Cystitis prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Steven C. Campbell, M.D., Ph.D. Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]

Prevention

Non-antimicrobial approach

• Though it is difficult to apply, but abstinence or reduce frequency of sexual intercourse (which is the strongest risk factor for UTI)is a good method to reduce the risk of infection.
• Increasing the intake of fluids may allow frequent urination to flush the bacteria from the bladder. Urinating immediately after sexual intercourse may help eliminate any bacteria that may have been introduced during intercourse. Refraining from urinating for long periods of time may allow bacteria time to multiply, so frequent urinating may reduce risk of cystitis in those who are prone to urinary tract infections.
• Using contraception methods other than spermicides especially with diaphragm or spermicide-coated condoms, because they alter normal vaginal flora allowing pathogens to colonize.
• Topical estrogen for postmenopausal women maintains normal vaginal flora and reduces risk of UTIs.
• Cranberry juice, capsules or tablets:although it inhibits uropathogen from adherence to uroepithelial cells, but studies revealed no benefit from using cranberry juice.
• D-mannose theoretically inhibits E.Coli= adherence to oruepithelium, but no studies support the benefit or effectiveness..

Antimicrobials approach

• Self-diagnosis and self treatment: for women with previous infection that can self-diagnose a subsequent cystitis are advised to start first line regimen at the onset of urinary symptoms.85-95% accuracy of diagnosis with no clinic visit needed so it has better satisfaction.
• Antimicrobial prophylaxis

Postcoital regimen used when coitus related UTI is suspected.

Postcoital prophylaxis Single dose ▸ Nitrofurantoin 50-100 mg PO ▸TMP-SMX 40/200 mg or 80/400 mg PO. ▸TMP 100 mg PO. ▸Cephalexin 250 mg PO.

• Urine culture should be done to confirm absence of bacteriuria.

Continuous prophylaxis Bed time daily dose except Fosfomycin ▸ Nitrofurantoin 50-100 mg PO. ▸TMP-SMX 40/200 mg PO. ▸TMP 100 mg PO. ▸Cephalexin 250 mg PO. ▸Fosfomycin 3 g every 10 days.

Recommend abstinence or reduction in frequency of intercourse Sexual intercourse is the strongest risk factor for uncomplicated UTIs; often this behavioral strategy is not feasible If spermicides are used, recommend changing to another method for contraception or prevention of infection Spermicide use, including use of spermicide-coated condoms, is a strong risk factor, especially if used with a diaphragm; spermicides alter the vaginal flora and favor the colonization of uropathogens Recommend that patient urinate soon after intercourse, drink fluids liberally, not routinely delay urination, wipe front to back after defecation, avoid tight-fitting underwear, avoid douching In case–control studies, none of these strategies have been shown to be associated with a reduced risk of recurrent UTIs, and none have been studied prospectively; however, it is reasonable to suggest them to the patient, since they pose a low risk and might be effective Biologic mediators Cranberry juice, capsules or tablets Biologic plausibility is based on the inhibition of uropathogen adherence to uroepithelial cells; clinical data supporting a protective effect have been limited by design flaws40; a recent randomized, placebo-controlled trial showed no benefit from cranberry juice41 Topical estrogen In some postmenopausal women, topical estrogen normalizes the vaginal flora and reduces the risk of recurrent UTIs42; oral estrogens are not effective Adhesion blockers (D-mannose, available in health-food stores and online, is occasionally used as preventive therapy) UTIs caused by E. coli are initiated by adhesion of the bacteria to mannosylated receptors in the uroepithelium by means of FimH adhesin located on type 1 pili; theoretically, mannosides could block adhesion; however, D-mannose has not been evaluated in clinical trials

Strategy Comments Self-diagnosis and self-treatment First-line antimicrobial regimen is prescribed for future use; patient is advised to take it at onset of UTI symptoms This is not a preventive strategy. Women with previously diagnosed cystitis can accurately self-diagnose subsequent cystitis in more than 85 to 95% of cases and can successfully treat themselves43; higher patient satisfaction with this strategy than with traditional visits to provider for UTI symptoms and less antimicrobial exposure than with continuous antimicrobial prophylaxis; should be reserved for motivated women with previous culture-confirmed cystitis who will comply with the treatment regimen; urine culture should be obtained periodically before treatment to confirm presence of UTI and drug susceptibilities Antimicrobial prophylaxis† Postcoital antimicrobial prophylaxis: single dose of antimicrobial agent as soon as feasible after intercourse Nitrofurantoin, 50–100 mg‡ TMP-SMX, 40 mg and 200 mg or 80 mg and 400 mg§ TMP, 100 mg§ Cephalexin, 250 mg‡ In a placebo-controlled trial, the rate of recurrent cystitis with postcoital TMP-SMX, 40 mg and 200 mg, was 0.3 episodes per patient-year, vs. 3.6 with placebo (a 92% reduction)44; can be used if UTIs are temporally related to coitus; absence of bacteriuria should first be confirmed by negative results on urine culture; results in less antimicrobial exposure than with continuous prophylaxis; fluoroquinolones (e.g., ciprofloxacin, 125 mg) are highly effective but are not recommended§ Continuous antimicrobial prophylaxis: daily bedtime dose (except fosfomycin; see below) Nitrofurantoin, 50–100 mg‡ TMP-SMX, 40 mg and 200 mg (3 times weekly is also effective)§ TMP, 100 mg§ Cephalexin, 125–250 mg‡ Fosfomycin, 3-g sachet every 10 days‡45 Randomized, placebo-controlled trials have shown a reduction in cystitis recurrences of approximately 95%; side effects are common (e.g., rash, yeast vaginitis); absence of bacteriuria should first be confirmed by negative results on urine culture; a 6-month trial is recommended, then treatment is discontinued and the patient observed; about 50% of patients have a reversion to the previous pattern of recurrences of cystitis24; if recurrences continue, prophylaxis may be restarted; rare toxic effects of long-term exposure to nitrofurantoin include pulmonary hypersensitivity, chronic hepatitis, and peripheral neuropathy; fluoroquinolones (e.g., ciprofloxacin, 125 mg) are highly effective but not recommended§; antimicrobial resistance in colonizing strains or breakthrough infections are reported in some studies