How to prevent recurrent urinary tract infections (UTIs) in patients with diabetes mellitus (DM)

From the Guidelines

Preventing recurrent urinary tract infections (UTIs) in patients with diabetes mellitus (DM) should prioritize methenamine hippurate as a first-line intervention, given its strong recommendation and non-inferiority to antibiotics in preventing UTIs, as evidenced by recent studies 1. To prevent recurrent UTIs in patients with DM, consider the following strategies:

• Maintain optimal glycemic control, aiming for HbA1c levels below 7% through medication adherence and lifestyle modifications, as high blood sugar creates an ideal environment for bacterial growth.
• Ensure adequate hydration by drinking 2-3 liters of water daily to flush bacteria from the urinary tract.
• Practice proper hygiene, including wiping front to back after urination and emptying the bladder completely.
• For women, avoid douches, spermicides, and consider switching from diaphragms to alternative contraception methods.
• Consider cranberry products (unsweetened juice or supplements with 36 mg proanthocyanidins daily) to help prevent bacterial adhesion to urinary tract walls, although the evidence is weak and contradictory 1.
• For patients with 3 or more UTIs per year, antibiotic prophylaxis may be considered, such as low-dose nitrofurantoin (50-100 mg daily), trimethoprim-sulfamethoxazole (40/200 mg daily), or cephalexin (250 mg daily) for 6-12 months, but methenamine hippurate is a preferred alternative due to its antimicrobial-sparing properties 1.
• Postmenopausal women might benefit from vaginal estrogen therapy if not contraindicated, as it has a strong recommendation for preventing recurrent UTIs 1. Regular urologic evaluation is important to identify structural abnormalities, and patients should promptly report UTI symptoms (burning, frequency, urgency) for early treatment. These strategies are particularly important for diabetic patients as they have higher UTI risk due to immune dysfunction, glycosuria providing bacterial nutrients, and often experience autonomic neuropathy affecting bladder emptying.

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. To prevent recurrent UTI in patients with DM, methenamine hippurate can be used as a prophylactic or suppressive treatment, but only after the infection has been eradicated by other appropriate antimicrobial agents 2.

• The drug should be used to treat or prevent infections caused by susceptible bacteria.
• Culture and susceptibility information should be considered when selecting or modifying antibacterial therapy.

From the Research

Prevention of Recurrent UTI in Patients with DM

To prevent recurrent UTI in patients with diabetes mellitus (DM), several strategies can be employed:

• Cranberry products: Cranberry products, such as juice or tablets, have been shown to reduce the risk of UTIs in certain populations, including women with recurrent UTIs and children 3, 4.
• Methenamine hippurate: Methenamine hippurate may be an alternative to low-dose antibiotics for the prevention of recurrent UTIs, with similar rates of recurrence and adverse effects to trimethoprim 5.
• Prophylactic regimens: Different prophylactic regimens, such as antimicrobial therapy, can be used to reduce exposure to antibiotics and prevent recurrent UTIs 6.
• Lifestyle modifications: Lifestyle modifications, such as increasing fluid intake and practicing good hygiene, may also help prevent recurrent UTIs.

Specific Considerations for Patients with DM

Patients with DM may be at increased risk for UTIs due to factors such as impaired immune function and neuropathy. Therefore, it is essential to:

• Monitor blood sugar levels: Keeping blood sugar levels under control can help prevent UTIs in patients with DM.
• Practice good hygiene: Practicing good hygiene, such as wiping from front to back and washing hands after using the bathroom, can help prevent UTIs.
• Stay hydrated: Drinking plenty of water can help flush out bacteria and prevent UTIs.

Additional Considerations

Additional considerations for preventing recurrent UTIs in patients with DM include:

• Avoiding unnecessary antibiotic use: Avoiding unnecessary antibiotic use can help prevent the development of antibiotic-resistant bacteria.
• Using alternative treatments: Using alternative treatments, such as cranberry products or methenamine hippurate, may be effective in preventing recurrent UTIs and reducing antibiotic use 5, 3, 4.