Prevalence, risk factors, and antimicrobial resistance in recurrent urinary tract infections: Impact of culture-guided therapy in Palestinian women

Background Urinary tract infections (UTIs) are among the most common bacterial infections in women, with recurrent UTIs (rUTIs) posing significant clinical and public health challenges. In Palestine, data on rUTIs and antimicrobial resistance (AMR) remain limited. Objectives To determine the prevalence of rUTIs among Palestinian women, identify associated risk factors, characterize antimicrobial resistance patterns, and evaluate the impact of culture-guided therapy on outcomes. Design A retrospective cohort study was conducted across four hospitals in southern West Bank (2016–2025). Methods Medical records of 380 women aged ≥18 years with UTI were reviewed. Demographic, clinical, microbiological, and treatment variables were extracted. rUTI was defined as ≥2 episodes within six months or ≥3 within twelve months. Descriptive and inferential statistics, including logistic regression, were performed. Results The prevalence of rUTIs was 27.4% (104/380). In the adjusted regression model, age, comorbidities, UTI classification, and infection type were not significantly associated with recurrence. UTI location was independently associated, with pyelonephritis showing lower odds of recurrence compared to cystitis (aOR = 0.16, 95% CI: 0.07–0.36, p < 0.001). Culture-guided therapy was protective, as patients who did not receive therapy had higher odds of recurrence (aOR = 2.60, 95% CI: 1.05–6.46, p = 0.039). Gram-negative pathogens predominated, with Escherichia coli (40.5%) and Klebsiella spp. (9.7%) as leading isolates. Extended-spectrum beta-lactamase (ESBL)-producing strains were common, reducing cephalosporin and fluoroquinolone effectiveness. Empirical therapy was dominated by ceftriaxone (43.2%), while meropenem (23.9%) became most frequent after culture results. Clinical resolution occurred in 93.4%, but reinfection (14.2%) and history of multidrug-resistant (MDR) infections (28.9%) remained substantial challenges. Conclusion rUTIs are prevalent among Palestinian women and closely associated with resistant Gram-negative pathogens. Culture-guided therapy improved outcomes, underscoring the need for strengthened stewardship and diagnostic infrastructure in resource-limited settings.