Dear colleagues—urologists, gynaecologists, general practitioners, and all healthcare professionals involved in the management of urinary tract infections (UTIs).

The management and prevention of UTIs constitute a routine component of clinical practice for many healthcare providers. This newsletter aims to review the most recent recommendations regarding the management and prevention of UTIs. 

Our principal objectives are to reduce the incidence of infection, minimise inappropriate antibiotic prescribing in order to limit the development of antimicrobial resistance, and evaluate the available evidence supporting non-antibiotic preventive strategies. The information presented herein is based on robust scientific evidence and current guideline recommendations.

This newsletter summarises the presentations delivered during the meeting of the GUFFU (Group of Functional Urology, Female Urology and Urodynamics) of the Spanish Association of Urology (AEU), where emerging therapies for the management and prevention of UTIs were reviewed.

UTIs remain one of the leading causes of antibiotic prescribing worldwide. Traditionally, antibiotic therapy has been considered the standard treatment for UTIs. However, it should be recognised that most UTIs present with localised symptoms in patients without risk factors for recurrence. The Urological Infections Guidelines of the European Association of Urology (EAU) state that non-antibiotic treatment of acute cystitis may result in a 63% reduction in antibiotic use. Therefore, antibiotic-sparing approaches may be offered for the management and prevention of acute cystitis within a shared decision-making framework.

A non-antibiotic alternative to UTIs prevention

Among the available alternatives, xyloglucan has demonstrated efficacy in preventing recurrence, with a level of evidence of 1a. These findings are reported in a systematically review and meta-analysis (Antibiotics (Basel). 2021 Dec 23;11(1):14. doi: 10.3390/antibiotics11010014). 

Xyloglucan, commercially known as Utipro^® Plus AF in Spain, has demonstrated several beneficial mechanisms in in vitro studies. These include increasing the resistance of epithelial tight junctions, protecting cells against Escherichia coli adhesion, and forming a physical bioprotective film on the intestinal mucosa. Furthermore, it reduces intestinal colonisation by E. coli reservoirs, thereby helping to prevent UTIs. 

Research conducted by Expósito et al. demonstrated that Utipro^® Plus AF reduced bacterial load by approximately 70%. Clinical studies evaluating the effect of xyloglucan in patients with UTIs have also reported reductions in urinary tract symptoms and in the proportion of patients requiring antibiotic treatment. 

Furthermore, Kostev et al. evaluated the efficacy of xyloglucan in the prevention of recurrent UTIs and reported a reduction in infection rates across all age groups. The proportion of patients diagnosed with UTIs at baseline was as high as 80%, decreasing to 27–45% after 12 months of treatment with Utipro^® Plus AF.

Importance of urinary pH in the management of UTIs

Another important aspect in the management of urinary tract infections is the influence of urinary pH. Urinary pH affects both bacterial growth and the efficacy of antimicrobial agents and plays a significant role in the pathophysiology and treatment of UTIs, optimising the therapeutic outcome.

Several antibiotics commonly prescribed as first-line treatments for UTIs, including fosfomycin, nitrofurantoin, ampicillin, and cephalosporins, have demonstrated greater efficacy in combination with L-methionine, providing an acidic urine. Moreover; it has been investigated the iron chelation by phytate. Iron is an essential element for the proliferation and survival of uropathogenic bacteria. 

Therefore, the combination of urinary acidification and iron chelation (Metiofitina^®) may contribute to reducing the incidence of UTIs. 

Urinary acidification may also be beneficial in postmenopausal women by helping to restore normal vaginal pH. Using this hipothesis, L-methionine has been evaluated in both pregnant women and kidney transplant recipients. These studies reported reductions of approximately 70% in positive urine cultures among pregnant women and a decrease in the median number of UTIs from four episodes before treatment to two episodes after treatment in kidney transplant recipients.

It should also be noted that some antibiotics commonly prescribed for urinary tract infections, particularly fluoroquinolones and trimethoprim, demonstrate enhanced antimicrobial activity at alkaline urinary pH. 

In this context, the combination of phytate, which acts as an iron chelator, and potassium citrate, which promotes urinary alkalinization (Citrafitina^®), has been evaluated as an adjunctive strategy in patients receiving these alkalophilic antibiotics. In addition to improving antibiotic activity, this combination may interfere with biofilm formation and contribute to limiting the development of antimicrobial resistance, a growing concern and one of the key challenges in contemporary urology.