimilar to that found in the bivariate analysis.
Engaging in one act of vaginal intercourse versus none
in the previous 2 weeks was positively associated with
recurrence with both a different (odds ratio (OR) =
1.60, 95 percent Cl: 1.19, 2.15) and the same (OR =
1.37, 95 percent Cl: 0.91, 2.07) uropathogen, as was
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1202 Foxmanetal.
TABLE 3. Time-dependent logistic regression model predicting risk of second urinary tract Infection
(UT1) In 224 college women wtth first UTI caused by Eschertchla coll (total person-months of exposure =
1,140), University of Michigan Hearth Service and University of Texas at Austin Health Service,
1992-1994*
Variable
Vaginal intercourse (1 time vs. none)!
Vaginal intercourse with a condom (1 time
vs. none)}:
Vaginal intercourse with diaphragm, cervical
cap, or spermicide (1 time vs. none)t
No birth control method
Length of current relationship (vs. £12 months)
No current sex partner
Sex partner <4 months
Sex partner 4 to <12 months
Sex partner 8 to <12 months
Month 4 (compared with month 2)
Month 6 (compared with month 2)Coefficient
0.5742
-0.4279
0.8148
-1.4005
0.2424
0.4369
-0.1160
-0.7672
-0.4518
-0.6250SEt
0.2387
0.2189
0.2536
0.7775
0.7091
0.4115
0.4086
0.5994
0.3586
0.3989P
value
0.02
0.05
0.00
0.07
0.73
0.29
0.78
0.20
0.21
0.12
Factors added one at a time to the base model
Site of recruitment
New sex partner
Cranberry juice
Vitamin C
No. of carbonated beverages in previous 2
weeks (vs. none)
1-3
4-7
8-10
Dally
Napkin only (vs. tampon only)
Tampon and napkin (vs. tampon only)
Deodorant menstrual protection
Voiding habits (times/day) vs. 4 times per day
<4
5-6
2:7-0.0793
0.5662
-0.2799
0.1979
-0.5857
-0.4786
-1.3966
-1.4429
0.2412
0.2577
-0.3916
-0.8488
-0.5973
-0.66890.1053
0.6728
0.3493
0.3484
0.5814
0.5403
0.6886
0.5741
0.4452
0.3532
0.4348
0.4940
0.3816
0.47810.45
0.40
0.42
0.57
0.31
0.38
0.04
0.01
0.59
0.47
0.37
0.09
0.12
0.16ORt
1.49
0.74
1.76
0.25
1.27
1.55
0.89
0.46
0.64
0.54
0.92
1.76
0.76
1.22
0.56
0.62
0.25
0.24
1.27
1.29
0.68
0.43
0.55
0.5195%Clt
1.08,2.06
0.55, 1.00
1.25,2.48
0.05, 1.13
0.32, 5.12
0.69, 3.47
0.40, 1.98
0.14, 1.50
0.32, 1.29
0.24, 1.17
0.75, 1.14
0.47, 6.59
0.38, 1.50
0.62, 2.41
0.18,1.74
0.21, 1.79
0.06, 0.95
0.08, 0.73
0.53, 3.05
0.65, 2.59
0.29, 1.59
0.16,1.13
0.26,1.16
0.20,1.31
Table continues
using a diaphragm, cervical cap, or spermicide (same
uropathogen: OR = 1.53, 95 percent CI: 0.95, 2.47;
different uropathogen: OR = 1.77, 95 percent CI:
1.22, 2.58) (data not shown). Having a new sex partner
in the previous 2 weeks was positively associated with
a second UTI caused by the same E. coli (OR = 3.60,
95 percent CL1.28, 10.09) but not with a different
uropathogen (OR = 0.82, 95 percent CI: 0.27, 2.49).
Condom use protected against recurrence caused by a
different uropathogen (OR = 0.68, 95 percent CI:
0.48, 0.99) but had no association with a second UTI
caused the same E. coli (OR = 0.99, 95 percent CI:
0.66, 1.50).
We also fit a discrete-time survival model that con-
sidered all symptomatic second UTI as the outcome
(table 3). After adjustment for the presence of other
variables (see Materials and Methods), a single sex act
during the previous 2 weeks increased risk of a secondUTI by 49 percent (OR = 1.49, 95 percent CI: 1.08,
2.06). Vaginal intercourse with a condom modestly
decreased risk of a second UTI (OR = 0.74, 95 percent
CI: 0.55, 1.00), and vaginal intercourse with a
diaphragm, cervical cap, or spermicide increased risk
almost twofold (OR = 1.76,95 percent CI: 1.25, 2.48).
Length of partnership and new sex partner since enroll-
ment were not significantly associated with risk of a
second UTI. When both variables were included in the
model, having a new sex partner was positively, but not
statistically, significantly associated with risk of second
UTI (OR = 1.76,95 percent CI: 0.47, 6.59), and a part-
ner of less than 4 months duration had no association
(OR = 1.04, 95 percent CI: 0.30, 3.61) (data not
shown). Thus, we included only the length of the rela-
tionship in the base model. The remaining potential risk
factors were added to the base model one at a time.
Adjustment for behavioral variables brought the effects
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Risk Factors for Second Urinary Tract Infection 1203
TABLE 3. Continued
Variable
Wait to urinate sometjmes/frequentiy/always
(vs. never)
Wiping after urination (vs. front to back)
Wipe back to front
Wipe either direction/other pattern
Urination around sex (vs. before and after sex)
Urinate oniy before sex
Urinate only after sex
Urinate neither before nor after sex
Cigarettes
Antibiotics during previous 2 weeks
First UTI treatment regimen (vs. trimethoprim-
sulfa)
Nitrofurantoin
Other
Aerobactjn (aer)
Capsule (KpsMT)
Cytotoxic necrotizing factor I (cnf1)
Dr binding adhesins (drb)
Hemolysin (hty)
Outer membrane protein T (ompT)
P pili (prf)
S fimbril adhesin (sfa)Coefficient
-0.1957
-0.0659
0.2973
-0.5054
-0.5059
0.2235
0.0639
0.6158
-0.0916
-0.7563
0.1706
0.2273
0.0524
0.4352
-0.1406
0.1841
0.0186
0.0681SE
0.3232
0.3859
0.3793
0.7464
0.5515
0.6609
0.3653
0.3785
0.3415
0.6504
0.6667
0.6454
0.6944
0.7217
0.6839
0.6460
0.6632
0.6917P
value
0.54
0.86
0.43
0.50
0.36
0.74
0.86
0.10
0.79
0.25
0.80
0.72
0.94
0.55
0.84
0.78
0.98
0.92OR
0.82
0.94
1.35
0.60
0.60
1.25
1.07
1.85
0.91
0.47
1.19
1.26
1.05
1.55
0.87
1.20
1.02
1.0795% Cl
0.44, 1.55
0.44, 1.99
0.64, 2.83
0.14, 2.61
0.20, 1.78
0.34, 4.57
0.52,2.18
0.88, 3.89
0.47, 1.78
0.13, 1.68
0.32, 4.38
0.35, 4.45
0.27, 4.11
0.38, 6.36
0.23, 3.32
0.34, 4.26
0.28, 3.74
0.28,4.15
* All parameter estimates adjusted for the frequency of vaginal intercourse, condom use, use of spermicldes,
no birth control method, length of current sexual relationship, and time. Behaviors were assessed at 2, 4, and 6
months after first UTI and at time of recurrence. Fifty-three second UTI were detected after initial E. coll UTI.
Bacterial virulence factors are relative to bacteria having type I pili (fim) only (see Materials and Methods).
t SE, standard error; OR, odds ratio; Cl, confidence interval.
t Mutually exclusive categories.
of bacterial virulence factors closer to the null. For the
remaining variables, the confidence intervals are wide,
and the estimated odds ratios differ only slightly from
rate ratios presented in the bivariate analyses.
DISCUSSION
The identification of risk factors for recurrent UTI
has been complicated by the multiagent nature of the
syndrome and the interactions of bacterial virulence
factors, host behaviors, and host characteristics.
Comparisons of the bacterial virulence characteristics
of E. coli causing recurrent UTI with those causing
first UTI have been relatively uninformative (19), and
comparison of behaviors of women with recurrent UTI
with those with first UTI often highlights factors that
change in response to UTI rather than risk factors for
recurrent UTI (20). Host characteristics, including
secretor status (21) and vaginal flora (22), have been
associated with recurrent UTI, but their relative impor-
tance remains to be shown. We focused upon risk fac-
tors for second UTI, subclassifying first UTI into those
caused by E. coli and by non-E. coli, and used molec-
ular techniques to further subclassify second UTI into
second UTI due to the same or a different uropathogen.We observed a higher rate of second UTI when the
first UTT was caused by E. coli than when it was
caused by non-E. coli (24 vs. 8 percent). Women
with first UTI due to E. coli were more likely than
were those with non-E. coli first UTI to have
engaged in vaginal intercourse prior to their first
UTI. We found no difference in other behaviors,
including urination habits around intercourse, but
our numbers are small, limiting our ability to detect
associations. We are unaware of any previous reports
of different recurrence rates for non-E. coli UTI or of
the stronger association of E. coli first UTI with
vaginal intercourse.
Among women with first UTI caused by E. coli,
vaginal intercourse also increased rate of second UTI,
regardless of whether the second UTI was caused by
the same or a different uropathogen. Vaginal inter-
course has been associated with first and recurrent UTI
in the same (8, 9, 20) and similar (4) populations.
When a uropathogen is already present in the vagina or
periurethral area, the movement of uropathogens and
trauma associated with vaginal intercourse may
increase risk of symptomatic infection. Vaginal inter-
course may also introduce a uropathogen from a sex
partner or an internal reservoir.
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1204 Foxmanetal.
The significantly protective effect of drinking car-
bonated beverages on risk of second UTI is hard to
explain. When the Michigan first UTI cases were com-
pared with population controls (8), drinking carbon-
ated beverages was an apparent risk factor for acquir-
ing first UTI. These results require further study for
proper interpretation.
One third of second UTI after E. coli UTI were
caused by the same E. coli, and the timing of second
UTI was different than that for second UTI caused by
a different pathogen. Recurrence with the same E. coli
was concentrated in the first 3 months after first UTI,
while recurrence with a different uropathogen was
spread more evenly throughout the follow-up period.
These results are consistent with those of a Finnish
study that followed 179 nonpregnant women with
community-acquired E. coli cystitis (5). That study
also found that one third of the recurrences were with
the index strain and that recurrences with the index
strain occurred more frequently in the first few
months after the index UTI. An internal reservoir may
serve as source of reinfection; this reservoir may be
lost or replaced by a new uropathogen over time. We
did not collect vaginal or fecal specimens and so can-
not comment on whether second infection was from
an internal reservoir or a new infection. While type or
duration of treatment may be important in removing
an internal reservoir, we did not find an association
between type or duration of therapy for first UTI and
risk of second UTI either with the same or a different
uropathogen.
Of the nine different E. coli virulence factors stud-
ied here, only Dr was positively associated with the
risk of a second UTI and that only weakly and not sig-
nificantly. This is consistent with the results of the
Finnish study, which examined expression of viru-
lence factors (MR adhesin, P fimbriae, non-P MR
adhesins, type IC fimbriae, hemolysin, and serotypes
K5, K, 02, 08, and 075) and found that they did not
increase the risk of recurrence during a 1-year follow-
up period (5). However, they found that strains with
these factors were more likely to persist and cause a
second infection. We found a negative association
between the presence of P pili, S fimbrial adhesin,
cytotoxic necrotizing factor I, and hemolysin and
recurrence with the same strain and no association of
these factors with a second UTI due to a different
uropathogen.
In conclusion, we followed women with a first UTI
in order to avoid the methodological pitfalls associ-
ated with studying women with a history of varying
numbers of previous UTI. This strategy allowed us to
confirm the role of several behavioral risk factors
and to identify the importance of the genus of the ini-tial uropathogen on risk of second UTI. Although
risk of second UTI is strongly influenced by sexual
behavior, E. coli first UTI are more likely than are
non-£. coli first UTI to result in a second UTI within
6 months.
ACKNOWLEDGMENTS
Supported by National Institute of Digestive and Kidney
Diseases grant DK35368 to Dr. Betsy Foxman.
The authors thank Charlotte Williams and her excellent
staff at the University of Michigan Health Service
Laboratory and Brenda Lucke and other excellent laboratory
staff at the University of Texas at Austin Health Service for
their cooperation. They appreciate the support of Dr. Caesar
Briefer, Director of the University of Michigan Health
Service, hi addition, they would like to thank the following
individuals whose efforts led to excellent data quality and
follow-up of study participants during the course of the pro-
ject: Bonnie Andree, Shirley Arldt, Mary Carlson, Nell
Curtis, Dr. Ann Geiger, Barbara Krienke, Nicole Wilson
Rubin, and die many students who assisted with laboratory
tests, participant recruitment, medical record review, and
data coding and entry.
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