A Multimodal Approach to Preventing Recurrent UTI: Alternatives to Antibiotics Work!

Objectives: Recurrent urinary tract infections (rUTIs) impact up to 25% of women, negatively affecting quality of life, and contributes to >2 billion dollars in annual healthcare costs. Treatment options are limited; prophylactic antibiotics are associated with a wide range of adverse side effects while methenamine carries a risk of breakthrough infections during and after therapy. There are limited studies evaluating a combination of low-risk, non-antibiotic interventions to decrease rUTIs. The objective of our study was to evaluate a novel multimodal prevention strategy for women suffering from rUTIs.

Methods: A retrospective analysis was performed on all rUTI patients at a large-volume referral center seen by a single provider between 2020-2023. Females over 18 years with a history of ≥2 UTIs in 6 months or ≥3 in 12 months with ≥6 months of follow-up were included. Exclusion criteria included patients with urinary tract anatomical abnormalities, requiring a urinary catheter, or a post-void residual ≥250 mL. Patients were counseled on up to five interventions: (1) increased water intake (≥2.5L/daily), (2) vaginal estrogen (3) cranberry supplementation with ≥36 mg proanthocyanindins, (4) one 30-day course of vaginal probiotic suppositories with multi-strain Lactobacilli and (5) increased fiber to mitigate constipation. Patients who did not complete any of the 5 interventions were excluded from analysis. Satisfaction with protocol was measured based on chart review using a 5 point Likert scale. The number of reported UTIs before and culture-proven UTIs after initiation of the protocol was analyzed using Mann-Whitney U test.

Results: Sixty women with rUTIs met inclusion criteria (75.9% follow-up rate). Median follow-up interval was 6.5 months (IQR 6, 10.8). After initiation of our protocol, the median number of UTIs decreased from 3 (IQR 2, 4) to 0 (IQ 0, 1) (p < 0.01). During the study period, the majority of patients post-intervention had 0 UTIs (n=34, 57.0%) and 13 (21.7%) had only 1 UTI. When stratified by menopausal state and vaginal estrogen usage, the difference was not statistically significant (p=0.29). 52 (86.6%) completed ≥2 interventions. Patients who completed all interventions (n=8, 13.3%) had the highest improvement, with a reduction of median UTIs from 4.5 (IQR 4, 5.75) to 0 (IQR 0,0), but this was of borderline significance (p=0.05). Average satisfaction with outcome of the protocol was 4.6 out of 5 (STD = 0.91).

Conclusions: With growing concerns of antibiotic resistance requiring widespread antibiotic stewardship, and the increasing body of knowledge regarding the importance of preserving the vaginal and bladder microbiome, antibiotic alternatives are needed to address rUTIs. Our study demonstrates that patient counseling and initiation of a multi-modal prevention strategy resulted in fewer UTIs and improved satisfaction, without the use of suppression antibiotics nor Methenamine. Further analysis on a larger scale will better ascertain the extent of benefit for these interventions.