• Question: As a GP I am faced with an epidemic of patients with recurrent urinary tract infection. There are a number of non-bacterial treatments for UTI eg d-mannose, methenamine hippurate, cranberry - with varying evidence for them - any views from the panel on managing these patients? Antibiotic prophylaxis works, but I have obvious concerns about widespread use of this approach.

    Asked by drjonrees on 16 Nov 2015.
    • Photo: Elizabeth Beech

      Elizabeth Beech answered on 16 Nov 2015:

      Hello Jon. As a CCG based prescribing adviser I get asked this question a lot, and I find it very hard to provide a robust evidence based answer. My first question is what sort of patients are in your epidemic? This will influence approach. If older women over the age of 65 years, then be sure the diagnostic process is based on clinical symptoms and (if possible) a urine sample culture and not a urine dip stick. This is particularly important in the care home population. In addition do check patients have adequate hydration, again especially in the care home population, and analgesia.
      Nitrofurantoin is the first choice antibiotic in terms of lowest reported resistance rates – about 3% in samples sent to PHE. But in patients with reduced renal function has limited use.
      You are correct to have concerns about the recurrent use of antibiotics in these patients, as this can lead to both resistant organisms and increased risk of CDI.
      The evidence for use of non-bacterial agents is weak, and the existing guidelines provide conflicting advice – for example CKS do not recommend the use of cranberry products, while SIGN 88 and PHE do. CKS does not advise use of Methenamine, which has a Cochrane review, as this also shows weak evidence. However I am aware that it has recently been included in a number of CCG primary care prescribing guidelines as a ‘least worst’ approach. Again CKS and PHE do not support the use of topical oestrogen in women with post menopausal recurrent UTIs although urology specialist often do!
      Certainly capturing urine samples each time is important for sensitivity reporting, and PHE guidelines and some microbiologists advise use of Stand By 3 day treatment courses kept at home instead of daily prophylaxis. This approach may be worth trying in preference to daily low dose antibiotic prophylaxis.
      I understand d-mannose is used in animals, and there is one report of use in a small number of humans – so no good evidence yet. However as it can be easily purchased on the internet, some women may choose to self medicate. Again while it seems safe, the evidence is not there.
      Michael is the expert researching the use of non-bacterial agents in UTI (and UTIs in general) so he may be able to provide a more useful steer for you.
      Lastly a reminder of the NICE guidelines NG12 published earlier this year – Suspected cancer: recognition and referral. These include advice on referral of patients with repeated UTIs for investigation for possible bladder cancer

    • Photo: Michael Moore

      Michael Moore answered on 17 Nov 2015:

      I would agree with what Elizabeth has said. Whilst antibiotic prophylaxis does reduce the frequency of urinary infections it does not have a long term effect. I think it is still useful at times simply to give women a period of respite from their symptomatic recurrent infections. It is then probably easier to negotiate stopping long term treatment and going for a short term treat option with home antibiotics.
      Once the episodes of symptoms are clearly associated with msu proven infection I think there is less of a role for multiple msu samples other than to monitor for resistant organisms.
      This is an area which causes very difficult symptoms for women and for which we have very limited treatment options. I have one patient who has reported great success with D-mannose which has an effect on the organisms ability to stick to the bladder lining. I don’t think there is sufficient evidence to recommend it yet, however if women want to try it I would be happy with that. We are running a trial in Southampton using Chinese herbal medicines for recurrent UTI so we await the results of that trial with interest.

    • Photo: Cliodna McNulty

      Cliodna McNulty answered on 17 Nov 2015:

      Prophylaxis works, but compliance is a problem as at least 30% do not adhere to the regimens, leading to break through infections. An alternative is to offer a standby antibiotic for the patients if recurrence is not too common, to use as soon as the symptoms start. Cranberry juice has been shown to be effective in a systematic review by CH-Hung.

    • Photo: Christopher Butler

      Christopher Butler answered on 18 Nov 2015:

      Its not evidence based, but daily probiotics may be worth a try. Women tend to like the idea of ‘natural’ approaches. The concept is that probiotic strains may influence the bowel flora so auto-innoculaiton with pathogenic strains may be less easy. Some of my patients have enjoyed benefit from this, but as I say, the scientific evidence is not adequate yet!

Comments

  • Photo: athomson11

    athomson11 commented on :

    It is useful to know about the RCGP module as these are normally really useful. Use of antibiotics for this indication does make up a notable amount of antibiotic prescribing and there can be a tendency for review and descalation in primary care to be overlooked. Some patients have sporadic patterns of ordering suggesting the need for review. In Scotland we had recently got support from dermatology specialist bodies to promote a 6mthly review for these anyone on longterm antibiotics (following the initial review phase obviously) – which is a start to start focusing primary care prescribers (similar to we have done with UTI prophylaxis recommending 6mthly review). Making sure this happens is always the challenge though but at least it gives us a benchmark to review against.

  • Photo: drjonrees

    drjonrees commented on :

    Thanks to all the experts for their answers!
    All very useful – we desperately need good trials of non-antibiotic agents – I am glad to say we are a centre for the Atafuti trial that Michael mentioned, so will be watching that one with interest.
    Chris mentioned probiotics – there are a number of different preparations out there – what do you use / recommend??
    Cliodna mentions cranberry being supported by trial evidence – I have stopped recommending as I understood the Cochrane review was not supportive of cranberry.

    • Photo: Elizabeth

      Elizabeth commented on :

      To add to the comments on use of probiotics – as poor evidence base choosing a product is going to be a challenge. CCG prescribing advisers would request patients are advised to purchase any probiotic products, unless the local formulary does include them.