UTIs (Bladder Infections) – The Call for Prevention

I found a recent article in the New York Times (NYTs) about resistant UTIs1 to be timely and disturbing. It noted the New York City (NYC) Department of Health’s concern about drug-resistant UTIs and a new mobile phone app that gives prescribers access to a list of UTIs organisms and which drugs they are resistant to.  

The NYC Department of Health has found that an uncomplicated UTIs caused by the most common bacteria, E. coli was resistant to Bactrim, my go-to drug in many women who present with a recurrent uncomplicated UTI. Not surprising was that resistance to antibiotics has become one of the world’s most pressing health issues.  The concern is especially for women in reproductive years, as they are 50 times more likely than men to have a UTI; dropping to a ratio of 2 to 1 later in life. The NYTs article attributed UTI resistance to the overuse of these drugs in humans and livestock causing germs to develop defenses to survive, rendering a growing number of medicines ineffective in treating a wide range of illnesses, one of which are UTIs. I agree with the article about the need for clinicians to be more judicious when prescribing antibiotics.

I recently saw a 45 year old woman referred for evaluation of recurrent UTIs who reported being resistant to all commonly prescribed antibiotics. I am sure many reading this blog have had similar referrals. Of course, that is the best approach but I feel a more important approach to those adolescent girls and women with recurrent uncomplicated UTIs to prescribe preventive measures. Although the evidence for most preventive measures we routinely recommend to patients (e.g. increased fluid intake, ingestion of cranberry, transvaginal estrogen in post-menopausal women, etc.) may not be as supported as we like, clinicians need to be proactive in advancing what is known in this area.

A rapid review by my colleagues provides the current evidence and an algorithm for clinicians.2 Immediate increase in fluid intake, specifically water, once symptoms start is one measure I always recommend. Hooton and colleagues (2018) randomly assigned 163 healthy premenopausal women with recurrent cystitis (> three episodes) who were drinking less than 1.5 liters of fluid daily to either drinking (in addition to their usual fluid intake) 1.5 liters of water daily or no additional fluids for twelve months.

Primary outcome measures were frequent of recurrent cystitis over the twelve months and secondary outcome measures were the number of antimicrobial regimens used. Outcomes showed that increased water intake was an effective anti-microbial sparing strategy in preventing recurrent cystitis.3 

There have been recent professional guidelines to assist clinicians in diagnosing and treating UTIs, including an update on the management of asymptomatic bacteriuria by the Infectious Diseases Society of America.4

Also, recent guidelines on recurrent uncomplicated UTIs in women have been released by the American Urological Association, the Canadian Urological Association and the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction. These guidelines address recurrent UTIs, reviewing antibiotic prophylaxis and discusses non-antibiotic prophylaxis including the use of cranberry and transvaginal estrogen in post-menopausal women.5 I suggest you review these publications and proactively develop a prevention strategy for your patients.

Written by: Diane Newman, DNP, CRNP, FAAN, BCB-PMD, Nurse Practitioner (NP), Co-Director, Penn Center for Continence and Pelvic Health Director, Clinical Trials, Division of Urology, Adjunct Professor of Urology in Surgery, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Published Date: September 3rd, 2019

References:
1. Richtel, M. (2019). What You Need to Know About Resistant Urinary Tract Infections. Retrieved 8 August 2019, from https://www.nytimes.com/2019/07/13/health/uti-drug-resistant-info.html?action=click&module=Top%20Stories&pgtype=Homepage
2. Smith AL, Brown J, Wyman JF, Berry A, Newman DK, Stapleton AE. Treatment and prevention of recurrent lower urinary tract infections in women: A rapid review with practice recommendations. J Urol. 2018 Dec;200(6):1174-1191. doi: 10.1016/j.juro.2018.04.088
3. Hooton TM, Vecchio M, Iroz A, Tack I, Dornic Q, Seksek I, Lotan Y. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: A randomized clinical trial. JAMA Intern Med. 2018 Nov 1;178(11):1509-1515. doi: 10.1001/jamainternmed.2018.4204
4. Nicolle et al., Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 Mar 21. pii: ciy1121. doi: 10.1093/cid/ciy1121. https://www.idsociety.org/globalassets/idsa/practice-guidelines/2019-asymptomatic-bacteriuria.pdf
5. Recurrent Uncomplicated Urinary Tract Infections In Women: AUA/CUA/SUFU Guideline (2019) - American Urological Association. 2019. Auanet.Org. https://www.auanet.org/guidelines/recurrent-uti.
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