What is the best management approach for recurrent Urinary Tract Infections (UTIs) in patients performing intermittent urinary catheterization?

From the Guidelines

The most effective management approach for recurrent UTIs in patients performing intermittent catheterization is to optimize catheterization technique and use targeted antimicrobial coverage when necessary, rather than relying on daily antibiotic prophylaxis, as recommended by the most recent guidelines 1.

Key Considerations

• Optimize catheterization technique by ensuring proper hand hygiene, using clean or sterile catheters, and maintaining an appropriate catheterization schedule (typically 4-6 times daily) to reduce the risk of UTIs.
• Consider urine cultures before starting any prophylaxis to guide antibiotic selection, as recommended by various studies 1.
• For breakthrough infections, treat with a full course of appropriate antibiotics based on culture results, rather than using daily antibiotic prophylaxis, which may lead to increased bacterial resistance 1.
• Ensure adequate hydration (2-3 liters daily) to promote regular bladder emptying and reduce the risk of UTIs.

Prophylaxis Options

• Methenamine hippurate 1g twice daily can be used as a non-antibiotic alternative for prophylaxis, as it has been shown to be effective in preventing UTIs in some studies.
• Cranberry products (tablets or juice) may provide additional benefit by preventing bacterial adherence to the bladder wall, although the evidence for their effectiveness is limited.

Important Recommendations

• Do not use daily antibiotic prophylaxis in patients who manage their bladders with clean intermittent catheterization and do not have recurrent urinary tract infections, as recommended by the AUA/SUFU guideline 1.
• Consider the potential risks and benefits of antibiotic prophylaxis, including the development of antibiotic-resistant bacteria, and use targeted antimicrobial coverage when necessary.
• Regularly reassess the need for prophylaxis and adjust the treatment plan as needed to minimize the risk of UTIs and promote optimal bladder health.

From the FDA Drug Label

Methenamine hippurate tablets is indicated for prophylactic or suppressive treatment of frequently recurring urinary tract infections when long-term therapy is considered necessary. The best management approach for recurrent Urinary Tract Infections (UTIs) in patients performing intermittent urinary catheterization is prophylactic or suppressive treatment with an antibacterial agent such as methenamine hippurate tablets, after eradication of the infection by other appropriate antimicrobial agents 2.

• The choice of antibacterial agent should be based on culture and susceptibility information, when available.
• In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy. It is essential to use antibacterial agents only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria, to reduce the development of drug-resistant bacteria and maintain the effectiveness of the antibacterial drugs.

From the Research

Management of Recurrent UTI in Patients Performing Intermittent Urinary Catheterization

• The management of recurrent Urinary Tract Infections (UTIs) in patients performing intermittent urinary catheterization is a complex issue, with various studies providing insights into the best approaches 3, 4, 5, 6, 7.
• A study published in 1987 found that suppressive antibiotics, treatment of asymptomatic urinary tract infections, and full-course antibiotic therapy offered no advantage over placebo, treatment of symptomatic urinary tract infection only, and short-course therapy in the management of urinary tract infection in patients with an intermittently catheterized neurogenic bladder 3.
• Another study published in 2022 compared methenamine hippurate with trimethoprim for the prevention of recurrent UTI and found no difference between groups in recurrent UTI, with a 65% recurrence rate in both groups 4.
• A scoping review published in 2020 summarized evidence related to adherence to intermittent catheterization, complication rates, satisfaction with IC, and its effect on health-related quality of life, and found that urinary tract infections are the most common complication of IC, and that prophylactic antibiotic therapy may reduce the risk of recurrent UTIs 5.
• A literature review published in 2012 found that the most frequent complication of clean intermittent catheterization is urinary tract infection, and that treatment in those who catheterize for a long time is only necessary for symptomatic infections 6.
• A review of intermittent catheterization and current best practices published in 2011 provided an overview of the indications, use, and complications associated with intermittent catheterization, and presented current guidelines on self-catheterization and treatment of catheter-associated complications 7.

Prevention and Treatment of UTIs

• The use of prophylactic antibiotics, such as trimethoprim or methenamine hippurate, may be considered for the prevention of recurrent UTIs in patients performing intermittent urinary catheterization 4, 5.
• Treatment of symptomatic urinary tract infections is necessary, while asymptomatic infections may not require treatment 3, 6.
• The type of catheter used may also play a role in the prevention of UTIs, with some studies suggesting that special catheter types may be beneficial 6.

Future Research Directions

• Further research is needed to determine the best approaches for the prevention and treatment of recurrent UTIs in patients performing intermittent urinary catheterization 4, 5, 6.
• Studies should investigate the role of biofilms in CIC, the use of special catheter types, and the impact of frequency of catheterization and preservation of natural defense mechanisms in the lower urinary tract on the risk of UTIs 6.