CHICAGO — For the first time, the American Urological Association (AUA) has issued a guideline for the diagnosis and treatment of uncomplicated recurrent urinary tract infections (UTIs), which emphasizes the importance of cultures and antibiotic stewardship.
“We really felt as a panel that cultures were quite central to the care, abatement, and treatment of recurrent urinary tract infections,” said Jennifer Anger, MD, from the Cedars-Sinai Medical Center in Los Angeles, who chaired the guideline-development committee.
Cultures are necessary for diagnosis and for ruling out confounding infections, she added.
Anger presented highlights and themes of the guideline, which was developed in partnership with the Canadian Urological Association and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, here at the AUA 2019 Annual Meeting.
UTIs are the most common bacterial infection in women; they affect 50% to 60% of women at some point in their lives. They are “recurrent” if they happen two or more times in 6 months or three or more times in a year.
Antibiotics and Prophylaxis
The mandate for antibiotic stewardship is a strong theme in the guideline. When patients present with infections, “we need to provide the shortest course of an antibiotic that has the least systemic effect on the rest of their body,” Anger explained.
The use of cranberry as prophylaxis is a conditional recommendation (level C evidence). Cranberry — in juice or tablet form — has been the subject of an increasing number of randomized clinical trials. The mechanism of action is thought to be related to the ability of the proanthocyanidins in cranberries to prevent bacteria from adhering to the urothelium.
The use of vaginal estrogen treatment to mitigate future UTI risk in peri- and postmenopausal women with recurrent UTIs is a moderate recommendation (level B evidence).
Outside the formal recommendations, the panel agreed that intermittent courses of higher-dose antibiotics are more harmful to patients than a course of prophylactic antibiotics coupled with counseling on risk when UTIs continue to recur. Patients might be more flexible than physicians think, Anger explained.
“Patients often become more anxious about repeated courses of antibiotics than I think we realize as providers,” she pointed out. “They are often very open to the concept of waiting for cultures to come back before initiating treatment.”
In addition, physicians often underestimate the psychosocial effects of the condition, which include guilt and shame. “Alleviating the fear of recurrence, as well as the social and psychological burden, is a huge part of our care,” she said.
The guideline is not necessarily practice-changing but it is affirming, said Ajay Singla, MD, from Harvard Medical School and Massachusetts General Hospital in Boston.
“It’s helpful to know that we are following the guidelines,” he told Medscape Medical News.
The strong recommendation that clinicians not treat asymptomatic bacteriuria is “very useful,” he said. “That was a grey zone because there were no clear guidelines on how asymptomatic bacteriuria should be addressed.”
The committee cited a lack of evidence supporting the treatment of asymptomatic bacteriuria and clear evidence that it can cause harm in the form of adverse effects, the development of infections such as Clostridium difficile, and antibiotic resistance.
The committee seemed to be more positive about the evidence supporting cranberry as a nonantibiotic prophylaxis than he has been, Singla acknowledged, but he said he will now give it more consideration.
There is no risk or downside to cranberry, except in juice form, where the sugar can pose a diabetes risk, he added.
Anger and Singla have disclosed no relevant financial relationships.
J Urol. Presented May 1, 2019. Full text
American Urological Association (AUA) 2019 Annual Meeting. Presented May 5, 2019.