Recurrent UTI: Questions and Answers on Clinical Practice
1. Background and Aims
2. Materials and Methods
Search of Evidences
3. Results and Evidences
3.1. Which Is the Burden of Uncomplicated Urinary Tract Infections?
3.2. What Is the Psychological Burden of rUTI on the Patient’s Outcome and on the Adherence to the Treatment?
3.3. What Is the Role of Uncomplicated UTI Management in Antimicrobial Stewardship Programs?
- antibiotic treatment should be used in case of urinary symptoms and absence of vaginal infection
- antibiotic selection, antibiotic dosage, and time schedule should be selected in line with international guidelines recommendations
- treat asymptomatic bacteriuria only in pregnant women and before urological procedures
3.4. Is the Presence of Bacteria in the Urine Always a Symptom of Infection and Does It Need to Be Treated?
3.5. If, after an Episode of Acute Cystitis, Urine Culture Is Still Positive Must the Antibiotic Treatment Be Repeated?
3.6. Is the Execution of Urine Culture Always Necessary before Prescribing an Antibiotic in One Patient with Symptoms to Be Referred to as Cystitis?
- presence of urinary symptoms in absence of vaginal discharge
- data in local antimicrobial resistance surveillance
- patient’s previous antibiotic exposure
3.7. After Antibiotic Therapy in a Woman with Acute Cystitis, Is It Always Necessary to Perform a Urine Culture?
3.8. What Are the Risk Factors Related to a High Risk of UTI Recurrence?
3.9. Can I Use Antibiotic Therapy as a Prophylaxis for Recurrent Cystitis, at the First Evaluation?
3.10. What Are the Most Appropriate Strategies for Reducing the Risk of Recurrent UTI?
- Increase fluid intake
- Use immunoactive prophylaxis
- Use vaginal estrogen replacement in post-menopausal women
- Use of local or oral probiotics containing strains of proven efficacy for vaginal flora regeneration
- Use endovesical instillations of hyaluronic acid or a combination of hyaluronic acid and chondroitin sulphate
- Use continuous or post-coital antimicrobial prophylaxis when nonantimicrobial interventions have failed. Self-administered short-term antimicrobial therapy should be considered, too. Please stick to the principles of antimicrobial stewardship
- Use of cranberry products and D-mannose, even if the quality of evidence is low and there are some contradictory findings
3.11. Which Is the Xyloglucan Mechanism of Action in Reducing Recurrent UTI?
4. Discussion and Final Remarks
- Consider the high impact of uncomplicated and recurrent UTIs on patients’ quality of life (Level 3; Grade B).
- The management of recurrent UTIs should be performed in line with international guidelines (Level 1; Grade A).
- Antibiotic treatment should be used in case of urinary symptoms and absence of vaginal infection (Level 1; Grade A).
- Antibiotic treatment duration should be minimized, with the exact dosage and time schedule depending on the type of infection and in line with international guidelines recommendations (Level 1; Grade A).
- Treat asymptomatic bacteriuria only in pregnant women and before urological procedures (Level 1; Grade A).
- Before prescribing antibiotic therapy, please consider all possible collateral damages caused by antibiotics!
- After empiric therapy, please do not prescribe a urine culture unless the woman has experienced recurrence symptoms (Level 2; Grade B).
- Please consider risk factors evaluation as a pivotal step in the management of rUTI (Level 2; Grade B).
- In the era of antibiotic resistance, an antibiotic-sparing approach represents an important and needed alternative treatment of uncomplicated cystitis in women (Level 1; Grade A).
Conflicts of Interest
- Wagenlehner, F.M.E.; Bjerklund Johansen, T.E.; Cai, T.; Koves, B.; Kranz, J.; Pilatz, A.; Tandogdu, Z. Epidemiology, definition and treatment of complicated urinary tract infections. Nat. Rev. Urol. 2020, 17, 586–600. [Google Scholar] [CrossRef] [PubMed]
- Cai, T. Recurrent uncomplicated urinary tract infections: Definitions and risk factors. GMS Infect. Dis. 2021, 9, Doc03. [Google Scholar] [CrossRef]
- Anger, J.; Lee, U.; Ackerman, A.L.; Chou, R.; Chughtai, B.; Clemens, J.Q.; Hickling, D.; Kapoor, A.; Kenton, K.S.; Kaufman, M.R.; et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J. Urol. 2019, 202, 282–289. [Google Scholar] [CrossRef] [PubMed]
- Nicolle, L.E.; Bradley, S.; Colgan, R.; Rice, J.C.; Schaeffer, A.; Hooton, T.M. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin. Infect. Dis. 2005, 40, 643–654. [Google Scholar] [CrossRef] [PubMed]
- Medina, M.; Castillo-Pino, E. An introduction to the epidemiology and burden of urinary tract infections. Ther. Adv. Urol. 2019, 11, 1756287219832172. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Cai, T.; Tamanini, I.; Collini, L.; Brugnolli, A.; Migno, S.; Mereu, L.; Tateo, S.; Pilatz, A.; Rizzo, M.; Liguori, G.; et al. Management of Recurrent Cystitis in Women: When Prompt Identification of Risk Factors Might Make a Difference. Eur. Urol. Focus. 2022, S2405-4569(22)00037-2. [Google Scholar] [CrossRef]
- Wimble, M. Understanding Health and Health-Related Behavior of Users of Internet Health Information. Telemed. J. E. Health 2016, 22, 809–815. [Google Scholar] [CrossRef][Green Version]
- Kwakernaak, J.; Eekhof, J.A.H.; De Waal, M.W.M.; Barenbrug, E.A.M.; Chavannes, N.H. Patients’ Use of the Internet to Find Reliable Medical Information About Minor Ailments: Vignette-Based Experimental Study. J. Med. Internet Res. 2019, 21, e12278. [Google Scholar] [CrossRef][Green Version]
- Cai, T.; Tascini, C.; Novelli, A.; Anceschi, U.; Bonkat, G.; Wagenlehner, F.; Johansen, T.E.B. The Management of Urinary Tract Infections during the COVID-19 Pandemic: What Do We Need to Know? Uro 2022, 2, 55–64. [Google Scholar] [CrossRef]
- Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D.G.; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann. Intern. Med. 2009, 151, 264–269. [Google Scholar] [CrossRef]
- Köves, B.; Cai, T.; Veeratterapillay, R.; Pickard, R.; Seisen, T.; Lam, T.B.; Yuan, Y.; Bruyere, F.; Wagenlehner, F.; Bartoletti, R.; et al. Benefits and Harms of Treatment of Asymptomatic Bacteriuria: A Systematic Review and Meta-analysis by the European Association of Urology Urological Infection Guidelines Panel. Eur. Urol. 2017, 72, 865–868. [Google Scholar] [CrossRef]
- Naber, K.G.; Tirán-Saucedo, J.; Wagenlehner, F.M.E.; RECAP group. Psychosocial burden of recurrent uncomplicated urinary tract infections. GMS Infect. Dis. 2022, 10, Doc01. [Google Scholar] [CrossRef]
- Cai, T.; Verze, P.; Johansen, T.B. The Quality of Life Definition: Where Are We Going? Uro 2021, 1, 14–22. [Google Scholar] [CrossRef]
- Wagenlehner, F.; Wullt, B.; Ballarini, S.; Zingg, D.; Naber, K.G. Social and economic burden of recurrent urinary tract infections and quality of life: A patient web-based study (GESPRIT). Expert Rev. Pharm. Outcomes Res. 2018, 18, 107–117. [Google Scholar] [CrossRef]
- EAU. European Association of Urology Guidelines on Urological Infections. 2019. Available online: http://uroweb.org/guideline/urological-infections/ (accessed on 16 October 2022).
- Cai, T.; Mazzoli, S.; Mondaini, N.; Meacci, F.; Nesi, G.; D’elia, C.; Malossini, G.; Boddi, V.; Bartoletti, R. The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: To treat or not to treat? Clin. Infect. Dis. 2012, 55, 771–777. [Google Scholar] [CrossRef][Green Version]
- Cai, T.; Nesi, G.; Mazzoli, S.; Meacci, F.; Lanzafame, P.; Caciagli, P.; Mereu, L.; Tateo, S.; Malossini, G.; Selli, C.; 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, 1655–1661. [Google Scholar] [CrossRef]
- Cai, T.; Mazzoli, S.; Migno, S.; Malossini, G.; Lanzafame, P.; Mereu, L.; Tateo, S.; Wagenlehner, F.M.; Pickard, R.S.; Bartoletti, R. Development and validation of a nomogram predicting recurrence risk in women with symptomatic urinary tract infection. Int. J. Urol. 2014, 21, 929–934. [Google Scholar] [CrossRef][Green Version]
- Stapleton, A.; Nudelman, E.; Clausen, H.; Hakomori, S.; E Stamm, W. Binding of uropathogenic Escherichia coli R45 to glycolipids extracted from vaginal epithelial cells is dependent on histo-blood group secretor status. J. Clin. Investig. 1992, 90, 965–972. [Google Scholar] [CrossRef][Green Version]
- Cai, T.; Anceschi, U.; Tamanini, I.; Migno, S.; Rizzo, M.; Liguori, G.; Garcia-Larrosa, A.; Palmieri, A.; Verze, P.; Mirone, V.; et al. Xyloglucan, Hibiscus and Propolis in the Management of Uncomplicated Lower Urinary Tract Infections: A Systematic Review and Meta-Analysis. Antibiotics 2021, 11, 14. [Google Scholar] [CrossRef]
- Camilleri, M.; Madsen, K.; Spiller, R.; Meerveld, B.G.-V.; Verne, G.N. Intestinal barrier function in health and gastrointestinal disease. Neurogastroenterol. Motil. 2012, 24, 503–512. [Google Scholar] [CrossRef]
- Guglietta, A. Recurrent urinary tract infections in women: Risk factors, etiology, pathogenesis and prophylaxis. Future Microbiol. 2017, 12, 239–246. [Google Scholar] [CrossRef]
- Esposito, E.; Campolo, M.; Casili, G.; Lanza, M.; Franco, D.; Filippone, A.; Peritore, A.F.; Cuzzocrea, S. Protective Effects of Xyloglucan in Association with the Polysaccharide Gelose in an Experimental Model of Gastroenteritis and Urinary Tract Infections. Int. J. Mol. Sci. 2018, 19, 1844. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Fraile, B.; Alcover, J.; Royuela, M.; Rodríguez, D.; Chaves, C.; Palacios, R.; Piqué, N. Xyloglucan, hibiscus and propolis for the prevention of urinary tract infections: Results of in vitro studies. Future Microbiol. 2017, 12, 721–731. [Google Scholar] [CrossRef] [PubMed]
- Costache, R.C.; Novac, B.; Bardan, T.R.; Agapie, D.N.; Edu, A. Xyloglucan + Gelose Combination versus Placebo as Adjuvant Therapy to First-Line Antimicrobials for Uncomplicated Urinary Tract Infection in Adults. Urol. Int. 2019, 102, 468–475. [Google Scholar] [CrossRef] [PubMed]
- Cai, T.; Tamanini, I.; Cocci, A.; Di Maida, F.; Caciagli, P.; Migno, S.; Mereu, L.; Tateo, S.; Malossini, G.; Palmieri, A.; et al. Xyloglucan, hibiscus and propolis to reduce symptoms and antibiotics use in recurrent UTIs: A prospective study. Future Microbiol. 2019, 14, 1013–1021. [Google Scholar] [CrossRef]
|Author||Year||Type of Study||Aim||Findings Description|
|Anger J. ||2019||AUA/CUA/SUFU Guideline||Recommendations on rUTI in women||Recommendations on rUTI management.|
|Nicolle LE. ||2005||IDSA|
|Recommendations on asymptomatic bacteriuria||Recommendations on asymptomatic bacteriuria management.|
|Medina M. ||2019||Narrative review||Evaluate the epidemiology, burden of rUTIs and actual management.||rUTIs are related to high prevalence, and high social and economic impact.|
|Cai T. ||2022||Prospective study||Evaluate the impact of risk factors evaluation on the natural history of rUTI.||Risk factor identification and counseling may change the natural history of recurrent urinary tract infections, reducing the number of symptomatic episodes, antibiotic usage, and improving patients’ quality of life.|
|Cai T. ||2022||Review||Evaluate UTI management during the COVID-19 pandemic||During the COVID-19 pandemic, all physicians are asked to maintain a high level of adherence to antimicrobial stewardship.|
|Naber KG. ||2022||Review||Evaluate the psychosocial burden of rUTI||The psychosocial burden of rUTI seems high in everyday clinical practice but little data are available.|
|Cai T. ||2021||Review||Evaluate the aspects of the patient’s quality of life in urology||Quality of life assessment is mandatory in the management of patients affected by rUTI.|
|Wagenlehner F. ||2018||Prospective study||Web-based survey in 5 countries (Germany, Switzerland, Poland, Russia, and Italy), on women affected by rUTI.||rUTIs have a significant impact on the QoL of women in Europe.|
|Bonkat G ||2022||EAU|
|Recommendations on rUTI in women||Recommendations on rUTI management.|
|Cai T. ||2012||Randomized study||Evaluate the impact of asymptomatic bacteriuria treatment on the recurrence rate in rUTI||Asymptomatic bacteriuria should not be treated in rUTI.|
|Cai T. ||2015||Longitudinal cohort study||Evaluate the impact of asymptomatic bacteriuria treatment on antibiotic resistance in rUTIs||Asymptomatic bacteriuria is associated with a higher occurrence of antibiotic-resistant bacteria.|
|Cai T. ||2014||Prospective study||Development and validation of a nomogram.||LUTIRE nomogram is able to predict the risk of a new symptomatic episode in women with rUTI.|
|Stapleton A. ||1992||Observational study||To investigate the hypothesis that blood group secretor status is associated with a higher risk of rUTI.||The blood group’s non-secretor status increased susceptibility to recurrent UTI.|
|Cai T. ||2021||Systematic review and Meta-analysis||Evaluate the effectiveness and safety profile of xyloglucan, hibiscus, and propolis in rUTI||Xyloglucan, hibiscus, and propolis are superior to comparator regimens in terms of microbiological and clinical efficacy in rUTI.|
|Camilleri M. ||2012||Review||The role of the intestinal barrier in rUTI||Intestinal barrier function has a pivotal role in the genesis of rUTI.|
|Guglietta A. ||2017||Review||Risk factors evaluation in rUTI.||Risk factors evaluation is an important step in the management of rUTI.|
|Esposito E. ||2018||Animal model||Evaluate the intestinal barrier effect of xyloglucan in rats.||Xyloglucan shows a protective barrier properties in the prevention of UTI in an animal model.|
|Fraile B. ||2017||In vitro study||Evaluate the role of Xyloglucan in the prevention of urinary infections.||Xyloglucan shows a nonpharmacological barrier property for the management of urinary tract infections.|
|Costache RC. ||2019||Prospective study||Xyloglucan versus placebo in UTI management.||Xyloglucan + gelose is able to reduce bacteriological and symptomatic parameters in women with rUTI.|
|Young and Pre-Menopausal Women||Post-Menopausal and Elderly Women|
|Sexual intercourse||History of UTI before menopause|
|Use of spermicide||Urinary incontinence|
|A new sexual partner||Atrophic vaginitis due to estrogen deficiency|
|A mother with a history of UTI||Cystocele|
|History of UTI during childhood||Increased post-void urine volume|
|Blood group antigen secretory status||Blood group antigen secretory status|
|Urine catheterization and functional status|
deterioration in elderly institutionalized women
|Low-Risk Group||Moderate-Risk Group||High-Risk Group|
|evaluation of risk factors||evaluation of risk factors||evaluation of risk factors|
|active prophylaxis (motivate patients)||active prophylaxis (all patients)|
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Cai, T.; Lanzafame, M.; Tascini, C. Recurrent UTI: Questions and Answers on Clinical Practice. Uro 2022, 2, 262-269. https://doi.org/10.3390/uro2040029
Cai T, Lanzafame M, Tascini C. Recurrent UTI: Questions and Answers on Clinical Practice. Uro. 2022; 2(4):262-269. https://doi.org/10.3390/uro2040029Chicago/Turabian Style
Cai, Tommaso, Massimiliano Lanzafame, and Carlo Tascini. 2022. "Recurrent UTI: Questions and Answers on Clinical Practice" Uro 2, no. 4: 262-269. https://doi.org/10.3390/uro2040029