WASHINGTON – Recurring, uncomplicated urinary tract infections in female patients may be treated in the future through bacterial interference and other novel approaches, but for now, treatment involves an individualized approach with possible postcoital prophylaxis, chronic low-dose prophylaxis, or self-therapy, said urologist Robert M. Moldwin.
Addressing the case of a 35-year-old, otherwise-healthy woman who has had three culture-documented, symptomatic bacterial cystitis episodes over the last 3 months, Dr. Moldwin said that chronic low-dose prophylaxis may be considered when recurring infections are not related to intercourse.
Chronic prophylaxis should be reserved for frequently recurring infections, he emphasized, and the “goal is to grade down on the dose arbitrarily over a 6- to 12-month span, perhaps going to every other night or every third night, and then hopefully discontinuing this regime altogether,” he said during a panel discussion on UTIs at the meeting.
The two agents that are best supported in the literature for chronic low-dose prophylaxis are nitrofurantoin and methenamine hippurate. Trimethoprim-sulfamethoxazole and early generation cephalosporins “have also been espoused,” said Dr. Moldwin of Hofstra University, Hempstead, N.Y.
“Unfortunately, though,” he said, “recurrent infections are bound to show up at some point when prophylaxis is discontinued.”
Self-therapy can “really pay off” in cases in which infections are recurring less frequently, and it can also be “a great protocol to institute when one takes a patient off of antibiotic prophylaxis,” said Dr. Moldwin, also of the Arthur Smith Institute for Urology in New Hyde Park, N.Y.
In this scenario, the patient is armed with a sterile collection cup, a urinalysis and urine culture prescription, and a prescription for an antibiotic. “At the first sign of infection, the patient is instructed to obtain a midstream urine sample … and start [herself] on an appropriate course of an antibiotic,” he said. “Within 24-48 hours, the patient can bring the specimen to the local laboratory” and can have the results sent to her physician for analysis if symptoms don't resolve, he added.
Cranberry juice has been touted for UTI prevention because it contains various chemicals that may prevent bacterial adherence to the bladder wall. Evidence that was published several years ago concluded that “after many disclaimers, [there] is some evidence to recommend cranberry juice for the prevention of uncomplicated UTIs in women with symptomatic infections,” a randomized clinical trial published this year showed no difference in UTI recurrence between patients who used cranberry juice and those who used placebo (Clin. Infect. Dis. 2011;52:23-30), Dr. Moldwin said.
The trial of 319 college students is “the most recent and probably the best” that has been published to date, he said.
A Google search shows 45,000-61,000 hits, he said, but a Pub Med search on
Other forms of bacterial interference may prove efficacious, however. The use of vaginal or oral probiotics, for instance, or the introduction of nonpathogenic Escherichia coli “to the vaginal vault, the gut, or even the bladder itself” are among the “novel and viable options that we hope to see more work on in the future,” he said.
There is some evidence to recommend cranberry juice for prevention of recurring uncomplicated UTIs.
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