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Management of Uncomplicated Recurrent Urinary Tract Infections

      Abstract

      Mostly young but also postmenopausal women are often affected by recurrent urinary tract infections (rUTIs), defined as three or more symptomatic UTI episodes per year or two or more UTIs within 6 mo. Approximately 20–30% of women with a UTI have a recurrence. UTIs are associated with considerable morbidity. Treatable predisposing factors in uncomplicated rUTI are rare but have to be considered. According to the 2015 European Association of Urology guidelines, the recommendations for prophylaxis of rUTI are first, behavioral changes and second, nonantimicrobial measures. Antibiotic prophylaxis should only be considered if the former recommendations are not sufficiently effective, to avoid adverse events and the collateral damage of unnecessary long-term antibiotic use. General behavioral recommendations can lower the recurrence rate by about 30%. Of the nonantimicrobial measures, immunoprophylaxis and local estriol substitution are effective to lower the recurrence rate, especially in postmenopausal women. Cranberry products on the market are widely variable and seem to have too low a proanthocyanidin content to prevent rUTI effectively. Other promising modalities need to be tested in further controlled trials to prove their preventive benefit. For long-term antibiotic prophylaxis, oral fosfomycin, nitrofurantoin, trimethoprim, cotrimoxazole, and oral cephalosporins (especially during pregnancy) are recommended. Placebo-controlled studies show a high efficacy of long-term antibiotic prophylaxis, but this strategy does not appear to modify the natural history of rUTI, and most of the studies were performed at a time when antibiotic resistance was not an issue.

      Patient summary

      Women of all ages experience recurrent urinary tract infections (rUTIs) that cause considerable morbidity. Treatable predisposing factors in uncomplicated rUTI are rare but have to be considered. Guidelines for the prophylaxis of rUTI episodes recommend behavioral changes followed by nonantimicrobial measures and only then by antibiotic prophylaxis to avoid adverse events and the collateral damage of unnecessary long-term antibiotic use.

      Keywords

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      References

      1. Grabe M, Bartoletti R, Bjerklund-Johansen TE, et al. Guidelines on urological infections. European Association of Urology Web site. http://uroweb.org/wp-content/uploads/19-Urological-infections_LR2.pdf. Updated 2015.

        • Foxman B.
        Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden.
        Infect Dis Clin North Am. 2014; 28: 1-13
        • Eriksson I.
        • Gustafson Y.
        • Fagerstrom L.
        • Olofsson B.
        Do urinary tract infections affect morale among very old women?.
        Health Qual Life Outcomes. 2010; 8: 73-78
        • Abrahamian F.M.
        • Krishnadasan A.
        • Mower W.R.
        • Moran G.J.
        • Coker J.R.
        • Talan D.A.
        The association of antimicrobial resistance with cure and quality of life among women with acute uncomplicated cystitis.
        Infection. 2011; 39: 507-514
        • Fowler Jr., J.E.
        Urinary tract infections in women.
        Urol Clin North Am. 1986; 13: 673-683
        • Stamey T.A.
        Recurrent urinary tract infections in female patients: an overview of management and treatment.
        Rev Infect Dis. 1987; 9: S195-S210
        • Schaeffer A.J.
        Recurrent urinary tract infections in women. Pathogenesis and management.
        Postgrad Med. 1987; 81: 51-58
        • Rosen D.A.
        • Hooton T.M.
        • Stamm W.E.
        • Humphrey P.A.
        • Hultgren S.J.
        Detection of intracellular bacterial communities in human urinary tract infection.
        PLoS Med. 2007; 4: 1949-1958
        • Hooton T.M.
        Prevention of recurrent urogenital tract infections in adult women.
        in: Naber K.G.S.A. Heyns C.F. Matsumoto T. Shoskes D.A. Bjerklund Johansen T.E. Urogenital Infections. European Association of Urology, Arnhem, The Netherlands2010: 236-239
        • Lundstedt A.C.
        • Leijonhufvud I.
        • Ragnarsdottir B.
        • Karpman D.
        • Andersson B.
        • Svanborg C.
        Inherited susceptibility to acute pyelonephritis: a family study of urinary tract infection.
        J Infect Dis. 2007; 195: 1227-1234
        • Cai T.
        • Mazzoli S.
        • Migno S.
        • et al.
        Development and validation of a nomogram predicting recurrence risk in women with symptomatic urinary tract infection.
        Int J Urol. 2014; 21: 929-934
        • Vahlensieck W.
        Therapy strategies in recurrent urinary tract infections [in German].
        Nieren- und Hochdruckkrkh. 2015; 44: 299-306
        • Su S.B.
        • Wang J.N.
        • Lu C.W.
        • Guo H.R.
        Reducing urinary tract infections among female clean room workers.
        J Womens Health (Larchmt). 2006; 15: 870-876
        • O’Grady F.
        • Cattell W.R.
        Kinetics of urinary tract infection. II. The bladder.
        Br J Urol. 1966; 38: 156-162
        • Kunin C.M.
        Urinary tract infections. Detection, prevention, and management.
        ed 5. Lippincott Williams & Wilkins, Philadelphia, PA1997
        • Raz R.
        • Gennesin Y.
        • Wasser J.
        • et al.
        Recurrent urinary tract infections in postmenopausal women.
        Clin Infect Dis. 2000; 30: 152-156
        • Li Y.
        • Qu H.
        • Xiang Q.
        • Su Z.
        • Huang Y.
        Overview on the recent study of antimicrobial peptides: origins, functions, relative mechanisms and application.
        Peptides. 2012; 37: 207-215
        • Hertting O.
        • Holm A.
        • Luthje P.
        • et al.
        Vitamin D induction of the human antimicrobial Peptide cathelicidin in the urinary bladder.
        PLoS One. 2010; 5: e15580
        • Glaser R.
        • Harder J.
        • Lange H.
        • Bartels J.
        • Christophers E.
        • Schroder J.M.
        Antimicrobial psoriasin (S100A7) protects human skin from Escherichia coli infection.
        Nat Immunol. 2005; 6: 57-64
        • Hooton T.M.
        Recurrent urinary tract infection in women.
        Int J Antimicrob Agents. 2001; 17: 259-268
        • Moore E.E.
        • Hawes S.E.
        • Scholes D.
        • Boyko E.J.
        • Hughes J.P.
        • Fihn S.D.
        Sexual intercourse and risk of symptomatic urinary tract infection in post-menopausal women.
        J Gen Intern Med. 2008; 23: 595-599
        • Albert X.
        • Huertas I.
        • Pereiró I.I.
        • Sanfélix J.
        • Gosalbes V.
        • Perrota C.
        Antibiotics for preventing recurrent urinary tract infection in non-pregnant women.
        Cochrane Database Syst Rev. 2004; : CD001209
        • Wagenlehner F.M.
        • Vahlensieck W.
        • Bauer H.W.
        • Weidner W.
        • Piechota H.J.
        • Naber K.G.
        Prevention of recurrent urinary tract infections.
        Minerva Urol Nefrol. 2013; 65: 9-20
        • Larsson B.
        • Jonasson A.
        • Fianu S.
        Prophylactic effect of UVA-E in women with recurrent cystitis: a preliminary report.
        Curr Ther Res. 1993; 53: 441-443
        • Dudar I.O.
        • Loboda O.M.
        • Krot V.F.
        • Khimich V.I.
        • Kryzhanivska V.M.
        • Bryzhachenko T.P.
        12-month comparative study of administration of Canephron® N in the treatment of patients with the urinary tract infection.
        Health of Man Ukraine. 2009; 3: 85-90
        • Kontiokari T.
        • Sundqvist K.
        • Nuutinen M.
        • Pokka T.
        • Koskela M.
        • Uhari M.
        Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women.
        BMJ. 2001; 322: 1571
        • Stothers L.
        A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women.
        Can J Urol. 2002; 9: 1558-1562
        • Jepson R.G.
        • Williams G.
        • Craig J.C.
        Cranberries for preventing urinary tract infections.
        Cochrane Database Syst Rev. 2012; : CD001321
        • Lee B.
        • Bhuta T.
        • Craig J.
        • Simpson J.
        Methenamine hippurate for preventing urinary tract infections.
        Cochrane Database Syst Rev. 2002; : CD003265
        • Fuenfstueck R.
        • Straube E.
        • Schildbach O.
        • Tietz U.
        Prevention of reinfection by L-methionine in patients with recurrent urinary tract infection [in German].
        Med Klin (Munich). 1997; 92: 574-581
        • Günther M.
        • Noll F.
        • Nützel R.
        • Gläser E.
        • Kramer G.
        • Stöhrer M.
        Prophylaxis of urinary tract infections [in German].
        Urologe B. 2002; 42: 218-220
        • Naber K.G.
        • Cho Y.H.
        • Matsumoto T.
        • Schaeffer A.J.
        Immunoactive prophylaxis of recurrent urinary tract infections: a meta-analysis.
        Int J Antimicrob Agents. 2009; 33: 111-119
        • Beerepoot M.A.
        • Geerlings S.E.
        • van Haarst E.P.
        • van Charante N.M.
        • ter Riet G.
        Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials.
        J Urol. 2013; 190: 1981-1989
        • Uehling D.T.
        • Hopkins W.J.
        • Elkahwaji J.E.
        • Schmidt D.M.
        • Leverson G.E.
        Phase 2 clinical trial of a vaginal mucosal vaccine for urinary tract infections.
        J Urol. 2003; 170: 867-869
        • Riedasch G.
        • Moehring K.
        Immunotherapy in women with recurrent urinary tract infections [in German].
        Therapiewoche. 1986; 6: 896-900
        • Anukam K.C.
        • Osazuwa E.
        • Osemene G.I.
        • Ehigiagbe F.
        • Bruce A.W.
        • Reid G.
        Clinical study comparing probiotic Lactobacillus GR-1 and RC-14 with metronidazole vaginal gel to treat symptomatic bacterial vaginosis.
        Microbes Infect. 2006; 8: 2772-2776
        • Stapleton A.E.
        • Au-Yeung M.
        • Hooton T.M.
        • et al.
        Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection.
        Clin Infect Dis. 2011; 52: 1212-1217
        • Kranjcec B.
        • Papeš D.
        • Altarac S.
        D-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial.
        World J Urol. 2014; 32: 79-84
        • Madersbacher H.
        • van Ophoven A.
        • van Kerrebroeck P.E.
        GAG layer replenishment therapy for chronic forms of cystitis with intravesical glycosaminoglycans–a review.
        Neurourol Urodyn. 2013; 32: 9-18
        • Raz R.
        Urinary tract infections in postmenopausal women.
        in: Naber K.G.S.A. Heyns C.F. Matsumoto T. Shoskes D.A. Bjerklund Johansen T.E. Urogenital Infections. European Association of Urology, Arnhem, The Netherlands2010: 225-234
        • Schaeffer A.J.
        • Stuppy B.A.
        Efficacy and safety of self-start therapy in women with recurrent urinary tract infections.
        J Urol. 1999; 161: 207-211
        • Pfau A.
        • Sacks T.G.
        Effective prophylaxis for recurrent urinary tract infections during pregnancy.
        Clin Infect Dis. 1992; 14: 810-814
      2. L’Agence française de sécurité sanitaire des produits de santé (afssaps). Nitrofurantoïne et risqué de survenue d’effets indésirables hépatiques et pulmonaires lors de traitements prolongés. Pharmacovigilance 2011. Infectiologie Web site. http://www.infectiologie.com/site/medias/_documents/consensus/lp-110311-%20nitrofurantoine.pdf

        • Cai T.
        • Mazzoli S.
        • Mondaini N.
        • et al.
        The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: to treat or not to treat?.
        Clin Infect Dis. 2012; 55: 771-777
        • Sunden F.
        • Hakansson L.
        • Ljunggren E.
        • Wullt B.
        Escherichia coli 83972 bacteriuria protects against recurrent lower urinary tract infections in patients with incomplete bladder emptying.
        J Urol. 2010; 184: 179-185
        • Darouiche R.O.
        • Green B.G.
        • Donovan W.H.
        • et al.
        Multicenter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder.
        Urology. 2011; 78: 341-346