What are other treatments for recurrent urinary tract infections (UTIs)?

Treatments for Recurrent Urinary Tract Infections

For recurrent urinary tract infections (rUTIs), a stepwise approach should be implemented starting with non-antimicrobial interventions before considering antimicrobial prophylaxis, with methenamine hippurate and vaginal estrogen (for postmenopausal women) being strongly recommended first-line options.

Diagnostic Approach

• Confirm recurrent UTI diagnosis via urine culture before initiating any treatment 1
• Recurrent UTIs are defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 1
• Extensive workup (cystoscopy, abdominal ultrasound) is not routinely recommended for women under 40 years without risk factors 1

Non-Antimicrobial Interventions (First-Line)

• Behavioral and Lifestyle Modifications:

  • Increased fluid intake for premenopausal women 1
  • Avoidance of spermicide-containing contraceptives 1

• Strongly Recommended Options:

  • Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1
  • Vaginal estrogen replacement for postmenopausal women (strong recommendation) 1
  • Immunoactive prophylaxis (e.g., OM-89/Uro-Vaxom) for all age groups (strong recommendation) 1

• Additional Options with Weaker Evidence:

  • Cranberry products (minimum 36 mg/day proanthocyanidin A), though evidence is contradictory 1
  • D-mannose, though evidence is weak and contradictory 1
  • Probiotics with specific strains (Lactobacillus rhamnosus GR-1 or Lactobacillus reuteri RC-14) 1
  • Endovesical instillations of hyaluronic acid or combination with chondroitin sulfate for patients where other approaches have failed 1
  • Acupuncture for patients unresponsive to or intolerant of antibiotic prophylaxis 1

Antimicrobial Prophylaxis (When Non-Antimicrobial Interventions Fail)

• Continuous Prophylaxis:

  • Only after non-antimicrobial measures have failed 1
  • Options include trimethoprim-sulfamethoxazole, trimethoprim, nitrofurantoin, cefaclor, cephalexin, or fosfomycin 1
  • Typical regimens: nitrofurantoin 50mg daily, trimethoprim-sulfamethoxazole half tablet twice weekly, or once weekly 2, 3
  • Duration typically 6-12 months 1
  • Can reduce infection rates by approximately 90% 4

• Post-Coital Prophylaxis:

  • For patients with UTIs associated with sexual intercourse 1
  • Single dose of antibiotic taken after sexual activity 5

• Self-Administered Short-Term Therapy:

  • For patients with good compliance 1
  • Patient-initiated treatment at onset of symptoms 1, 6
  • Requires patient education and reliable follow-up 1

Special Considerations

• Before initiating antimicrobial prophylaxis, confirm eradication of previous UTI with negative urine culture 1-2 weeks after treatment 1
• Choice of antimicrobial should be based on identification and susceptibility pattern of the causative organism 1, 3
• Prophylactic antibiotics have been shown to significantly reduce UTI episodes, emergency room visits, and hospital admissions 3
• Continuous antibiotic prophylaxis should be considered a last resort due to concerns about antibiotic resistance and adverse effects 6, 4

Pitfalls and Caveats

• Avoid treating asymptomatic bacteriuria, especially in older adults 6
• Avoid fluoroquinolones for uncomplicated UTIs due to resistance concerns and adverse effects 6
• Antimicrobial prophylaxis can reduce gut and vaginal flora diversity and potentially select for resistant organisms 4
• Despite evidence supporting continuous antibiotic prophylaxis efficacy, it is underutilized (only 55% of eligible patients) 3
• Non-pharmacological interventions and specialist referrals (urology, gynecology) are frequently overlooked in management 3