How can I prevent a UTI

Recurrent Urinary Tract Infections: How To Avoid And Treat?

SUPPLEMENT: Perspectives in Urology

Dtsch Arztebl 2015; 112 (37): [16]; DOI: 10.3238 / PersUro.2015.0911.03

Different forms, causes and special risk situations, which require specific measures for prevention and treatment, have to be considered.

Chronic recurrent urinary tract infections (rHWI) - defined as at least three episodes per year or two every six months - represent a very common disease with an incidence of one to five percent in women are rather rare. In the absence of correctable predisposing factors, the effect of long-term prophylaxis has been well documented (1–8).

Young and postmenopausal women are often affected. Established premenopausal risk factors include sexual intercourse and the use of spermicidal contraceptives. Postmenopausal risk factors are urinary incontinence, residual urine, cystocele formation and a positive UTI history before menopause.

As the most common bacterial infection, UTIs are not only of great individual but also socio-economic importance.

General prophylaxis

A third of all patients can become infection-free with the help of behavioral recommendations for micturition, genital and sexual hygiene and by increasing diuresis, possibly in connection with urinary acidification (4, 5, 9).

Drinking amount: If the influence of the drinking amount on the development of rHWI is unclear, according to experts, attention should be paid to a sufficient, but not too high, drinking and urine amount (about 1.5 l / d) to avoid substances in the urine that inhibit bacterial growth like the Tamm-Horsfall protein or cathelicidin not to be diluted (overview at 6, 7, 8, 10).

Food: Regular consumption of fruit juices, especially from berries, as well as milk products fermented with probiotic bacteria lowers the rHWI rate. An effect lowering the rHWI rate has not yet been reported for food supplements (overview in 6–8).

The influence of the consumption of fruits, vegetables, fat or meat on the UTI rate has not yet been systematically investigated (5).

Obesity with a BMI greater than 30 increases the risk of UTIs by a factor of 2.5–5 (11).

Sexual intercourse: The UTI rate correlates with the rate of genital contact with an increase of up to 60 times. (Temporary) sexual abstinence can lower the rate of UTIs (reviewed in 4–7, 12–14).

Contraceptive methods: The use of intravaginal ovules or diaphragms coated with spermicides (nonoxynol-9) or condoms and intrauterine IUDs increases the UTI risk 2 to 14 times (overview in 5, 6, 8, 13).

Oral contraceptives led to contradicting results (overview in 5, 6, 13).

Urinary bladder emptying and coitus: Despite contradicting literature, emptying the urinary bladder after coitus makes sense (6, 13, 15).

Hypothermia: Two to three days after targeted cooling of the feet, cystitic symptoms occurred in an open, controlled study in women with rHWI (16). Therefore, hypothermia should be avoided; swimming without hypothermia does not lead to UTI symptoms.

Hygiene behavior: Excessive intimate hygiene damages the local protective environment (lactobacilli, antimicrobial peptides) (overview at 6).

Hygiene measures such as hand washing before going to the toilet, wiping technique from front to back after defecation, no intimate sprays or bidet rinses, baths without bath additives, only cotton underwear and cleaning the genital area before / after sexual intercourse led to contradicting results (13,15).

In case-control studies, the type of menstrual hygiene or pantyhose, partner hygiene or cycling had no influence on the rHWI rates (6, 13).

Training measures

In placebo groups of various long-term prophylaxis (LP) studies, 14–40 percent of patients remained without recurrence after specific advice (4, 5). Counseling alone reduced the incidence of UTIs in a Chinese study from 9.8 percent to 1.6 percent (4).

Dysfunction / micturition

Urinary bladder storage and emptying disorders: The relationship between rHWI and urinary incontinence is unclear (6, 13, 14).

In studies in adults, urination frequency or habitual suppression of urination had no effect on UTI rate. Nevertheless, a sufficiently frequent, relaxed urination can be recommended, as a subgroup of patients may benefit from this and these measures can lead to a reduction in rHWI by up to 83 percent in children.

Increased residual urine increases the rHWI rate in the postmenopause (6, 12, 13).

Vesicoureterorenal reflux: After successful reflux therapy, the frequency of pyelonephritis relapses decreases, while the rate of vesical infections often remains unchanged (4).

Antibiotic prophylaxis

Antibiotic prophylaxis is considered to be the most effective and best established method to date for avoiding UTI recurrence (1, 17–19). The guideline recommends nitrofurantoin, trimethoprim, cotrimoxazole and fosfomycin-trometamol as well as, where appropriate, cephalexin and fluoroquinolones (table).

Guideline recommendation of the European Association of Urology (EAU) on long-term antimicrobial prophylaxis for recurrent urinary tract infections in women

Low-dose long-term therapy over three to six months, a single post-coital dose, or patient-initiated self-therapy can reduce rHWI by up to 95 percent (2, 4–6, 8, 20, 21). Breakthrough infections are each half caused by a lack of compliance or by resistant pathogens (4).

Cephalosporins or fluoroquinolones should only be used in exceptional cases because of the risk of increasing resistance as collateral damage.

Side effects, increasing resistance and the often unchanged UTI rate after the end of antibiotic LP lead to a critical reassessment of antibiotic prophylaxis and an intensive search for alternatives (4).

Disinfectants

Chemical: After the lack of a positive evaluation in a Cochrane review, the methenamine salts that release formalin in the urinary bladder are out of trade in Germany (4–6).

Vegetable: The large number of herbal products with different compositions and unclear effective concentrations make it difficult to carry out valid studies and to compare the data.

Bearberry leaves with dandelion root (20) (after one month of prophylaxis for one year, no UTI recurrences, placebo 23 percent) and nasturtiums with horseradish (22) (0.43 UTI over three months, placebo 0.77 UTI) reduced the rate of UTIs .

A preparation made from centaury, lovage and rosemary has also produced initial positive results, which have to be confirmed in controlled studies (23).

Further phytotherapeutic agents have not yet been tested in controlled studies on their effectiveness in LP rHWI.

Bearberry leaves (liver damage, macular degeneration), sandalwood and juniper berries (kidney damage) can lead to serious side effects in long-term use (5, 6).

Acidification of the urine: The data on uric acidification in rHWI (for example with L-methionine 3 × 0.5–1.0 g / d, vitamin C 3 × 1 g / d) are contradictory. Contraindications are in particular renal insufficiency, hyperuricaemia, metabolic acidosis, liver insufficiency, uric acid or cystine stones and homocysteinuria (1, 5, 6). Many antibiotics work better in a slightly acidic environment (pH 5.5–7) (6).

Immunotherapy and vaccines

Effective vaccines against the "adhesion tools" (fimbriae) of bacteria do not yet exist (6, 24). Only case reports are available for vaccines made individually from uropathogenic pathogens.

General immune stimulation through a plant-based diet, regular sporting activities and psychosocial measures such as maintaining social contacts and achieving a positive attitude towards life are recommended even without scientific confirmation.

Oral immune stimulation

Bacterial cell wall components (OM 89, Uro-Vaxom®): Two meta-analyzes with five double-blind, placebo-controlled studies with the same design on Uro-Vaxom® (OM 89) (a capsule with 6 mg cell wall fractions from 18 uropathogenic E. coli strains / d) for rHWI have confirmed the effectiveness (24, 25). Within six to twelve months, there was an average reduction in recurrence rates of 39 percent compared to placebo. The treatment duration for breakthrough infections was shortened and the infection rate at the end of the study compared to placebo was reduced (24–26). Uro-Vaxom was present in girls with rHWI® Equi-effective to nitrofurantoin (27). Mild side effects (mostly dizziness or skin reactions) were rare overall.

Prophylaxis can already be started during acute therapy and should not be interrupted in the event of a breakthrough infection. After seven to nine months, if the relapse occurs again, it can be boosted for ten days at a time and, if necessary, repeated after a treatment-free three-month interval. Uro-Vaxom® is recommended in the EAU guideline for LP by rHWI (1).

Parenteral immune stimulation

StroVac®: StroVac® (Perison®) is a vaccine that 109 contains inactivated pathogens from a total of ten strains from five uropathogenic species. He is administered i.m. three times at one to two-week intervals. administered in the upper arm. A booster vaccination can be given after one year. A parallel application to the acute therapy is possible.

In several controlled studies, the breakthrough infection rate decreased by 26–93 percent during therapy compared to placebo. The rate of side effects was 28–47 percent (predominantly local irritation or immune reactions) (overview in 4, 6). StroVac® is recommended in the EAU guideline for the LP of rHWI (20).

Immune stimulation through vaginal or cutaneous therapy: In some, partly controlled studies, the intravaginal application of killed bacteria (currently no commercial drug available) (24), acupuncture (28, 29) or inpatient rehabilitation (overview in 6) were successful in reducing the risk the recurrence rate in rHWI.

Change in the gut microbiome

Oral uptake of probiotics and prebiotics: Oral uptake of lactobacilli (L. rhamnosus GR-1, L. reuteri RC-14) is recommended in the EAU guideline on LP for rHWI (overview at 1, 6, 30–32). A comparison between the oral administration of these probiotics and sulfonamides could not prove the equivalence of these two therapeutic strategies, but the low superiority of sulfonamide prophylaxis is compensated for by the lower side effect profile of probiotics (17).

Changes in the microbiome in the vagina and urethra: Before a urinary bladder inflammation, the causative pathogens often settle in the vestibulum vaginae or the perineum without causing symptoms there.

This is favored by increased pH values ​​with a reduction in lactobacilli in the vagina, especially postmenopausally (4, 33).

Hormone substitution: According to several controlled studies, local estriol substitution (0.5 mg / d) is the drug of choice for reducing the UTI rate in menopause and for treating vaginal atrophy (vaginal pH value> 4.5). Relevant side effects rarely occur. Scandinavian studies show neither an increased risk of breast cancer (32, 34) nor its doctorate (35). If gynecological tumors are present, however, the attending gynecologist should be consulted. The duration of treatment (initially two weeks, then intermittently), use in premenopause, and comparison or combination with antibiotic LP have not yet been adequately documented (4, 6, 33, 36–39).

Decrease in bacterial adherence

Vaccinium species: The juice of vaccinium species (cranberry and common cranberry) lowers the ability of E. coli to bind to fimbriae on urothelial cells in vitro due to the content of proanthocyanidins (cranberry) and fructose (6, 40–42). After the first positive results, a current Cochrane analysis including larger studies could no longer find any advantage for cranberry juice. The statement on tablets is unclear. The previously recommended dose of 36 mg proanthocyanidin A / d may have to be increased (1, 6, 20, 40, 43, 44, 45). The data for comparison with the antibiotic LP are contradicting (7, 18).

Mannose: In a three-armed, prospective, controlled, open study compared to placebo, the UTI rate could be statistically significantly reduced by 2 g D-mannose / d. There was no significant difference compared to the antimicrobial LP with nitrofurantoin (46).

Intravaginal probiotics (lactobacilli): Intravaginal lactobacilli (L. reuteri RC-14, L. rhamnosus GR-1) once or twice a week significantly reduced the UTI recurrence rate (overview in 1, 19, 31, 47–49).

Intravesical prophylaxis: Intravesical prophylaxis with disinfectants, antibiotics or the settlement of non-pathogenic germs should be discouraged in uncomplicated rHWI (overview in [31, 50]). In contrast, the first positive results of intravesical prophylaxis with substances that restore the glucosaminoglycan layer, such as hyaluronic acid and chondroitin sulfate, are available individually and in combination (35, 51). ▄

DOI: 10.3238 / PersUro.2015.0911.03

Priv.-Doz. Dr. med. Winfried Vahlensieck

Specialist Urology Clinic, Kurpark Clinic, Bad Nauheim

Prof. Dr. Dr. med. habil. Harwig W. Bauer

Urological practice, LMU Munich

Prof. Dr. med. Hansjürgen Piechota

Clinic for Urology, Pediatric Urology and Urological Oncology, Minden

Dr. med. Martin Ludwig

Urological practice Marburg

Prof. Dr. med. Florian Wagenlehner

Clinic and Polyclinic for Urology, Pediatric Urology and Andrology, Giessen

Conflict of Interest:
Winfried Vahlensieck has received consultancy fees from the companies Bionorica and Repha; Fees for publications for the company Infectopharm and fees for lectures from the company Strathmann.

@Literature on the Internet:
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