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Treatment of urinary tract infections (UTIs) is one of the leading reasons for prescription of antibiotics, and suppressive antibiotics remain a common treatment option for patients with recurrent UTIs.
Antibiotic use and overuse cause significant problems to individuals and society. Antibiotics have numerous side effects and pose the risk of building antibiotic resistance. Additionally, the growing body of research on asymptomatic bacteriuria (ASB) shows that antibiotic use when patients are not acutely symptomatic can actually lead to an increase in recurrent UTIs.
The recurrent UTI guidelines written by the American Urology Association, Canadian Urological Association, and Society for Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction stress the importance of increased research on the prevention of recurrent UTIs. It states that,
critical to these investigative efforts is the discovery of methods to suppress symptoms without use of antibiotics. (F)
The common antibiotics used to treat urinary tract infections are seeing a dramatic increase in antibiotic resistance, making UTIs more and more difficult, and risky, to treat.
The harms of antibiotics are well documented. Antibiotic use is associated with adverse events including allergies, organ toxicities and clostridium difficile.
Tamma et al found a 20% rate of antibiotic associated adverse events in their inpatient cohort (C). Shehab et al reported that 19% of ED visits for drug related adverse events were due to antibiotics (D). Research shows that a longer antibiotic course is associated with a greater risk of c. difficile with certain antibiotics such as moxifloxacin, ciprofloxacin and clindamycin having a particularly increased risk (b).
Antibiotic use is also linked to an increase in drug-resistant organisms. Cephalosporin use has shown a connection to subsequent infections with vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, beta-lactam-resistant Acinetobacter species and clostridium difficile (A). Quinolone use has been connected to infections with methicillin-resistant Staphylococcus aureus and increased quinolone resistance in gram-negative bacilli such as pseudomonas aeruginosa (A).
Research has shown that treating ASB with antibiotics is not beneficial and specifically that treating ASB in patients with recurrent UTIs leads to an increased risk of urinary tract infections. Cai et al demonstrated that antibiotic treatment of ASB in patients with recurrent UTIs leads to an increase rate of UTI recurrence and a higher rate of antibiotic resistance (E).
It is difficult seeing a patient with recurrent UTIs; symptomatic episodes can be very disruptive to the patient’s’ life, and the patient often presents desperate for treatment. Antibiotic suppression continues to be a common treatment for patients with recurrent UTIs.
The AUA/CUA/SUFU guidelines on recurrent UTIs stress the importance of counseling patients on the risks, but do include antibiotics as the prophylaxis method with the highest level of evidence (level B). The guidelines mention other options including lactobacillus, increased water intake, D-mannose, methenamine, and herbs or supplements, but say that they cannot currently include them due to the limited research (F).
As there is more evidence highlighting the risks of antibiotics, it is essential that we have other options to offer patients.
(A) Paterson DL: “Collateral damage” from cephalosporin or quinolone antibiotic therapy. Clin Infect Dis 2004; 38: S341.
(B) Brown KA, Langford B, Schwartz KL, Diong C, Garber G, Daneman N. Antibiotic prescribing choices and their comparative C. difficile infection risks: a longitudinal case-cohort study [published online ahead of print, 2020 Feb 18]. Clin Infect Dis. 2020;ciaa124. doi:10.1093/cid/ciaa124
© Tamma PD, Avdic E, Li DX, et al. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med 2017; 177:1308–15.
(D) Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008;47(6):735–743.
(E) Cai T, Nesi G, Mazzoli S et al: Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis 2015; 61: 1655.
(F) Anger J, Lee U, Ackerman AL, Chou R, Chughtai B, Clemens JQ, Hickling D, Kapoor A, Kenton KS, Kaufman MR, Rondanina MA, Stapleton A, Stothers L, Chai TC (2019) Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol 202(2):282–289.