Disease management

Acute

In cases of uncomplicated acute cystitis in women, when antibiotics are needed, fosfomycin trometamol, pivmecillinam or nitrofurantoin can be used

  • In countries where local resistance rates are below 20%, trimethoprim-sulphamethoxazole is also a valid first-line option
  • The combination trimethoprim-sulphamethoxazole has no advantage over monotherapy with trimethoprim, which avoids the adverse effects caused by sulfonamid
  • Antimicrobials need to be used carefully as they can damage the beneficial microbiota of the urinary tract.


Symptomatic

Watchful waiting is a viable option

  • Anti-inflammatory drugs in conjunction with appropriate patient monitoring, for collaborative patients without underlying complications or other major risks, is possible
  • The patient needs to have a solid understanding of the treatment options, good compliance, and access to healthcare services in case of upper UTI
  • There is a growing number of studies investigating the efficacy of symptomatic treatment with anti-inflammatory drugs, which allow self-healing instead of eradicating all infecting bacteria with antibiotic treatment

Ibuprofen

Ibuprofen medication logo

In a clinical trial assessing ibuprofen vs. pivmecillinam in women with acute cystitis, 53% of patients in the ibuprofen group recovered without antibiotic treatment.

However, 7 cases of pyelonephritis occurred, all in the ibuprofen group, giving a number needed to harm of 26.

This data indicates that:

  • Faster symptom recovery occurs with antibiotic treatment
  • Antibiotics may provide better results, however half of patients were cured without antibiotics
  • Suitable patients should be better defined to avoid progression to pyelonephritis

Phenazopyridine (pyridium)

Phenazopyridine medication logo
  • Phenazopyridine (pyridium) is an analgesic which has been used to treat lower UTIs
  • No recent or conclusive data currently exists to support its use, however it has been shown to have a good safety profile in clinical trials and is popular among patients


Phytotherapeutic treatment

  • A randomized, controlled, phase III non-inferiority clinical trial, compared herbal therapy with BNO 1045 (n=325) to fosfomycin trometamol (FT, n=334) in treating acute uncomplicated cystitis
  • 83.5% of patients in the BNO 1045 group and 89.8% of patients in the FT group received no additional antibiotics
  • BNO 1045 was non-inferior to FT
  • Adverse event rates were similar between groups, but with a higher number of gastrointestinal adverse events in the FT group (27:13) and a higher number of cases of pyelonephritis in the BNO 1045 group (5:1)


There is a rationale for using specific phytotherapeutic agents instead of antibiotics to treat the infection, however evidence is limited, as comparative studies are rare. RECAP

A combined approach using symptomatic treatment during acute episodes alongside prophylactic treatment with immunotherapy is considered a viable management strategy.

Prophylaxis

Identifying the ideal prevention strategy is not easy and should always be performed individually, tailored to the patient’s risk-factors and lifestyle

A certain order and hierarchy of recommendations should be followed when planning the prevention strategy:

1. Identify risk factors

Possible risk factors (reversible and irreversible) for recurrences should be identified in detail.

2. Eliminate risk factors

Reversible risk factors should be eliminated (residual urine, low fluid intake, intrauterine device, use of spermicides etc).

3. Patient education

Patient education about basic microbiological and physiological aspects of the female pelvic microbial ecosystem and rUTIs should be given.


Permits patients to identify individual risk factors, which can be targeted


Allows patients to feel in control of their disease, which has a significant positive effect on their quality of life

4. Lifestyle advice & non-antimicrobial prevention

Lifestyle advice should be given, and non-antibiotic prevention methods should be applied based on the identified individual risk factors.

5. Antibiotic prophylaxis

Antibiotic prophylaxis should be applied as a last resort, when non-antibiotic prevention strategy has failed.


Primary antibiotic prophylaxis is only recommended in severe cases with very frequent recurrence or robust symptoms, leading to severe psychological distress


Use continuous or post-coital antimicrobial prophylaxis to prevent recurrent UTIs when non-antimicrobial interventions have failed and urine culture is positive. Counsel patients regarding possible side effects

6. Education on proper self-treatment

Patients should be educated about proper self-treatment of each acute cystitis episode. Avoiding unnecessary antibiotics is mandatory.


Apply non-antibiotic prophylaxis as first-line


The kind of non-antibiotic prophylaxis recommended should follow the rules of evidence based medicine


Fosfomycin-trometamol, nitrofurantoin, pivmecillinam should be prescribed for treatment if antibiotics are needed

What are the current options for prevention of recurrent UTIs according to EAU guidelines?

Lifestyle modifications

Lifestyle risk logo

Behavioural risk factors, eg sexual activity and form of contraception

Recommended non-antibiotic prophylaxis

Immunoactive therapy logo

Immunoactive therapy

Hormonal replacement (for postmenopausal women)

Other non-antibiotic prophylaxis

Cranberry products logo
  • D-Mannose
  • Lactobacillus (probiotics)
  • Cranberry products
  • Ascorbic acid
  • Methenamine salts

Antibiotics

Antibiotics prophylaxis logo
  • Continuous low dose prophylaxis
  • Post-coital prophylaxis
  • Patient initiated therapy

Alternative and tolerable options to antibiotics for prevention are needed, to improve clinical outcomes in patients who experience rUTIs, and to reduce the use of antibiotics and the disease burden.

Prophylaxis with immunomodulation

Oral immunotherapy

Oral immunotherapy with bacterial lysates (i.e. OM-89, 18 E.coli strains) to stimulate host immune defences against uropathogens, for prevention of and as a co-medication for acute infections of the lower urinary tract

Prophylaxis with immunomodulation

OM 89 boosts

OM-89 boosts the immune system through innate (non-specific responses), as well as adaptive polyclonal immunity (e.g. release of low-specificity antibodies such as IgA). However, its mechanism of action is not involved in the establishment of immunological B-cell memory, the hallmark of specific immunization (vaccination)

Prophylaxis with immunomodulation

Alternative and combined prophylactic

Alternative and combined prophylactic strategies to prevent recurrent cystitis are being evaluated and immunoactive prophylaxis with OM-89 is sufficiently well documented at sparing antibiotics with a good safety profile

What not to use

The EAU guidelines state that fluoroquinolones, aminopenicillins and cephalosporins should not be used to treat uncomplicated cystitis because of their:

  • Negative collateral effects on the vaginal flora
  • High resistance rates in the case of aminopenicillins
  • Increased selection for ESBL producing bacteria in the case of aminopenicillins
  • Restricted indication by the European Medicines Agency in the case of fluoroquinolones

Non-antibiotic methods of prevention should not be misinterpreted as methods of treatment. Sometimes patients and even clinicians have a misconception in this regard. This leads to false expectations about treatment effect of non-antibiotic prevention approaches, like using or recommending cranberry products or OM-89 for treatment of acute infections.

Certain prophylaxis options should be avoided

Antibiotic prophylaxis

Antibiotics prophylaxis logo

Antibiotic prophylaxis should not be applied as a first line prophylaxis, if avoidable


If antibiotic prophylaxis is initiated, the use of fluoroquinolones is not recommended, as it is restricted by the EMA in this indication

Bladder irrigation

Bladder irrigation logo

Bladder irrigation with antibiotics or antiseptics is not recommended, as there is no proven efficacy of these approaches

Other non-antibiotic prophylaxis

Non antibiotic prophylaxis logo

The evidence surrounding other non-antibiotic prophylaxis (e.g D-Mannose, Lactobacillus (probiotics), cranberry products, ascorbic acid and methenamine salts) is contradictory, therefore no recommendation can be made

Cranberry products

Cranberry cochrane logo

The latest Cochrane meta-analysis concluded that cranberry products did not significantly reduce the occurrence of symptomatic infections for women with rUTIs. However, this may reflect the methodological

insufficiencies of the included trials rather than the lack of effect of cranberry

OM Pharma Logo

The RECAP board is a panel of international experts in urological infections. The opinions presented within this educational material are those of the RECAP board and not those of OM Pharma. Members of the RECAP board include: Jose Tiran Saucedo (Mexico), Yvette León (Mexico), Gernot Bonkat (Switzerland), Kurt G. Naber (Germany), Florian ME. Wagenlehner (Germany), J C. Nickel (Canada), Flavia Rossi (Brazil), Enrique Ubertazzi (Argentina), Agnaldo L. da Silva Filho (Brazil), Tamara S. Perepanova (Russia), Bela Köves (Hungary) & Tommaso Cai (Italy).

Patient version : MED-HQ-UV-2100071 / HCP version : MED-HQ-UV-2100070
Date of preparation: December 2021