Recurrent UTI: Questions and Answers on Clinical Practice
Abstract
:1. Background and Aims
2. Materials and Methods
Search of Evidences
3. Results and Evidences
3.1. Which Is the Burden of Uncomplicated Urinary Tract Infections?
3.2. What Is the Psychological Burden of rUTI on the Patient’s Outcome and on the Adherence to the Treatment?
3.3. What Is the Role of Uncomplicated UTI Management in Antimicrobial Stewardship Programs?
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- antibiotic treatment should be used in case of urinary symptoms and absence of vaginal infection
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- antibiotic selection, antibiotic dosage, and time schedule should be selected in line with international guidelines recommendations
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- treat asymptomatic bacteriuria only in pregnant women and before urological procedures
3.4. Is the Presence of Bacteria in the Urine Always a Symptom of Infection and Does It Need to Be Treated?
3.5. If, after an Episode of Acute Cystitis, Urine Culture Is Still Positive Must the Antibiotic Treatment Be Repeated?
3.6. Is the Execution of Urine Culture Always Necessary before Prescribing an Antibiotic in One Patient with Symptoms to Be Referred to as Cystitis?
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- presence of urinary symptoms in absence of vaginal discharge
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- data in local antimicrobial resistance surveillance
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- patient’s previous antibiotic exposure
3.7. After Antibiotic Therapy in a Woman with Acute Cystitis, Is It Always Necessary to Perform a Urine Culture?
3.8. What Are the Risk Factors Related to a High Risk of UTI Recurrence?
3.9. Can I Use Antibiotic Therapy as a Prophylaxis for Recurrent Cystitis, at the First Evaluation?
3.10. What Are the Most Appropriate Strategies for Reducing the Risk of Recurrent UTI?
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- Increase fluid intake
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- Use immunoactive prophylaxis
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- Use vaginal estrogen replacement in post-menopausal women
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- Use of local or oral probiotics containing strains of proven efficacy for vaginal flora regeneration
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- Use endovesical instillations of hyaluronic acid or a combination of hyaluronic acid and chondroitin sulphate
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- Use continuous or post-coital antimicrobial prophylaxis when nonantimicrobial interventions have failed. Self-administered short-term antimicrobial therapy should be considered, too. Please stick to the principles of antimicrobial stewardship
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- Use of cranberry products and D-mannose, even if the quality of evidence is low and there are some contradictory findings
3.11. Which Is the Xyloglucan Mechanism of Action in Reducing Recurrent UTI?
4. Discussion and Final Remarks
- Consider the high impact of uncomplicated and recurrent UTIs on patients’ quality of life (Level 3; Grade B).
- The management of recurrent UTIs should be performed in line with international guidelines (Level 1; Grade A).
- Antibiotic treatment should be used in case of urinary symptoms and absence of vaginal infection (Level 1; Grade A).
- Antibiotic treatment duration should be minimized, with the exact dosage and time schedule depending on the type of infection and in line with international guidelines recommendations (Level 1; Grade A).
- Treat asymptomatic bacteriuria only in pregnant women and before urological procedures (Level 1; Grade A).
- Before prescribing antibiotic therapy, please consider all possible collateral damages caused by antibiotics!
- After empiric therapy, please do not prescribe a urine culture unless the woman has experienced recurrence symptoms (Level 2; Grade B).
- Please consider risk factors evaluation as a pivotal step in the management of rUTI (Level 2; Grade B).
- In the era of antibiotic resistance, an antibiotic-sparing approach represents an important and needed alternative treatment of uncomplicated cystitis in women (Level 1; Grade A).
Author Contributions
Funding
Conflicts of Interest
References
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Author | Year | Type of Study | Aim | Findings Description |
---|---|---|---|---|
Anger J. [3] | 2019 | AUA/CUA/SUFU Guideline | Recommendations on rUTI in women | Recommendations on rUTI management. |
Nicolle LE. [4] | 2005 | IDSA Guideline | Recommendations on asymptomatic bacteriuria | Recommendations on asymptomatic bacteriuria management. |
Medina M. [5] | 2019 | Narrative review | Evaluate the epidemiology, burden of rUTIs and actual management. | rUTIs are related to high prevalence, and high social and economic impact. |
Cai T. [6] | 2022 | Prospective study | Evaluate the impact of risk factors evaluation on the natural history of rUTI. | Risk factor identification and counseling may change the natural history of recurrent urinary tract infections, reducing the number of symptomatic episodes, antibiotic usage, and improving patients’ quality of life. |
Cai T. [9] | 2022 | Review | Evaluate UTI management during the COVID-19 pandemic | During the COVID-19 pandemic, all physicians are asked to maintain a high level of adherence to antimicrobial stewardship. |
Naber KG. [12] | 2022 | Review | Evaluate the psychosocial burden of rUTI | The psychosocial burden of rUTI seems high in everyday clinical practice but little data are available. |
Cai T. [13] | 2021 | Review | Evaluate the aspects of the patient’s quality of life in urology | Quality of life assessment is mandatory in the management of patients affected by rUTI. |
Wagenlehner F. [14] | 2018 | Prospective study | Web-based survey in 5 countries (Germany, Switzerland, Poland, Russia, and Italy), on women affected by rUTI. | rUTIs have a significant impact on the QoL of women in Europe. |
Bonkat G [15] | 2022 | EAU Guidelines | Recommendations on rUTI in women | Recommendations on rUTI management. |
Cai T. [16] | 2012 | Randomized study | Evaluate the impact of asymptomatic bacteriuria treatment on the recurrence rate in rUTI | Asymptomatic bacteriuria should not be treated in rUTI. |
Cai T. [17] | 2015 | Longitudinal cohort study | Evaluate the impact of asymptomatic bacteriuria treatment on antibiotic resistance in rUTIs | Asymptomatic bacteriuria is associated with a higher occurrence of antibiotic-resistant bacteria. |
Cai T. [18] | 2014 | Prospective study | Development and validation of a nomogram. | LUTIRE nomogram is able to predict the risk of a new symptomatic episode in women with rUTI. |
Stapleton A. [19] | 1992 | Observational study | To investigate the hypothesis that blood group secretor status is associated with a higher risk of rUTI. | The blood group’s non-secretor status increased susceptibility to recurrent UTI. |
Cai T. [20] | 2021 | Systematic review and Meta-analysis | Evaluate the effectiveness and safety profile of xyloglucan, hibiscus, and propolis in rUTI | Xyloglucan, hibiscus, and propolis are superior to comparator regimens in terms of microbiological and clinical efficacy in rUTI. |
Camilleri M. [21] | 2012 | Review | The role of the intestinal barrier in rUTI | Intestinal barrier function has a pivotal role in the genesis of rUTI. |
Guglietta A. [22] | 2017 | Review | Risk factors evaluation in rUTI. | Risk factors evaluation is an important step in the management of rUTI. |
Esposito E. [23] | 2018 | Animal model | Evaluate the intestinal barrier effect of xyloglucan in rats. | Xyloglucan shows a protective barrier properties in the prevention of UTI in an animal model. |
Fraile B. [24] | 2017 | In vitro study | Evaluate the role of Xyloglucan in the prevention of urinary infections. | Xyloglucan shows a nonpharmacological barrier property for the management of urinary tract infections. |
Costache RC. [25] | 2019 | Prospective study | Xyloglucan versus placebo in UTI management. | Xyloglucan + gelose is able to reduce bacteriological and symptomatic parameters in women with rUTI. |
Young and Pre-Menopausal Women | Post-Menopausal and Elderly Women |
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Sexual intercourse | History of UTI before menopause |
Use of spermicide | Urinary incontinence |
A new sexual partner | Atrophic vaginitis due to estrogen deficiency |
A mother with a history of UTI | Cystocele |
History of UTI during childhood | Increased post-void urine volume |
Blood group antigen secretory status | Blood group antigen secretory status |
Urine catheterization and functional status deterioration in elderly institutionalized women |
Low-Risk Group | Moderate-Risk Group | High-Risk Group |
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evaluation of risk factors | evaluation of risk factors | evaluation of risk factors |
counseling | counseling | counseling |
active prophylaxis (motivate patients) | active prophylaxis (all patients) |
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Cai, T.; Lanzafame, M.; Tascini, C. Recurrent UTI: Questions and Answers on Clinical Practice. Uro 2022, 2, 262-269. https://doi.org/10.3390/uro2040029
Cai T, Lanzafame M, Tascini C. Recurrent UTI: Questions and Answers on Clinical Practice. Uro. 2022; 2(4):262-269. https://doi.org/10.3390/uro2040029
Chicago/Turabian StyleCai, Tommaso, Massimiliano Lanzafame, and Carlo Tascini. 2022. "Recurrent UTI: Questions and Answers on Clinical Practice" Uro 2, no. 4: 262-269. https://doi.org/10.3390/uro2040029