Dr. med. Dirk Manski



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Urinary Tract Infections (4/4): Antibiotic Treatment and Prevention

Review literature: (Krieger, 2002) (Nickel, 2005a) (Nickel, 2005b) (Sussman and Gally, 1999) (Wagenlehner and Naber, 2006) (DGU 2009, S3-guideline for UTI).

Prevention of Urinary Tract Infections

Fluid intake:

Increasing fluid intake leads to an increased diuresis and is thus protective against urinary tract infections.

Cranberries:

Regular consumption of cranberry juice or concentrate (twice daily) reduces the incidence of urinary tract infections (RR 0.6). The interaction of cranberries with the adherence of uropathologic bacteria (UPEC) with the urothelium is responsible for the preventive effect.

Sexual Behavior and Urinary Tract Infections

Sexual behavior is a relevant risk factor for urinary tract infections. Recurrent urinary tract infections can be reduced with micturition after sexual intercourse, avoiding anal intercourse, and not using diaphragms or spermicides for contraception.

To avoid frequent urinary tract infections after sexual intercourse despite above mentioned techniques, prevention is possible with a single dose of antibiotic after sex, e.g. ciprofloxacin 500 mg or cotrimoxazole 840 mg p.o.

Pharmacological Approaches for the Prevention of Urinary Tract Infections

Acidification of Urine:

Acidification of urine may lower the rate of urinary tract infections in chronic bladder catherization (see below).

Immunization against urinary tract infections:

Oral vaccination is possible with inactivated but immunogenic E. coli strains. Vaccination shows a protective effect, the dosage is one capsule per day for 3 months. Meta-analysis (Bauer et al, 2002).

Parenteral immunization against surface proteins of bacteria (e.g. FimCH adhesin on type 1 pili of E. coli) has been developed and shows promising results in animal experiments.

Antibiotic prophylaxis:

The following antibiotics may be used for antibiotic prophylaxis, up to a year, the dosage is once daily in the evening: nitrofurantoin 50 mg, trimethoprim 50 mg, cotrimoxazole 420 mg, ofloxacin 100 mg, ciprofloxacin 125–250 mg, norfloxacin 200 mg.

With frequent UTIs after sexual intercourse, antibiotic prophylaxis is possible with a single dose of ciprofloxacin 500 mg or cotrimoxazole 840 mg after sex.

Prevention of Urinary Tract Infection in Chronic Bladder Catheterization

Asepsis:

Aseptic techniques for catheterization offer only a short effect in the prevention of urinary tract infections. After a few days of bladder catheterization, the bladder gets colonized by bacteria. From the third day, the prevalence of bacteriuria rises 3–8% per day. After 3 weeks, almost every bladder with catheter is colonized by bacteria. Standard care is the use of closed dependent drainage systems, always free urine flow, positioning of the drainage bag always below bladder level and aseptic manipulations of the drainage system.

Suprapubic catheter:

Transurethral catheters probably cause a slightly higher rate of urinary tract infections in the perioperative setting as compared to suprapubic catheters. For longer periods of catheterization, no differences are detectable. A clear advantage of suprapubic catheters is minimizing the trauma to the male urethra and preventing urethral strictures.

Intermittent catheterization:

Intermittent catheterization is the method of choice for bladder emptying disorders as an alternative to indwelling catheters. Guidelines of the EAU and DGU endorse the use of aseptic techniques for intermittent catheterization.

Acidification of urine:

Urinary acidification is used to prevent urinary tract infections, e.g. with L-methionine or methenamin hippurate (urinary target pH 5.7 to 6.2). The rate of side effects is low. However, there is not enough evidence to support urinary acidification to prevent urinary tract infections (Lee et al, 2002).

Change of Bladder Catheter:

Approximately every 6 weeks, the catheter should be changed to prevent urinary retention due to encrustation. If antibiotic treatment of a symptomatic urinary tract infection becomes necessary, the bladder catheter must be changed after beginning of the antibiotic treatment.

Unsuccessful prevention and treatment approaches:

Antibiotic Treatment in Urinary Tract Infections

Initial Antibiotic Treatment:

Often, urine culture is not available when antibiotic treatment is necessary due to urinary tract infections. Before the start of antibiotic treatment, a urine culture should be collected. In uncomplicated cystitis in premenopausal women, urine culture may be omitted. Important factors for choosing an antibiotic are: severity and location of infection, uncomplicated or complicated UTI, history of allergy, hepatic or renal insufficiency.

For organ-specific diagnosis and calculated initial therapy, see the following sections: bladder infection, gonorrhea, urinary tract infections in pregnancy, pyelonephritis, bacterial prostatitis, epididymitis and urosepsis.

Duration of Antibiotic Treatment in Urinary Tract Infections:

The duration of antibiotic therapy for urinary tract infections without involvement of parenchyma is about 3 days (e.g. cystitis in women). In men, only urethritis can be regarded as infection without parenchymal involvement. The treatment duration for UTI with involvement of the parenchyma should last 7–14 days, depending on severity and response to the initial calculated antibiotic treatment. In bacterial prostatitis, some authors recommend 4 weeks of antibiotic treatment to prevent chronic prostatitis. In recurrent urinary tract infection, it is important to identify risk factors (e.g. sexual behavior, vesicoureteral reflux, bladder stones or obstruction) to enable a causative treatment. In the absence of risk factors, long term antibiotic treatment is an option (see above).







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References

Deutsche Gesellschaft für Urologie, S3-guideline for urinary tract infection
Epidemiologie, Diagnostik, Therapie und Management unkomplizierter bakterieller ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten
AWMF, 2010, Register-Nr. 043/044

Bauer u.a. 2002 BAUER, H. W. ; RAHLFS, V. W. ; LAUENER, P. A. ; BLESSMANN, G. S.:
Prevention of recurrent urinary tract infections with immuno-active E. coli fractions: a meta-analysis of five placebo-controlled double-blind studies.
In: Int J Antimicrob Agents
19 (2002), Nr. 6, S. 451–6

Kass 2002 KASS, E. H.:
Asymptomatic infections of the urinary tract. 1956.
In: J Urol
167 (2002), Nr. 2 Pt 2, S. 1016–9; discussion 1019–21

Lee, B.; Bhuta, T.; Craig, J. & Simpson, J.
Methenamine hippurate for preventing urinary tract infections.
Cochrane Database Syst Rev, 2002, CD003265

Krieger 2002 KRIEGER, J. N.:
Urinary tract infections: what’s new?
In: J Urol
168 (2002), Nr. 6, S. 2351–8

Nickel 2005a NICKEL, J. C.:
Management of urinary tract infections: historical perspective and current strategies: Part 1–Before antibiotics.
In: J Urol
173 (2005), Nr. 1, S. 21–6

Nickel 2005b NICKEL, J. C.:
Management of urinary tract infections: historical perspective and current strategies: Part 2-Modern management.
In: J Urol
173 (2005), Nr. 1, S. 27–32

Sobel und Vazquez 1999 SOBEL, J. D. ; VAZQUEZ, J. A.:
Fungal infections of the urinary tract.
In: World J Urol
17 (1999), Nr. 6, S. 410–4

Sussman und Gally 1999 SUSSMAN, M. ; GALLY, D. L.:
The biology of cystitis: host and bacterial factors.
In: Annu Rev Med
50 (1999), S. 149–58

Tauchnitz 1991 TAUCHNITZ, C:
Sepsis.
In: HAHN, H (Hrsg.) ; FALKE, D (Hrsg.) ; KLEIN, P (Hrsg.): Medizinische Mikrobiologie.
Berlin, Heidelberg : Springer, 1991, S. 501–507

Wagenlehner und Naber 2006 WAGENLEHNER, F. M. ; NABER, K. G.:
Treatment of bacterial urinary tract infections: presence and future.
In: Eur Urol
49 (2006), Nr. 2, S. 235–44


  Deutsche Version: Therapie der Harnwegsinfektion