Prevention of Urinary Tract Infection (UTI)

Prevention of Urinary Tract Infection (UTI)

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Approximately 25% of women with acute cystitis develop recurrent urinary tract infections (UTIs). (See Urinary Tract Infections in Females.) The number of recurrences experienced varies for each woman (range, 0.3-7.6 episodes per year), and recurrences often cluster in time. Most recurrent infections are from bacteria colonizing the fecal or periurethral reservoirs. [1]

Women who develop a UTI within 2 weeks of a treated UTI either have a new infection or have a recurrence of the infection caused by the original uropathogen. The latter is supported by cultures that grow the same species, especially if it is biotyped or shares the same antimicrobial sensitivities. Looking for a source of persistent infection, such as a structural abnormality (eg, calculus, abscess, cystic disease), is prudent.

Prevention of UTIs has become even more important because of the recognition of what has been described a “stealth pandemic” of Escherichia coli sequence type 131 (ST131) that is resistant to both fluoroquinolones and extended spectrum beta-lactamases. Across the board, E coli is responsible for at least 80% of the 7 million uncomplicated outpatient UTIs that occur yearly in the United States. E coli ST131, is becoming more frequently isolated from clinical cases. [2]

The 3 main risk factors for recurrent urinary tract infection (UTI) in women are an increased frequency of sexual intercourse, the use of a spermicide and diaphragm, and the loss of estrogen’s effect in the vagina and periurethral structures. The last 2 situations lead to eradication of the vaginal lactobacilli. Patients using a spermicide should consider alternative methods of contraception.

Women with 2 or 3 recurrent UTIs yearly may benefit from behavioral modification. Behavioral modifications are generally easy, low-risk, and low-cost maneuvers.

A study of 140 women with recurrent UTIs showed that increased fluid intake reduces the risk of repeat infections. The study participants were otherwise healthy premenopausal women who had experienced three or more UTIs in the preceding year and who self-reported low fluid intake (<1.5 liters/day). The intervention group was instructed to increase their water intake by an additional 1.5 liters per day, while the control group was instructed to continue with their usual intake. At one year, the intervention group had experienced 48% fewer UTIs than the control group. The only fluid involved in the study was water, although other fluids would probably provide similar results, and the benefits would probably also apply to postmenopausal women. In addition, the intervention group used 47% fewer courses of antibiotics than the control group (1.8 vs 3.5; P<0.0001).<ref>3</ref>

Sexually active women may attempt voiding immediately after intercourse to lessen the risk of coitus-related introduction of bacteria into the bladder. Some authors recommend large urinary flow volumes as a measure that will reduce the risk of UTI.

Drinking cranberry juice (10 oz/day) or taking cranberry tablets may offer some benefit in reducing recurrent UTI and does not appear to be harmful. The positive effect appears mainly to women with recurrent UTIs [4]

One study found lower rates of UTI recurrence in women who drank 50 mL of cranberry-lingonberry concentrate daily for 6 months. [5] The mechanism of action of cranberry juice has not been fully clarified. [6] The juice is bacteriostatic perhaps due to hippuric acid. Another mechanism may involve suppression of Escherichia coli fimbriae by proanthocyanidins (tannins). This theoretically should be under the attachment of urinary pathogens to the bladder mucosal cells. The studies conducted have generally been flawed because of small numbers, unknown amounts of active ingredients, and a high rate of nonadherence to drinking adequate amounts of cranberry juice. [7] Ascorbic acid (vitamin C) has no preventative growth because it does not cause significant urinary acidification.

Self-initiated antibiotic therapy may be an acceptable alternative for women with recurrent UTIs. The clinician should educate the patient about the warning signs of a persistent or worsening infection despite therapy.

In one study, women with a history of at least 2 urinary tract infections (UTIs) in the past year proved capable of self-diagnosing and treating UTIs. [8] Uropathogens were isolated in 84% of 172 UTIs and sterile pyuria in 11%; clinical and microbiologic cures were achieved in about 95% of episodes. Self-treatment consisted of ofloxacin tablets, 200-mg tablets taken twice daily for 3 days if UTI symptoms developed, or levofloxacin, 250-mg tablets taken once daily for 3 days.

A study from China evaluated patient-initiated single-dose antibiotic prophylaxis and continuous long-term low-dose daily antibiotic use for the prevention of recurrent UTI in 68 postmenopausal women, finding that the former was as effective as the latter and was associated with fewer gastrointestinal adverse events. [9]

Women with more than 3 recurrent UTIs yearly should be considered for more aggressive prophylactic regimens in addition to behavioral modification. Women whose recurrent UTIs are associated with sexual intercourse should be offered postcoital prophylaxis. This involves taking a single dose of an effective antimicrobial (eg, nitrofurantoin 50 mg, trimethoprim-sulfamethoxazole [TMP-SMX] 40/200 mg, or cephalexin 500 mg) after sexual intercourse.

A double-blind, double-dummy noninferiority trial found that TMP-SMX (480 mg once daily) is more effective than cranberry capsules (500 mg twice daily) in preventing recurrent UTIs. However, after 1 month, patients in the TMP-SMX group showed increased resistance to the antibiotic as well as to trimethoprim, amoxicillin, and ciprofloxacin. This resistance reached baseline levels 3 months after discontinuance. [10]

Continuous antimicrobial prophylaxis may be required for women in whom a postcoital regimen fails; women who do not associate frequent UTIs with a modifiable cause; or those who are at risk for recurrent complicated UTIs. Regimens include the following:

TMP-SMX – 40/200 mg at bedtime or 3 times weekly

Nitrofurantoin – 50-100 mg at bedtime or 3 times weekly

Norfloxacin – 200 mg at bedtime or 3 times weekly

Trimethoprim – 100 mg at bedtime or 3 times weekly

These regimens have been shown to be safe and effective, even after 5 years of use. However, after 6-12 months, a trial without the medication is warranted, because as many as 30% of women experience a prolonged UTI-free period. Prophylaxis may be reinstituted if the patient again develops recurrent UTIs.

Postmenopausal women who have recurrent UTIs may benefit from estrogen replacement, either systemic or local. A randomized, double-blind, placebo-controlled trial in 93 postmenopausal women found that estriol in a vaginal cream (0.5 mg nightly for 2 weeks, then twice weekly for 8 months) significantly reduced the incidence of recurrent UTI. [11] The effect probably is related to the restoration of lactobacilli, which replace Enterobacteriaceae and decrease the vaginal pH.

For patients with spinal cord injury, the efficacy of prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin has been demonstrated. The possibility of developing resistant organisms is a concern, especially in an institutional setting. One option includes the use of methenamine (1 g 3 times daily), alternating every 2 months with nitrofurantoin (50-100 mg twice daily). Methenamine is converted into formic acid, which is bactericidal.

Risk can also be decreased by the use of intermittent catheterization. (See Urinary Tract Infections in Spinal Cord Injury Patients and Urethral Catheterization in Women.)

Many steps can be taken to prevent catheter-associated urinary tract infections (UTIs). [12] These steps can postpone the development of a UTI for weeks but are not likely to be successful in chronically catheterized patients. One to three days of antibiotic prophylaxis at the time of catheter removal results in a decrease a symptomatic UTIs. This should probably be considered in patients who are severely immunosuppressed, not as a general practice, which may result in a significant increase in the use of antibiotics in hospitalized patients. [13] (See Catheter-Related Urinary Tract Infections and Urethral Catheterization in Women.)

UTI is an important complication after renal transplantation, especially in the initial months after the procedure, and can result in graft failure and patient mortality. Prophylaxis with TMP-SMX (1 tablet/day orally), beginning 2-4 days after surgery and continuing for 4-8 months, can reduce the incidence of UTIs (especially after catheter removal), febrile hospital days, bacterial infections (during and after hospitalization), and graft rejection.

Nosseir SB, Lind LR, Winkler HA. Recurrent Uncomplicated Urinary Tract Infections in Women: A Review. J Womens Health (Larchmt). 2011 Dec 2. [Medline].

Lautenbach E. Editorial commentary: flying under the radar: the stealth pandemic of Escherichia coli sequence type 131. Clin Infect Dis. 2013 Nov. 57(9):1266-9. [Medline].

Frellick M. Drinking More Water Reduces Repeat Urinary Tract Infections. Medscape Medical News. Available at http://www.medscape.com/viewarticle/886775. October 9, 2017; Accessed: October 10, 2017.

Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008 Jan 23. CD001321. [Medline].

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 Jun 30. 322(7302):1571. [Medline]. [Full Text].

Barbosa-Cesnik C, Brown MB, Buxton M, Zhang L, DeBusscher J, Foxman B. Cranberry juice fails to prevent recurrent urinary tract infection: results from a randomized placebo-controlled trial. Clin Infect Dis. 2011 Jan 1. 52 (1):23-30. [Medline].

Jepson R, Craig J, Williams G. Cranberry products and prevention of urinary tract infections. JAMA. 2013 Oct 2. 310(13):1395-6. [Medline].

Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med. 2001 Jul 3. 135(1):9-16. [Medline]. [Full Text].

Zhong YH, Fang Y, Zhou JZ, Tang Y, Gong SM, Ding XQ. Effectiveness and Safety of Patientinitiated Single-dose versus Continuous Low-dose Antibiotic Prophylaxis for Recurrent Urinary Tract Infections in Postmenopausal Women: a Randomized Controlled Study. J Int Med Res. 2011. 39(6):2335-43. [Medline].

Beerepoot MA, ter Riet G, Nys S, van der Wal WM, de Borgie CA, de Reijke TM, et al. Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. Arch Intern Med. 2011 Jul 25. 171(14):1270-8. [Medline].

Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. 1993 Sep 9. 329(11):753-6. [Medline]. [Full Text].

[Guideline] Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr. 31(4):319-26. [Medline]. [Full Text].

Marschall J, Carpenter CR, Fowler S, Trautner BW. Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis. BMJ. 2013 Jun 11. 346:f3147. [Medline]. [Full Text].

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Prevention of Urinary Tract Infection (UTI)

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