Hello urologists, gynaecologists, primary care doctors and all of you who have to deal with urinary tract infections. Urinary tract infection management and prevention is one of the activities on a routine basis for all caregivers. This Newsletter intends to review the last recommendation for managing and preventing urinary infections. Our focus is reducing the number of infections, avoiding antibiotic use when not indicated to prevent resistance and reviewing the evidence about non-antibiotic measures to prevent infections. Scientific support of the evidence and practice guidelines recommendations will be the key to all the information in the Newsletter.

The focus of this issue is the revision of three articles that review the usefulness of non-antibiotic treatment for the prevention of recurrent-urinary tract infections. As age is one of the main risk factors for urinary tract infections, it is included an article that reviews the management of urinary infections in frail or comorbid older individuals.

2'

Non-antibiotic prophylaxis is the treatment of choice for the prevention of recurrent urinary tract infections. Among them several dietary supplement have been used. According to the EAU Guidelines on Infections in Urology version 2024, the evidence is limited as several principles and doses have been used. It is of paramount importance the evaluation of possible side effect and interactions of dietary supplements.

This systematic review focused on the safety of concurrent use of food, herbal or dietary supplement and warfarin. A total of 149 articles were included with 78 herbs, food or dietary; such as Chinese wolfberry, chamomile tea, cannabis, cranberry, chitosan, green tea, Ginkgo biloba, ginger, spinach, St. John's Wort, sushi and smoking tobacco. It is reported potentiation with 45 (57.7%) herbs, food or dietary supplements while 23 (29.5%) reported inhibition and 10 (12.8%) reported limited impact on warfarin pharmacokinetics and pharmacodynamics. Cranberry supplements may be associated with potentiation of the effect of the warfarin as contains anthocyanins, which are flavonoids that are metabolised by CYP2C9 and CYP3A4. These enzymes also metabolise warfarin. Higher risk of haemorrhage can be related to consumption of bilberry fruit, cranberry juice, ginger, Ginkgo biloba, Chinese wolfberry, Japanese food, PC-SPES nutritional supplement, pomegranate juice, grapefruit juice, red clover.  

Authors conclude that healthcare providers must take the time to ask patients on their use of complimentary alternative medicines, so that this can be used to make an informed recommendation to the patient on the suitability of the complementary medicine.

3'

According to the European of Urology Guidelines on infections in Urology, version 2024, immunoprophylaxis can recommended as one of the tools for the prevention of recurrent urinary tract infections (UTI) as reduce the number of infections and the consumption of antibiotics. However, there are several products and doses that can be used as immunoprophylaxis.

This systematic review evaluates the effectiveness of vaccinations in preventing rUTIs. The revision included fourteen comparative studies and 2822 patients with five different vaccination types. The immunoprophylaxis included orally administered tablet for three months containing lyophilized lysates of uropathogenic E. coli (UPEC); intravaginal or intramuscular injection and heat-killed whole bacteria administered sublingually. The results reported that the percentage of patients UTI free in the short term (6-12 month) was 1.52 (95% confidence interval [CI] 1.05-2.20) with a number needed to treat of 6.45 (95% CI 2.80-64.80). However, most of the studies have several biases and low quality of evidence with short follow-up. Many results include a few numbers of patients, and the comparative group is placebo or the number of UTIs before to immunoprophylaxis.

Authors stated that research that evaluate the utility of immunoprophylaxis in the prevention of recurrent UTIs most compare the vaccine against antibiotic therapy, such as some studies that used heat-killed whole bacteria administered sublingually. Moreover, there is few studies reviewing the efficacy of immunoprophylaxis in men, as out of the eight studies that investigated vaccine efficacy against placebo, only two studies included men, and they represented <15% of the sample population. Authors concluded that there is limited evidence to suggest that vaccinations are effective at reducing UTI recurrence within the short term in adult female patients without precipitating factors. There is substantial study heterogeneity, with discrepancies in how key terms are defined and the chosen primary endpoints. Further research is required to create a more rigorous evidence base regarding the use of prophylactic immunostimulants before routine clinical use is recommended. Standardisation across studies is a priority. Future trials should use one approved definition of recurrence and rUTIs to avoid ambiguity and aid intertrial comparison.

1'

Urinary tract infection (UTI) is common among older individuals, especially those with frailty and comorbidity. It is estimated that more than 10% of women older than 65 years reported at least one UTI in the last year. Asymptomatic bacteriuria is also common in this group and does not require treatment and 30% in those older than 85 years. Risk factors for UTIs in old patients include urinary and fecal incontinence, dehydration, impaired cognitive function, and reduced mobility increase an individual’s vulnerability to infection. The first challenging issue in old patients is the diagnosis of UTI as in many cases there are atypical signs and symptoms such as confusion or functional decline. Moreover, it should be emphatizes that asymptomatic bacteriuria should not be treated. Treatment strategies for UTI in older people generally align with those for younger people, using the same antibiotics and treatment duration unless complicating factors are present. Fosfomycin, nitrofurantoin, pivmecillinam, fluoroquinolones, and cotrimoxazole (trimethoprim/sulfamethoxazole) exhibit a slight, albeit insignificant, age-associated resistance effect. 

Prevention measures for recurrent UTIs in older patients in frail women correspond to those for postmenopausal women including local estrogen therapy. However, explicit guidance for men is lacking because of insufficient data. In general, adherence to overall body and intimate hygiene as well as increased fluid intake is advisable. Cranberry supplements have shown varying efficacy, and the role of vaccinations is currently being investigated. Finally, it is crucial to carefully consider comorbidities, polypharmacy, and the risk of potential adverse events.