Clinical Notes : Urology

159. Recurrent UTI prescribing

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Recurrent UTI prescribing

 

Recurrent UTI prescribing

This guideline sets out an antimicrobial prescribing strategy for preventing recurrent urinary tract infections in children, young people and adults who do not have a catheter. It aims to optimise antibiotic use and reduce antibiotic resistance.

 

UTI (recurrent): antimicrobial prescribing

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Choice of antibiotic: people aged 16 years and over

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Choice of antibiotic: children and young people under 16 years

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Antibiotic treatment

  • Antibiotic stewardship requires careful, reasonable, and accountable use of antibiotics to preserve their value and efficacy

    • follow the recommendations regarding choice of antibiotic when sensitivities are provided with microbiological results

 

  • Choice of antibiotic is based on a variety of factors, including:

    • pathogens identified from urine culture

    • local variations in resistance and susceptibility patterns 

    • comorbidities; e.g. nitrofurantoin should be used cautiously in patients with renal impairment

      • refer to summaries of product characteristics for precautions and warnings

    • interactions with concomitant drugs; e.g. folate antagonism may occur when trimethoprim is used with methotrexate

      • refer to summaries of product characteristics for drug interactions

    • multiple antibiotics should not be combined unless on expert advice 

 

  • A 3-day course of antibiotics is usually sufficient for most adult non‑pregnant women over 16 years of age

    • if the patient remains symptomatic at the end of this course, reassess the diagnosis and consider continuing antibiotics after obtaining an MSU for culture and sensitivities

 

  • Patients with recurrent UTI can be treated via three approaches:

    • self-start antibiotics

      • many patients with recurrent UTI can accurately self‑diagnose new episodes; these patients can access antibiotics via repeat prescription, keeping a course at home to start when they develop the first symptoms of an infection

        • limit the number of repeats so that patients are reviewed after six courses

      • consider monitoring to ensure that patients are not acquiring antibiotic‑resistant organisms

    • continuous antibiotic prophylaxis

      • patients take low-dose antibiotics daily to prevent recurrence

      • consider non-antibiotic prophylaxis for all patients before starting continuous antibiotic prophylaxis

        • non-antibiotic prophylaxis may be continued as combination therapy if continuous antibiotic prophylaxis is started later

      • ask the patient to try no treatment after 3–6 months without infection and restart if UTI recurs

        • a single UTI following the cessation of prophylactic treatment is not uncommon, and patients should be informed of this possibility 

        • the recommencement of prophylactic treatment should not be triggered by a single UTI after completion of a period of prophylactic treatment

      • if a patient develops a breakthrough infection while on antibiotic prophylaxis:

        • stop prophylaxis 

        • order urine culture to check for resistant organisms 

        • use a different agent to treat the acute episode 

        • restart the original prophylaxis after the acute episode is resolved if resistance has not developed

      • audit antibiotic prophylaxis regularly and review patients who have been taking prophylactic antibiotics for 6–12 months to justify their continued use and with a view to stopping prophylaxis 

    • single-dose antibiotic prophylaxis

      • useful in women whose UTIs are trigged by intercourse with no other triggers 

        • post-coital prophylaxis should be taken within 2 hours of intercourse

        • ask the patient to try no treatment after 3 months without infection and restart if UTIs recur 

      • patients with other triggers, such as runners and cyclists, may also benefit from this approach 

      • there is no evidence that this approach leads to increased resistance compared with continuous antibiotic prophylaxis

        • consider monitoring to ensure that patients are not developing antibiotic-resistant organisms

 

  • Side-effects of antibiotic prophylaxis

    • antibiotic prophylaxis can have side-effects such as gastrointestinal upset

    • vaginal thrush is a common side-effect of antibiotic prophylaxis, but the risk is lower than with standard treatment doses; ideally, treat the thrush, but do not stop the antibiotic

    • pulmonary toxicity is a rare side-effect of long‑term nitrofurantoin use; any patient that develops breathlessness while taking low‑dose nitrofurantoin should stop treatment and seek advice from their GP

    • long‑term nitrofurantoin use is also associated with hepatitis; patients should be monitored for signs such as brown urine

 

  • Antibiotic failure can be defined as no significant change in the frequency of UTIs in two comparative 6-month periods, after the suitability of the antibiotic and adherence to treatment have been taken into account

    • consider a different antibiotic in patients with antibiotic resistance 

    • emphasise the importance of adherence to treatment in patients who are non-adherent to their antibiotic regimen 

    • consider non-antibiotic options 

    • refer to specialist care for consideration of specialist options

 

 

Non-antibiotic treatments

  • Consider non-antibiotic therapies in all eligible patients

    • choose therapies with clinical evidence supporting their use in the treatment of recurrent UTI

    • take into account availability, ease of administration, cost-effectiveness, contraindications, and patient preferences

 

  • Treatments may need to be used in combination; none of the non-antibiotic treatments discussed are contraindicated with other non-antibiotic options

 

Topical oestrogens

 

  • Use of vaginal oestrogens prior to antibiotic prophylaxis in peri/postmenopausal women with oestrogen deficiency, particularly those with other symptoms of oestrogen deficiency such as vaginal itching and dryness, may be beneficial for recurrent UTI

    • because oral HRT has no effect on recurrent UTI, consider adding vaginal oestrogen to oral HRT 

    • topical oestrogens can be administered by pessary, cream, or ring according to patient preferences, but patients may not achieve good internal coverage when applying cream

    • prescribe as directed according to choice of preparation

    • topical oestrogens can be continued after the discontinuation of antibiotic prophylaxis

 

  • Vaginal oestrogen products are not licensed for preventing recurrent UTI, so use for this indication would be off-label; the prescriber should follow relevant professional guidance, taking full responsibility for the decision, and informed consent should be obtained and documented

 

  • Although the risk of treatment with topical vaginal oestrogens is thought to be small, it is advisable to discuss possible risks of oestrogens, in line with NICE guidance:

    • breast tenderness and vaginal bleeding in postmenopausal women compared with placebo, no treatment, or oral antibiotics

    • increased risk of venous thromboembolism, stroke, endometrial cancer (reduced by a progestogen), breast cancer, and ovarian cancer

    • increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause

 

Methenamine hippurate

  • Methenamine hippurate 

    • has antibacterial properties when present in the urine

    • is well tolerated and effective

    • may be ineffective in patients with neuropathic bladder or an abnormal renal tract

    • is contraindicated in patients with gout, severe renal and liver impairment, and dehydration

    • is an option for women who prefer to avoid antibiotics, but can also be taken in addition to antibiotic treatment

      • prescribe 1 g twice a day for 6 months initially, then review

      • consider advising patients to take vitamin C to acidify the urine, although the necessity of acidic urine for the activation of methenamine is unclear

      • check liver function every 3 months 

      • continue use of methenamine hippurate as a prophylactic

 

Vaccines

  • Vaccines are immunostimulants rather than true vaccines

    • prophylactic treatment with vaccines consisting of combinations of inactivated uropathogenic bacteria has been shown to reduce the incidence and recurrence of UTIs

    • availability is an issue in the UK

    • further studies are needed to identify optimal utility, patient groups, dosing, and isolates for efficacy

 

 

Non-pharmacological options

Cranberry

  • Cranberry-based products are widely used in the prevention and treatment of UTI, may have beneficial effects with a low risk of harm 

    • the optimum dose and duration of use are unclear

    • capsules may be better than juice and high‑strength capsules may be most effective

    • cranberry may be an option for patients who do not want to take antibiotics, although SIGN guidance recommends that patients taking warfarin should avoid taking cranberry products

 

d -mannose

  • d -mannose is not a medicine; it is a sugar that is available as a powder or tablets

    • the use of d -mannose is recommended in NICE guidance on recurrent UTI

    • d -mannose showed similar efficacy to nitrofurantoin in preventing recurrent UTI in a single, relatively small RCT

    • the dose used in this RCT was 1000 mg twice daily, but the optimum dose is unclear

    • d -mannose is well tolerated, but it should be used cautiously in patients with diabetes

 

 

Specialist options

Intravesical GAG layer replacement

  • Damage to or deficiencies in the glycosaminoglycan (GAG) layer of the bladder may be aetiological in recurrent UTI 

    • GAG layer therapies reduce the recurrence of UTIs with minimal side‑effects

    • GAG layer therapies are often administered by a specialist through a catheter, but a catheter-free option is available that may facilitate administration by non-specialists 

    • patients competent in self-catheterisation may be able to self-administer GAG layer therapies following training

 

Intravesical antibiotics

  • Intravesical installation of antibiotics, most commonly gentamicin and amikacin, has been used in specialist centres and has been anecdotally reported to be helpful for some patients; however, this approach should only be used with expert advice

 
 
 
 
 

Reassessment

Review antibiotic prophylaxis for recurrent UTI at least every 6 months, with the review to include:

  • assessing the success of prophylaxis

  • discussion of continuing, stopping or changing prophylaxis (taking into account the person's preferences for antibiotic use and the risk of antimicrobial resistance)

  • a reminder about behavioural and personal hygiene measures and self-care treatment

  • If antibiotic prophylaxis is stopped, ensure that people have rapid access to treatment if they have an acute UTI.

 

Self-care

Be aware that:

  • some women with recurrent UTI may wish to try D‑mannose if they are not pregnant

  • some women with recurrent UTI may wish to try cranberry products if they are not pregnant (evidence of benefit is uncertain and there is no evidence of benefit for older women)

  • some children and young people under 16 years with recurrent UTI may wish to try cranberry products with the advice of a paediatric specialist (evidence of benefit is uncertain).

 

  • Advise people taking cranberry products or D‑mannose about the sugar content of these products, which should be considered as part of the person's daily sugar intake.

  • evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI.

 
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Diagnosis of urinary tract infections

Public Health England. 

November 2018

Access

 

Urological Infections

​EAU Urological Infections Guidelines Panel

2018

Access

Urinary tract infection (recurrent): antimicrobial prescribing

National Institute for Health and Care Excellence

NG112

October 2018

Access

Giesen, L. G. et al.

Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs.

BMC Family Practice. 2010;11(78).

Access

Michaels T, Sands J.

Dysuria: Evaluation and Differential Diagnosis in Adults.

American Family Physician. 2015;92(9)

Access

Management of suspected bacterial urinary tract infection in adults.

Scottish Intercollegiate Guidelines Network (SIGN).

July 2012

Access

Urinary tract infections in women

BMJ Best Practice

Last updated: January  2019

Last reviewed: March 2019

Access

Urinary tract infections in men

BMJ Best Practice

Last updated: September 2018

Last reviewed: March 2019

Access

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The following oral antibiotics are available in Ireland :

Nitrofuradantoin as Macrobid (100mg BD) and as Macrodantin (100mg QID)

- Trimethoprim as Monoprim, Trimoptin

- Amoxicillin as Amoxil, Geramox, Pinamox

The following OTCs are available in Ireland :

- Methenamine Hippurate as Hiprex (1g BD)

- d-mannose (1g BD)

- cranberry high strength capsules (25,000mg OD)

The following oral antibiotics are not available in Ireland :

- Cefalexin 

 

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