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Recurrent Urinary Tract Infection in Women

Abstract

Purpose of Review

The purpose of this review is to discuss the pathophysiology, diagnosis, treatment, and prevention of recurrent urinary tract infection (UTI) in the setting of antimicrobial stewardship.

Recent Findings

Although recurrent UTI was traditionally thought to occur by repeated ascension of uropathogenic colonizers, newer evidence suggests that a subset of bacteria becomes internalized within uroepithelial cells forming quiescent intracellular reservoirs. These quiescent reservoirs do not elicit an immune response and persist after treatment of acute infection. In time, epithelial turnover results in release of these bacteria potentially leading to recurrent infection. Given the rise in antimicrobial resistance, the concept of antimicrobial stewardship has been developed to promote appropriate use of antimicrobials, improve patient outcomes, decrease microbial resistance, and reduce the spread of infections caused by multidrug-resistant organisms. This has sparked interest in non-antimicrobial measures for UTI prevention. Although cranberry products and probiotics may prevent UTI, the data for their efficacy are limited. Current evidence supports vaginal estrogen use for UTI prevention in postmenopausal women. Daily or post-coital low-dose antimicrobial prophylaxis may also be beneficial, particularly for women who develop UTI despite non-antimicrobial measures. Nevertheless, studies demonstrating the efficacy of antimicrobial prophylaxis are > 10 years old when antibiotic resistance was less common.

Summary

Prevention of recurrent UTI requires identifying and addressing risk factors for infection. Non-antimicrobial strategies should be recommended whenever possible given increasing antimicrobial resistance. However, more studies are needed to define the ideal populations that may benefit from current non-antimicrobial strategies and to identify other potential ways UTI may be prevented.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Schappert SM, Rechsteiner EA. Ambulatory medical care utilization estimates for. Natl Health Stat Report. 2007;2011:1–45.

    Google Scholar 

  2. Foxman B. The epidemiology of urinary tract infection. Nature Rev Urol. 2010;7(12):653–60.

    Article  Google Scholar 

  3. • Foxman B. Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect Dis Clin N Am. 2014 Mar;28(1):1–13. This review defines the different types of urinary tract infection syndromes and their bacteriology and epidemiology

  4. Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09. J Antimicrob Chemother. 2014;69(1):234–40. https://doi.org/10.1093/jac/dkt301.

    CAS  Article  PubMed  Google Scholar 

  5. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Atlanta, GA: CDC; 2013.

    Google Scholar 

  6. Antimicrobial Stewardship. Accessed from http://www.apic.org/Professional-Practice/Practice-Resources/Antimicrobial-Stewardship on 8/19/2017.

  7. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, 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. https://doi.org/10.1093/cid/ciq257.

  8. • Glover M, Moreira CG, Sperandio V, Zimmern P. Recurrent urinary tract infections in healthy and nonpregnant women. Urol Sci. 2014;25(1):1–8. This review discusses the etiology of UTI with an emphasis on molecular medicine and differentiates risk factors for UTI based on menopausal status

    Article  PubMed  PubMed Central  Google Scholar 

  9. Finer G, Landau D. Pathogenesis of urinary tract infections with normal female anatomy. Lancet Infect Dis. 2004;4(10):631–5.

    Article  PubMed  Google Scholar 

  10. Schaeffer AJ, Jones JM, Dunn JK. Association of in vitro Escherichia coli to vaginal and buccal epithelial cells with susceptibility of women to recurrent urinary tract infections. N Engl J Med. 1981;301:1062–6.

    Article  Google Scholar 

  11. Lomberg H, Cedergren B, Leffler H, et al. Influence of blood group on the availability of receptor for attachment of uropathogenic Escherichia coli. Infect Immun. 1986;51(3):919–26.

    CAS  PubMed  PubMed Central  Google Scholar 

  12. Stapleton A, Nudelman E, Clausen H, et al. Binding of uropathogenic Escherichia coli R45 to glycolipids extracted from vaginal epithelial cells is dependent on histo-blood group secretor status. J Clin Invest. 1992;90(3):965–72.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Scholes D, Hawn TR, Roberts PL, Li SS, Stapleton AE, Zhao LP, et al. Family history and risk of recurrent cystitis and pyelonephritis in women. J Urol. 2010;184:564–9.

  14. • McLellan LK, Hunstad DA. Urinary tract infection: pathogenesis and outlook. Trends in Mol Med. 22(11):2016, 946–957. https://doi.org/10.1016/j.molmed.2016.09.003. This article discusses the pathogenesis of UTI with an emphasis on molecular medicine and the newer theory of intracellular bacterial communities leading to recurrent UTI

  15. Smith HS, Hughes JP, Hooten TM, et al. Antecedent antimicrobial use increases the risk of uncomplicated cystitis in young women. Clin Infect Dis. 1997;25:63.

    CAS  Article  PubMed  Google Scholar 

  16. Scholes D, Hooten TM, Roberts PL, Stapleton AE, Gupta K, Stamm WE. Risk factors for recurrent urinary tract infection in young women. J Infect Dis. 2000;18:1177–82.

    Article  Google Scholar 

  17. Vyas S, Sharma P, Srivastava K, Nautiyal V, Shrotriya VP. Role of behavioural risk factors in symptoms related to UTI amount nursing students. J Clin Diagn Res. 2015;9(9):LC15–8. https://doi.org/10.7860/JCDR/2015/10995.6547.

    PubMed  PubMed Central  Google Scholar 

  18. Avasarala KA, Ahmed SM, Nandagiri S, Tadisetty S. Epidemiological differences of lower urinary tract symptoms among female subpopulations and group level interventions. Indian J Urol. 2008;24(4):498–503.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Bouassida K, Jaidane M, Bouallegue O, Tlili G, Naija H, Mosbah AT. Nosocomial urinary tract infections caused by extended-spectrum beta-lactamase uropathogens: prevalence, pathogens, risk factors, and strategies for infection control. Can Urol Assoc J. 2016;10(3–4):E87–93.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Raz R, Gennesin Y, Wasser J, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis. 2000;30:152–6.

    CAS  Article  PubMed  Google Scholar 

  21. Omli R, Skotnes LH, Romild U, Bakke A, Mykletun A, Kuhry E. Pad per day usage, urinary incontinence and urinary tract infections in nursing home residents. Age Ageing. 2010;39(5):554–9.

    Article  Google Scholar 

  22. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002;287(20):2701–10.

    Article  PubMed  Google Scholar 

  23. Hurlbut TA III, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol. 1991;96:582–8.

    Article  PubMed  Google Scholar 

  24. Stamm WE, Counts GW, Running KR, Fihn S, Turck M, Holmes KK. Diagnosis of coliform infection in acutely dysuric women. New Engl J Med. 1982;307:463–8.

    CAS  Article  PubMed  Google Scholar 

  25. European Association of Urology Guidelines (2017) on urological infections. Accessed from http://uroweb.org/guideline/urological-infections/ on 8/19/2017.

  26. Hooton TM. Uncomplicated urinary tract infection. N Engl J Med. 2012;366(11):1028–37.

    CAS  Article  PubMed  Google Scholar 

  27. • Abbo LM, Hooten TM. Antimicrobial stewardship and urinary tract infections. Antibiotics. 2014;3:174–92. This article discusses the concept of antimicrobial stewardship and reviews opportunities for antimicrobial stewardship when diagnosing, treating, and preventing UTI

    Article  PubMed  PubMed Central  Google Scholar 

  28. • Arnold JJ, Hehn LE, Klein DA. Common questions about recurrent urinary tract infections in women. Am Fam Physician. 2016;93(7):560–9. This article addresses the risk factors for and evaluation and management of recurrent UTI using a simple question and answer format

    PubMed  Google Scholar 

  29. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. Accessed from http://www.fda.gov/Drugs/DrugSafety/ucm511530.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery on 8/19/2017.

  30. • Vahlensieck W, Perepanova T, Johansen TEB, Tenke P, Naber KG, Wagenlehner FME. Management of uncomplicated recurrent urinary tract infections. Management of Uncomplicated Recurrent Urinary Tract Infections. Eur Urol Suppl. 2016;15(4):95–101. This article provides a general overview of various ways to prevent recurrent UTI with an emphasis on non-antimicrobial strategies

    Article  Google Scholar 

  31. Rudenko N, Dorofeyev A. Prevention of recurrent lower urinary tract infections by long-term administration of fosfomycin trometamol. Double blind, randomized, parallel group, placebo controlled study. Arzneimittelforschung. 2005;55:420–7.

    CAS  PubMed  Google Scholar 

  32. Albert X, Huertas I, Pereiró II, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004; CD001209.

  33. • Ahmed H, Davies F, Francis N, Farewell D, Butler C, Paranjothy S. Long-term antibiotics for prevention of recurrent urinary tract infection in older adults: systematic review and meta-analysis of randomized trials. BMJ Open. 2017;7(5):e015233. https://doi.org/10.1136/bmjopen-2016-015233. This meta-analysis addresses the effectiveness of antibiotic prophylaxis for UTI prevention in older adults

    Article  PubMed  Google Scholar 

  34. Geerlings SE, Beerepoot MAJ, Prins JM. Prevention of recurrent urinary tract infections in women. Infect Dis Clin N Am. 2014;28:135–47.

    Article  Google Scholar 

  35. Zhong YH, Fang Y, Zhou JZ, et al. Effectiveness and safety of patient-initiated single dose versus continuous low-dose antibiotic prophylaxis for recurrent urinary tract infections in postmenopausal women: a randomized controlled study. J Int Med Res. 2011;39(6):2335–43.

    CAS  Article  PubMed  Google Scholar 

  36. • Duenas-Garcia OF, Sullivan G, Hall CD, et al. Pharmacological agents to decrease new episodes of recurrent lower urinary tract infections in postmenopausal women: a systematic review. Female Pelvic Med Reconstr Surg. 2016;22(2):63–0. This review examines the effectiveness of various pharmacologic agents in decreasing the risk of recurrent UTI in postmenopausal women

    Article  PubMed  Google Scholar 

  37. Beerepoot MA, Geerlings SE, van Haarst EP, et al. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials. J Urol. 2013;190:1981–9.

    CAS  Article  PubMed  Google Scholar 

  38. Howell AB, Bott H, Combescure C, et al. Dosage effect of uropathogenic Escherichia coli anti-adhesion activity in urine following consumption of cranberry powder standardized for proanthocyanidin content: a multicentric randomized double blind study. BMC Infect Dis. 2010;10:94. https://doi.org/10.1186/1471-2334-10-94.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Huang Y, Nikolic D, Pendland S, Doyle BJ, Locklear TD, Mahady GB. Effects of cranberry extracts and ursolic acid derivatives on P-fimbriated Escherichia coli, COX-2 activity, pro-inflammatory cytokine release and the NF-κβ transcriptional response in vitro. Pharm Biol. 2009;47(1):18–25.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. Wang CH, Fang CC, Chen NC, et al. Cranberry-containing products for prevention of urinary tract infections in susceptible populations: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172:988–96.

    PubMed  Google Scholar 

  41. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012;10:CD001321.

    PubMed  Google Scholar 

  42. •• Liska DJ, Kern HJ, Maki KC. Cranberries and urinary tract infections: how can the same evidence lead to conflicting advice? Adv Nutr: Int Rev J. 2016;7(3):498–506. This review examines the methodologies of various published systematic reviews and meta-analyses on cranberry product use for UTI prevention

    Article  Google Scholar 

  43. Barbosa-Cesnik C, Brown MB, Buxton M, Zhang L, DeBusscher J, Foxman B. Cranberry juice fails to prevent recurrent urinary tract infection: results for a randomized placebo-controlled trial. Clin Infect Dis. 2011;5:23–30.

    Article  Google Scholar 

  44. • Maki KC, Kaspar KL, Kho C, Derrig LH, Schild AL, Gupta K. Consumption of a cranberry juice beverage lowered the number of clinical urinary tract infection episodes in women with a recent history of urinary tract infection. Am J Clin Nutr. 2016;103(6):1434–42. This multicenter, randomized double-blinded placebo-controlled trial suggests cranberry juice consumption may decrease the risk of clinical UTI in young women

    CAS  Article  PubMed  Google Scholar 

  45. • Juthani-Mehta M, Van Ness PH, Bianco L, Rink A, Rubeck S, Ginter S, et al. Effect of cranberry capsules on bacteriuria plus pyuria among older women in nursing homes: a randomized clinical trial. JAMA. 2016;316(18):1879–87. This randomized placebo-controlled trial found no decrease in bacteriuria and pyuria in female nursing home residents taking cranberry tablets

  46. Lee BS, Bhuta T, Simpson JM, Craig JC. Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev. 2012;10:CD003265.

    PubMed  Google Scholar 

  47. Bannwart C, Hagmaier V, Straumann E, et al. Modification of urinary pH through ascorbic acid. Helv Chir Acta. 1981;48:425–8.

    CAS  PubMed  Google Scholar 

  48. Hetey SK, Kleinberg ML, Parker WD, et al. Effect of ascorbic acid on urine pH in patients with injured spinal cords. Am J Hosp Phar. 1980;37(2):235–7.

    CAS  Google Scholar 

  49. Ochoa-Brust GJ, Fernandez AR, Villaneuva-Ruiz GJ, et al. Daily intake of 100 mg ascorbic acid as urinary tract infection prophylactic agent during pregnancy. Act Obstet Gynecol Scand. 2007;86(7):783–7.

    CAS  Article  Google Scholar 

  50. Barrons R, Tassone D. Use of Lactobacillus probiotics for bacterial genitourinary infections in women: a review. Clin Ther. 2008;30:453–68.

    CAS  Article  PubMed  Google Scholar 

  51. Stapleton AE, Au-Yeung M, Hooton TM, et al. Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection. Clin Infect Dis. 2011;52:1212–7.

    Article  PubMed  PubMed Central  Google Scholar 

  52. • Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev 2015: CD008772. This Cochrane review summarizes the literature addressing the effect of probiotic use on UTI prevention.

  53. Altarac S, Papeš D. Use of D-mannose in prophylaxis of recurrent urinary tract infections (UTIs) in women. BJU Int. 2014;113(1):9–10.

    Article  PubMed  Google Scholar 

  54. • 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(1):79–84. This randomized clinical trial provides level 1 evidence for D-mannose use in UTI prevention

    Article  PubMed  Google Scholar 

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Correspondence to Jeannine M. Miranne.

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Conflict of Interest

Dr. Miranne reports personal fees from the American Congress of Obstetricians and Gynecologists and a grant from Brigham and Women’s Hospital Department of Obstetrics, Gynecology, and Reproductive Biology outside the submitted work.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Urogynecology

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Miranne, J.M. Recurrent Urinary Tract Infection in Women. Curr Obstet Gynecol Rep 6, 282–289 (2017). https://doi.org/10.1007/s13669-017-0228-9

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  • DOI: https://doi.org/10.1007/s13669-017-0228-9

Keywords

  • Recurrent urinary tract infection
  • Antimicrobial stewardship
  • Risk factors for urinary tract infection
  • Prevention of recurrent urinary tract infection