Comprehensive Approach Needed to Address Recurrent UTIs
Addressing the problem of recurrent urinary tract infections (UTIs) among women requires a comprehensive approach that includes more accurate and timely diagnosis, improved use of antibiotics, closer attention to other treatable conditions and risk factors, and a greater emphasis on patient education and prevention.
There are an estimated 150-million UTI occurrences each year in the United States, resulting in more than 7-million physician visits, 1-million hospital admissions and $6 billion in healthcare expenditures, notes Ja-Hong Kim, MD, associate professor in the UCLA Division of Pelvic Medicine and Reconstructive Surgery. One-third of women will develop a UTI by the age of 24, and roughly half of these women will have at least one recurrence within a year. Dr. Kim points out that the recurrent UTI population tends to fall into two distinct categories: young, otherwise healthy women whose infections often are related to times of sexual intercourse; and a more complex population of women with a pre-existing urinary tract anomaly or who are elderly or immuno-compromised. “This complex group may need to be started on antibiotics earlier, because the stakes are higher. You don’t want to miss any infections that could progress to kidney involvement,” Dr. Kim says.
She notes that the problem of antimicrobial resistance is significant, with microbes evolving faster than the development of new drugs to treat them. “Some physicians are not following the practice guidelines for antimicrobial treatment of UTIs, and many women are being treated inappropriately without confirmatory cultures. Furthermore, inappropriate antibiotics that have potential for collateral damage are being prescribed,” Dr. Kim says. “The symptoms such as frequency, urgency and burning can coexist with other noninfectious bladder issues such as overactive bladder and interstitial cystitis, and patients who are reflexively being prescribed antibiotics may not have a bacterial infection at all.”
Dr. Kim has developed a protocol for treating women with recurrent UTIs that begins with a thorough history and physician exam, as well as review of all past urine cultures to confirm that the patient does in fact have a UTI caused by bacteria and not something else. “You also need to assess for atypical organisms such as mycoplasma and ureaplasma, as well as viral and fungal causes,” Dr. Kim says. “These do not get detected in a traditional urine culture, and they require a different type of antimicrobial treatment than what is given for a typical bacterial UTI.”
For patients who have been confirmed to have recurrent bacterial UTI, Dr. Kim focuses on prevention through education, optimization of bladder/vaginal health and rebuilding healthy gut flora. She counsels patients to recognize triggers, including intercourse, frequent and uncontrolled bowel movements, and diet. If it is determined that the UTIs are related to intercourse, patients are instructed to take a low-dose antibiotic immediately after the encounter. Hydration also is important. “As long as one drinks plenty of fluids to make enough urine that completely empties when voiding, the bladder will flush out the offending organisms,” Dr. Kim says.
Other prevention strategies include probiotics to restore the bowel flora, which can be affected by multiple courses of antibiotics. Vitamin C is recommended to boost the immune system, and cranberry tablets can be helpful in conjunction with other strategies, Dr. Kim says. She notes that cranberry tablets alone will not treat or prevent recurrent UTIs, based on recent studies. Some patients are encouraged to take supplements of D-Mannose, which can help to clear out the bacteria when there are early signs of a UTI. Dr. Kim also talks with her patients about perineal hygiene — a common contributor to recurrent UTIs among elderly and morbidly obese patients.
“Once you go through all of the prevention strategies, most patients will improve and see a drastic reduction in the number of UTIs,” Dr. Kim says. For those who don’t, and
who have been found to have three or more culture-proven UTI episodes in a year, second-level measures include prescribing a methenamine — a powerful way to acidify urine to prevent bacterial growth. An office-based cystoscopy also is indicated for many of these patients. For some women, particularly older patients with complex UTIs, the bladder may be filled with pus, which needs to be drained. Dr. Kim describes this approach as being akin to a “power wash” of the bladder.
Some patients need to be broken of their habit of calling in for an antibiotic every time they experience symptoms of an infection. “When the patient is given antibiotics without a confirmatory culture, we are treating blindly and can erroneously prescribe inappropriate antibiotics,” Dr. Kim says. For patients who are motivated to hold off on antibiotics until testing is done, Dr. Kim typically prescribes phenazopyridine and ibuprofen for symptom relief. “The real solution is giving the right antibiotic at the right time,” Dr. Kim says. “Currently, I am collaborating on research to develop a rapid diagnostic assay that will allow accurate culture results in three hours, which is much quicker than the traditional 48-hour cultures.”
Dr. Kim recommends that physicians whose patients are having three or more UTIs per year despite taking appropriate preventative measures refer their patients to a urologic expert. “Recurrent UTIs can have a significantly negative impact on quality life,” she says. “If a woman is running to the bathroom every 15-to-30 minutes due to pain and urgency, she can’t focus on herself, her work or her family. From a more global perspective, recurrent UTIs can be a dangerous source for propagating inappropriate antibiotic use that can have immeasurable impact on society through antibiotic resistance. We have to do everything we can to address this problem.”