Recurrent Urinary Tract Infections in Postmenopausal Women

Article No. 4

Recurrent Urinary Tract Infections in Postmenopausal Women

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INTRODUCTION

Recurrent Urinary tract infections (UTI) are defined as more than 3 episodes of UTI’s in a year.1 Recurrent UTI may be a result of Relapse i.e. infection by the same organism within 2-3 weeks of completing treatment successfully, or Reinfection i.e. infection by a different organism anytime or by same organism 2-3 weeks after a successful UTI treatment. Post menopausal women lack estrogen which causes urethritis, loss of lactobacilli in vaginal flora leading to periurethral colonization by E. coli and repeated infection.2,3

DIAGNOSIS

Clinical symptoms of UTI - burning micturition, increased frequency, dysuria, lower abdominal pain. (Level 1 evidence; Grade A recommendation that diagnosis can be made on clinical symptoms).

Local examination - vaginal atrophy, urethral mucosal prolapse.

Urine routine and microscopy – sample collection

1. clean catch midstream urine
2. sterile catheterization

Culture – Colony count of >105

Complicated causes- ruled out on history and physical examination. Uroflowmetry and determining post void residual urine (t/r/o urethral stenosis) are optional tests in post-menopausal women (Level 3 evidence, Grade C recommendation).

Culture and sensitivity analysis should be performed (Level 4 evidence, Grade C recommendation)

Cystoscopy and imaging are not routinely necessary in all women with recurrent UTI (Level 2 evidence, Grade B recommendation).

Women suspected of having a complicated UTI without knowledge of a specific abnormality should undergo abdominopelvic ultrasound, CT urogram, or an abdominal x-ray. Reference to a Urologist should be make (Level 4 evidence, Grade C Recommendation). 4

TREATMENT

Antibiotics- Continuous long-term prophylaxis (LP) with low dose antibiotics or single postcoital doses can reduce the recurrence rate of rUTIs to as low as 5%. 5 Continuous prophylaxis, post-coital prophylaxis and intermittent self-treatment with antimicrobials have all been demonstrated to be effective in the prevention of recurrent uncomplicated UTIs. The decision as to which approach to use depends upon the frequency and pattern of recurrences and willingness of the patient to commit to a specific regimen. A particular prescription for self start antibiotics can be given to the patient but if the symptoms do not reduce then urine culture needs to be done to check for antibiotic sensitivity.4,6  Fosfomycin, Nitrofuratoin, Trimethoprim/ Cotrimoxazole are antibiotics that can be used.7

PREVENTION

Following certain general conservative measures can help in prevention of UTI’s

1. Adequate hydration
2. Regular emptying of bladder- flushes bacteria out
3. Wash genital areas from front to back to avoid contamination
4. Good personal Sexual hygiene
5. Avoid bubble bath, sprays or soaps (irritants)
6. Change incontinence pads frequently
7. Set alarms for impaired memory patients to void

1. 1. Estrogens- After menopause only 25% to 30% of women have lactobacilli in the vagina.
   With estrogen replacement therapy this percentage may increase to 60% to 100%. 8,9  Studies have shown significant reduction in recurrent UTI in patients who have used Estrogen as compared to those who did not. Estrogen can be used in the form of vaginal gel, rings which  are active locally or as orally active agents.9
2. Lactobacilli- The precise interaction of lactobacilli with the commensal flora and the host, and the mechanism of action by which they exert their beneficial effects are still largely unknown. However, specific lactobacilli strains seem to have the ability to interfere with the adherence, growth, and colonization of uropathogenic bacteria. 9,10
3. Cranberries have been used in the prevention of UTIs for many years. The mechanism of action has not been completely elucidated. Based on in vitro studies, cranberries are thought to contain proanthocyanidins (PACs) that can inhibit adherence of P-fimbriated E. coli to the uroepithelial cell receptors 9,11.
4. D-Mannose- In vitro and in vivo animal studies have shown that d-mannose can inhibit the adhesion of Type 1 fimbria of uropathogenic bacteria to the uroepithelial cells12. Recently, the first randomized clinical trial that evaluated its effectiveness was published13

FUTURE PROSPECTS

1. Immunoprophylaxis- Oral Immunostimulant OM-89, Vaginal Vaccine Urovac are the available vaccines for prevention of Recurrent UTI. 9
2. Gastrointestinal Decolonization of Multiresistant Bacteria- the first case report was published of a patient with recurrent episodes of transplant pyelonephritis who was decolonized for ESBL-producing E. coli with a fecal microbiota transplantation 14

REFERENCES

1. Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C, Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev. 2004; (3):CD001209.
2. Nicolle et al, 1987
3. Reid etal, 1984
4. Can Urol Assoc J. 2011 Oct; 5(5): 316–322; DOI:10.5489/cuaj.11214
5. Prophylaxis of recurrent urinary tract infections, Urologe A. 2014 Oct;53(10):1468-75. doi: 10.1007/s00120-014-3562-9
6. Lichtenberger P1, Hooton TM. Antimicrobial prophylaxis in women with recurrent urinary tract infections, Int J Antimicrob Agents. 2011 Dec;38 Suppl:36-41. doi: 10.1016/j.ijantimicag.2011.09.005. Epub 2011 Nov 4.
7. Fosfomycin, interesting alternative drug for treatment of urinary tract infections created by multiple drug resistant and extended spectrum β-lactamase producing strains. Iran J Microbiol. 2016 Apr; 8(2): 125–131.
8. Reid G., Burton J., Devillard E. The rationale for probiotics in female urogenital healthcare.MedGenMed. 2004;6:49.
9. Non-Antibiotic Prophylaxis for Urinary Tract Infections Pathogens. 2016 Jun; 5(2): 36. Published online 2016 Apr 16. doi: 10.3390/pathogens5020036
10. Falagas M.E., Betsi G.I., Tokas T., Athanasiou S. Probiotics for prevention of recurrent urinary tract infections in women: A review of the evidence from microbiological and clinical studies. Drugs.2006;66:1253–1261. doi: 10.2165/00003495-200666090-00007.
11. Howell A.B., Botto H., Combescure C., Blanc-Potard A.B., Gausa L., Matsumoto T., Tenke P., Sotto A., Lavigne J.P. Dosage effect on 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;10:36 doi: 10.1186/1471-2334-10-94.
12. Altarac S., Papes D. Use of d-mannose in prophylaxis of recurrent urinary tract infections (UTIs) in women. BJU Int. 2014;113:9–10. doi: 10.1111/bju.12492.
13. Kranjcec B., Papes 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. doi: 10.1007/s00345-013-1091-6.
14. Singh R., van N.E., Nieuwdorp M., van D.B., ten Berge I.J., Geerlings S.E., Bemelman F.J. Donor feces infusion for eradication of Extended Spectrum beta-Lactamase producing Escherichia coli in a patient with end stage renal disease. Clin. Microbiol. Infect. 2014;20:977–978. doi: 10.1111/1469-0691.12683.