Prophylactic Treatment for UTIs in Patients with Bacterial Vaginosis
For patients with bacterial vaginosis (BV) who experience recurrent urinary tract infections (UTIs), antibiotic prophylaxis is recommended to decrease the risk of future UTIs, following appropriate treatment of the underlying BV. 1
Treatment of Underlying Bacterial Vaginosis
Before addressing prophylactic UTI treatment, the underlying BV must be properly treated:
Recommended BV Treatment Regimens:
- Metronidazole 500 mg orally twice a day for 7 days 1
- OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days 1
- OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1
Alternative BV Treatment Regimens:
- Metronidazole 2 g orally in a single dose (note: lower efficacy than other regimens) 1
- OR Clindamycin 300 mg orally twice a day for 7 days 1
- OR Clindamycin ovules 100 g intravaginally once at bedtime for 3 days 1
Prophylactic UTI Treatment Options
After successful BV treatment, the following prophylactic options can be considered for recurrent UTIs:
Antibiotic Prophylaxis:
- Daily antibiotic prophylaxis for 6-12 months is the most tested schedule for preventing recurrent UTIs 1
- Common prophylactic antibiotics include TMP, TMP-SMX, nitrofurantoin, and cephalexin 1
- For UTIs related to sexual activity, post-coital antibiotic prophylaxis is effective and associated with fewer adverse events 1
Non-Antibiotic Prophylaxis:
- Cranberry products may be offered as prophylaxis for recurrent UTIs 1
- For postmenopausal women, vaginal estrogen replacement is strongly recommended 2
- Immunoactive prophylaxis is recommended for women of all age groups 2
- Methenamine hippurate is recommended for women without urinary tract abnormalities 2
Special Considerations
- For patients with BV and recurrent UTIs, the combination of standard antibiotic therapy followed by vaginal probiotics has been shown to reduce recurrence of both BV and UTIs by up to 18.3% compared to standard therapy alone 3
- Avoid surveillance urine testing in asymptomatic patients with recurrent UTIs 1
- Do not treat asymptomatic bacteriuria in non-pregnant patients 1
- Recognize that recurrent UTIs significantly impact quality of life, affecting social and sexual relationships, self-esteem, and work capacity 2
Treatment Pitfalls to Avoid
- Avoid fluoroquinolones as first-line empiric therapy due to increasing resistance and adverse effects 2
- Be aware that all antibiotics have potential risks, including nitrofurantoin which has rare but serious risks of pulmonary and hepatic toxicity 1
- Treatment of male sex partners has not been beneficial in preventing recurrence of BV and is not recommended 1
- For patients with recurrent BV, consider extended treatment courses (metronidazole 500 mg twice daily for 10-14 days) before initiating UTI prophylaxis 4