Guideline of guidelines: management of recurrent urinary tract infections in women

Michael Kwok, Stephen McGeorge, Johanna Mayer-Coverdale, Bianca Graves, David L Paterson, Patrick N A Harris, Rachel Esler, Caroline Dowling, Sumudu Britton, Matthew J Roberts, Michael Kwok, Stephen McGeorge, Johanna Mayer-Coverdale, Bianca Graves, David L Paterson, Patrick N A Harris, Rachel Esler, Caroline Dowling, Sumudu Britton, Matthew J Roberts

Abstract

Objective: To compare recurrent urinary tract infection (rUTI) guidelines from major urological and non-urological organisations internationally and identify areas of consensus and discrepancy.

Methods: PubMed, Google Scholar and the official webpages of major urological, gynaecological, infectious diseases and general practice organisations were searched for rUTI guidelines in March 2022. Nine guidelines were included for review: European Association of Urology, National Institute for Health and Care Excellence (NICE), Society of Obstetricians and Gynaecologists of Canada, American Academy of Family Physicians, Mexican College of Gynaecology and Obstetrics Specialists, Swiss Society of Gynaecology and Obstetrics, Spanish Society of Infectious Diseases and Clinical Microbiology, German Association of Scientific Medical Societies, and the combined American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction.

Results: The definition and evaluation of rUTIs, and antibiotic prophylaxis strategies, were mostly consistent across guidelines, and emphasised the importance of obtaining urine cultures and limiting cystoscopy and upper tract imaging in women without risk factors. Variable recommendations were noted for symptomatic treatment, self-initiated antibiotics, and antibiotic-sparing preventative strategies such as cranberry, vaginal oestrogen, immunoactive prophylaxis with OM-89, intravesical glycosaminoglycan instillation, and phytotherapeutics. Recent randomised evidence supports the use of methenamine hippurate. Either continuous or post-coital prophylactic antibiotics were supported by all guidelines. None of the guidelines were tailored to the management recurrent complicated UTI.

Conclusion: Multiple rUTI guidelines were identified and mostly limited their recommendations to otherwise healthy non-pregnant women with uncomplicated cystitis. Variation was noted, particularly in antibiotic-sparing preventative strategies. Some conflicting recommendations are due to more recent guidelines including updated evidence. Future guidelines should consider recommendations to assist management of complex patient groups, such as recurrent complicated UTI.

Keywords: #UroUTI; #Urology; antibiotics; prevention; prophylaxis; recurrent urinary tract infections; treatment.

© 2022 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.

Figures

Fig. 1
Fig. 1
Recurrent UTI in women – assessment and initial management algorithm [30] with guideline recommendations (if general consensus) or considerations (if variation).
Fig. 2
Fig. 2
Recurrent UTI in women – long‐term preventative management options.

References

    1. Renard J, Ballarini S, Mascarenhas T et al. Recurrent lower urinary tract infections have a detrimental effect on patient quality of life: a prospective, observational study. Infect Dis Ther 2014; 4: 125–35
    1. Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare . The Fourth Australian Atlas of Healthcare Variation. Sydney, NSW: ACSQHC, 2021.
    1. OUTBREAK Consortium . A One Health Antimicrobial Resistance Economic Perspective. Sydney, NSW: UTS, 2020.
    1. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med 2002; 113(Suppl. 1): 5–13
    1. Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 2013; 369: 1883–91
    1. Heytens S, De Sutter A, Coorevits L et al. Women with symptoms of a urinary tract infection but a negative urine culture: PCR‐based quantification of Escherichia coli suggests infection in most cases. Clin Microbiol Infect 2017; 23: 647–52
    1. Horváth J, Wullt B, Naber KG, Köves B. Biomarkers in urinary tract infections–which ones are suitable for diagnostics and follow‐up? GMS Infect Dis 2020; 8: Doc24
    1. Fritzenwanker M, Imirzalioglu C, Chakraborty T, Wagenlehner FM. Modern diagnostic methods for urinary tract infections. Expert Rev Anti Infect Ther 2016; 14: 1047–63
    1. Cai T, Nesi G, Mazzoli S et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis 2015; 61: 1655–61
    1. Brouwers MC, Kho ME, Browman GP et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182: E839–42
    1. Anger J, Lee U, Ackerman AL et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol 2019; 202: 282–9
    1. Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Can Urol Assoc J 2011; 5: 316–22
    1. Bonkat G, Bartoletti R, Bruyére F et al. EAU Guidelines on Urological Infections 2022. European Association of Urology Guidelines 2022 Edition. Presented at the EAU Annual Congress Amsterdam 2022. Arnhem: European Association of Urology Guidelines Office, 2022.
    1. National Institute for Health and Care Excellence [Internet] . Urinary Tract Infection (Recurrent): Antimicrobial Prescribing. London: NICE, 2018. Available at: . Accessed April 2021
    1. Epp A, Larochelle A, Lovatsis D et al. Recurrent urinary tract infection. J Obstet Gynaecol Can 2010; 32: 1082–90
    1. Arnold JJ, Hehn LE, Klein DA. Common questions about recurrent urinary tract infections in women. Am Fam Physician 2016; 93: 560–9
    1. Kodner CM, Thomas Gupton EK. Recurrent urinary tract infections in women: diagnosis and management. Am Fam Physician 2010; 82: 638–43
    1. Del Pilar Velázquez M, Romero Nava LE, López de Avalos DR et al. Clinical practice guidelines. Recurrent infection of the urinary tract in women. Colegio Mexicano de Especialistas en Ginecología y Obstetricia. Ginecol Obstet Mex 2010; 78: S437–59
    1. Betschart C, Albrich WC, Brandner S et al. Guideline of the swiss Society of Gynaecology and Obstetrics (SSGO) on acute and recurrent urinary tract infections in women, including pregnancy. Swiss Med Wkly 2020; 150: w20236
    1. de Cueto M, Aliaga L, Alós J‐I et al. Executive summary of the diagnosis and treatment of urinary tract infection: guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC). Enferm Infecc Microbiol Clin 2017; 35: 314–20
    1. Kranz J, Schmidt S, Lebert C et al. The 2017 update of the German clinical guideline on epidemiology, diagnostics, therapy, prevention, and management of uncomplicated urinary tract infections in adult patients: Part 1. Urol Int 2018; 100: 263–70
    1. Kranz J, Schmidt S, Lebert C et al. The 2017 update of the German clinical guideline on epidemiology, diagnostics, therapy, prevention, and management of uncomplicated urinary tract infections in adult patients. Part II: therapy and prevention. Urol Int 2018; 100: 271–8
    1. Gupta K, Hooton TM, Naber KG et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52: e103–20
    1. Nicolle LE, Gupta K, Bradley SF et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019; 68: e83–110
    1. Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Clin Infect Dis 1999; 29: 745–58
    1. Venkatesan AM, Oto A, Allen BC et al. ACR appropriateness criteria® recurrent lower urinary tract infections in females. J Am Coll Radiol 2020; 17: S487–96
    1. Gupta K, Trautner BW. Diagnosis and management of recurrent urinary tract infections in non‐pregnant women. BMJ 2013; 346: f3140
    1. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012; (10): Cd001321
    1. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008;(2); Cd005131
    1. Sihra N, Malde S, Greenwell T, Pakzad M, Kujawa M, Sinclair A. Management of recurrent urinary tract infections in women. J Clin Urol 2022; 15: 152–64
    1. Kranjčec B, Papeš D, Altarac S. D‐mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial. World J Urol 2014; 32: 79–84
    1. Aune A, Alraek T, Lihua H, Baerheim A. Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women. Scand J Prim Health Care 1998; 16: 37–9
    1. Alraek T, Soedal LIF, Fagerheim SU, Digranes A, Baerheim A. Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women. Am J Public Health 2002; 92: 1609–11
    1. Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta‐analysis of randomized controlled trials. J Infect 2009; 58: 91–102
    1. Hoffmann T, Peiris R, Mar CD, Cleo G, Glasziou P. Natural history of uncomplicated urinary tract infection without antibiotics: a systematic review. Br J Gen Pract 2020; 70: e714–e22
    1. Beerepoot MA, Geerlings SE, van Haarst EP, van Charante NM, ter Riet G. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta‐analysis of randomized controlled trials. J Urol 2013; 190: 1981–9
    1. Crandall CJ, Hovey KM, Andrews CA et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women's Health Initiative Observational Study. Menopause 2018; 25: 11–20
    1. Chlebowski RT, Anderson GL, Aragaki AK et al. Association of menopausal hormone therapy with breast cancer incidence and mortality during long‐term follow‐up of the women's health initiative randomized clinical trials. JAMA 2020; 324: 369–80
    1. Naber KG, Cho YH, Matsumoto T, Schaeffer AJ. Immunoactive prophylaxis of recurrent urinary tract infections: a meta‐analysis. Int J Antimicrob Agents 2009; 33: 111–9
    1. Bauer HW, Rahlfs VW, Lauener PA, Blessmann GS. Prevention of recurrent urinary tract infections with immuno‐active E. coli fractions: a meta‐analysis of five placebo‐controlled double‐blind studies. Int J Antimicrob Agents 2002; 19: 451–6
    1. Lee BS, Bhuta T, Simpson JM, Craig JC. Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev 2012;(10); CD003265
    1. Forbes R, Ali A, Abouhajar A et al. ALternatives to prophylactic antibiotics for the treatment of recurrent urinary tract infection in women (ALTAR): study protocol for a multicentre, pragmatic, patient‐randomised, non‐inferiority trial. Trials 2018; 19: 616
    1. Harding C, Mossop H, Homer T et al. Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: multicentre, open label, randomised, non‐inferiority trial. BMJ 2022; 376: e068229
    1. Scott AM, Clark J, Del Mar C, Glasziou P. Increased fluid intake to prevent urinary tract infections: systematic review and meta‐analysis. Br J Gen Pract 2020; 70: e200–7
    1. De Vita D, Antell H, Giordano S. Effectiveness of intravesical hyaluronic acid with or without chondroitin sulfate for recurrent bacterial cystitis in adult women: a meta‐analysis. Int Urogynecol J 2013; 24: 545–52
    1. Goddard JC, Janssen DAW. Intravesical hyaluronic acid and chondroitin sulfate for recurrent urinary tract infections: systematic review and meta‐analysis. Int Urogynecol J 2018; 29: 933–42
    1. Chung E, Gillman M, Tuckey J, La Bianca S, Love C. A clinical pathway for the management of Peyronie's disease: integrating clinical guidelines from the International Society of Sexual Medicine, American Urological Association and European Urological Association. BJU Int 2020; 126: 12–7
    1. Lowrance WT, Murad MH, Oh WK, Jarrard DF, Resnick MJ, Cookson MS. Castration‐resistant prostate cancer: AUA guideline amendment 2018. J Urol 2018; 200: 1264–72
    1. Melekos MD, Naber KG. Complicated urinary tract infections. Int J Antimicrob Agents 2000; 15: 247–56

Source: PubMed

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