Recurrent Urinary Tract Infection Prevention

How I Practice Video Series 
James Greenberg, MD, FACOG
Boston, Massachusetts

When I see patients with recurrent urinary tract infections one of my first thoughts is what can I do for this patient and what can I do to prevent her from being exposed over the course of time to multiple antibiotics that are going to lead to resistant bacteria. With the escalation of antibiotic resistant bacteria growing I think this is an important component of treating any infections and as urinary tract infections are incredibly frequent this is an area where we can see some impact. My approach to these patients is always three steps. My first question is ‘Am I actually dealing with a urinary tract infection?’ perhaps this patient has another medical problem like interstitial cystitis or recurrent urinary calculi so I’d like to know that at least on some level of one the infections has been confirmed microbiologically. Then, my second question is what are the risk factors that this person has and how can we work together to eliminate those risk factors or at least mitigate how they are influencing the risks of urinary tract infection. So risk factors I think of are diaphragm or pessary use, are there other medical problems like diabetes or sickle cell trait, does the person have any anatomic problems such as pelvic organ prolapse cystocele or are these urinary tract infections repeatedly associated with intercourse or frequent bladder catheterization. Once we’ve gone down that pathway looking for risk factors we say ‘okay what can we do together to prevent this problem?’ At the extreme, some people are going to need surgical repair but more times than not, simpler interventions are going to take care of the problem. For example, I will have patients void consistently before and after intercourse if this is one of the issues, and if they are using a diaphragm we’ll look for other methods of birth control. Again, if this is associated with intercourse, we might try prophylactic single doses of older generation antibiotics, I’ll use something like nitrofurantoin. For many of my patients with recurrent urinary tract infections, I’ll also suggest consumption of cranberry juice. Cranberries actually contain two unique compounds, proanthocyanidins and xyloglucan oligosaccharides, which have been shown to inhibit the ability of bacteria to adhere to the bladder wall and cause urinary tract infections. There is a microbiologic background for how cranberries prevent urinary tract infections and in fact there was recent study that came out that showed women who consumed cranberry juice had a thirty-nine percent reduction in the clinically diagnosed reduce urinary tract infections. The nice thing about this study it was prospective, it was randomized, it was double blinded, and it was placebo controlled so it’s a nice trial showing you can reduce recurrent urinary tract infections by consumption of cranberry juice. But either way, with one hundred and fifty million urinary tract infections worldwide annually and the rise of resistant bacteria I think prevention of recurrent urinary tract infections is an important component that I focus on. So again, for me, I look at confirmation of the diagnosis, risk factors, and ways that I can work together with the patient to prevent the diagnosis and prevent the prescription of the antibiotics. That’s how I practice.

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