Guidelines on Management of Recurrent Cystitis
The different guidelines
Several guidelines are currently available on the management of recurrent cystitis, which are developed for specific countries or regions. Among them, two key materials are the European Association of Urology (EAU) guidelines and Latin American (LATAM) consensus paper.
When the EAU guidelines and LATAM experts’ consensus are compared, both similarities and differences can be seen, as they are specific to each region.
The EAU recommendations at a glance
Antibiotic treatment of an acute episode of UTI
There is a strong recommendation for using fosfomycin trometamol, pivmecillinam or nitrofurantoin as a first-line treatment for uncomplicated cystitis in women.
Cotrimoxazole or trimethoprim should only be considered as drugs of first choice in areas with known resistance rates to E. coli of <20%.
Aminopenicillins alone and in combination with β-Lactamase inhibitors and oral cephalosporins are, in general, not effective as short-term therapy. Do not use aminopenicillins or fluoroquinolones to treat uncomplicated cystitis (strong recommendation).
Antibiotic prophylaxis of rUTIs
Continuous low-dose or post-coital antibiotic prophylaxis should only be offered after counselling and when behavioural modifications and non-antimicrobial measures have been unsuccessful:
- Nitrofurantoin (50 mg or 100 mg daily)
- Fosfomycin trometamol (3 g every 10 days)
- Trimethoprim (100 mg once daily)
During pregnancy:
- Cephalexin 125 mg or 250 mg or cefaclor 250 mg once daily may be used. Self-diagnosis and self-treatment (short course) may be considered
Alternative non-antimicrobial prophylaxis
Immunoactive prophylaxis
OM-89 is an orally administered lyophilized lysate of 18 different E. coli strains. The immunotherapy OM-89 is sufficiently well documented & has been shown to be more effective than placebo in several randomized trials with a good safety profile. Therefore, it can be recommended (strong level of recommendation) for immunoprophylaxis recurrent lower UTIs.
Cranberry
Due to contradictory results, no recommendation on the daily consumption of cranberry products can be made.
D-mannose
A study showed that a daily dose of 2 g D-mannose was significantly superior to placebo and as effective as 50 mg nitrofurantoin in preventing rUTIs. This is indicative but not sufficient for a recommendation.
Hyaluronic acid & Chondroitin sulphate
No general recommendation is possible at this stage.
Oestrogens
Recommended in post-menopausal women vaginal oestrogen replacement therapy, but not oral oestrogens, showed a trend towards preventing rUTIs.
Probiotics, Lactobacilli
Differences in effectiveness between available preparations suggest further trials are needed before any definitive recommendation for or against their use can be made.
The LATAM recommendations at a glance
- Until 2018, there were no unique guidelines for the management of rUTIs in Latin American countries
- The LATAM experts’ consensus is the result of a meeting of presidents and representatives of the existing Latin American National Urogynecology societies
- The guidelines were created based on the best evidence published on the diagnosis and treatment of rUTIs, taking into account local resistances to antibiotics
Antibiotic treatment of an acute episode of UTI
Grade A: antibiotics should be considered the primary treatment option for symptomatic UTI, taking into account local pathogen resistance patterns.
Antibiotic prophylaxis of rUTIs
Grade A: low doses of antibiotics are recommended after nocturnal bladder emptying.
Alternative non-antimicrobial prophylaxis
Immunotherapy
Grade A: immunotherapy OM-89 should be prescribed for women with recurrent uncomplicated cystitis, alone or in combination with oestrogens in post-menopausal women.
Oestrogens
Grade B: oestrogens for vaginal application may be useful in the prevention of recurrent cystitis in post-menopausal women.
Cranberry
Grade C: there is currently no consensus on the use of cranberry for the prevention of recurrent cystitis due to conflicting data.
D-mannose
Grade C: more studies are required to validate the efficacy of D-mannose for the treatment of recurrent cystitis.
Hyaluronic acid and Chondroitin sulphate
Grade D: studies have included a small number of participants, therefore there is insufficient evidence to support their use for the treatment of recurrent cystitis.
Probiotics, Lactobacilli
Grade D: evidence for the use of probiotics for the treatment of recurrent cystitis is not clear and further study is needed.
Current gaps in the management of cystitis
There is still a lack of knowledge and data in certain areas, which have to be taken into account when dealing with non-antimicrobial measures, including:
- The long-term impact of non-antimicrobial treatments.
- Impact of non-antimicrobial treatments on high risk patients (e.g. patients with clinical comorbidities such as diabetes mellitus, associated urogenital pathology).
- Efficacy and safety of non-antimicrobial treatments on pregnant women.
- Level of implementation of guidelines in all countries.
