Dr. Philip Hanno, Professor of Urology at the Hospital of the University of Pennsylvania, Perelman School of Medicine, in Philadelphia, discusses recurrent urinary tract infections (UTIs) in women. Dr. Hanno discusses his approach to managing a variety of situations, ranging from recurrent symptomatic UTIs to asymptomatic bacteruria in elderly patients on intermittent catheterization. He is interviewed by Dr. Tony Nimeh, Research Fellow at Harvard Medical School.
Dr. Nimeh: Dr. Hanno, what is your approach to women who are referred to you for recurrent UTIs?
Dr. Hanno: As an urologist, I want to be sure that nothing abnormal in the urinary tract is predisposing the woman to this problem. In the old days, we used to do cystoscopies; but, because the yield on cystoscopy is virtually zero, we no longer do that. In a woman with recurrent infections, I do perform an ultrasound of the retroperitoneum at some point to make sure she doesn’t have any anatomic abnormality, any site of bacterial persistence in the urinary tract, because we don’t really type all these bacteria. Also, I want to make sure that she doesn’t have any infection stones. So, I like to at least get a screening ultrasound, and if the ultrasound is relatively normal and there’s no obstruction or anything, and the woman is cleared of bacteria between infections, then I’m confident in saying, “This is recurrent urinary infection from reinfection.” That’s Stamey’s classification; it’s just a nuisance, not a health risk.
Dr. Nimeh: How do you manage the nuisance of patients getting an infection every month or two or three?
Dr. Hanno: There are various strategies that can be used, and the one that I like, which results in giving them the least antibiotics, is to have them treat themselves. So, I give them a prescription for Macrobid or Bactrim or Keflex, which they keep in their pocketbook. At the first symptom that they’re getting an infection, I have them take the antibiotic for 2 or 3 days, no longer than that. That should be all they need if they catch it right away. Now, you could say, “Well, why don’t we just give them a single dose,” and the truth is, although a single dose will clear more than 80% of these infections, the symptoms may persist after the one dose, and, then, they’re likely to call you a day or two later that they’re still having symptoms.
Dr. Nimeh: When do you use cultures?
Dr. Hanno: If patients are still symptomatic 2 or 3 days later, I tell them to stop the antibiotic, get a culture because it may be something not sensitive to that antibiotic, or it may be some other problem. Then, we can treat it according to the results of the culture, and, if we do that and the culture shows another organism or something not sensitive, we’ll change the treatment. If it shows they’re sterile and they’re still having symptoms, then, we start to think about other problems, maybe overactive bladder, or bladder pain syndrome, other things. But, in general, they can take very few antibiotics, treat themselves, and not have to come into the doctor’s office. I would rather give them an antibiotic that’s inexpensive, and narrow-spectrum, and risk having them have a positive culture 2 days later for which they might need something like fluoroquinolone, rather than overtreat with fluoroquinolones and get an ever-growing population of resistant organisms in the community and in the patient, which may cause problems later.
I’m willing to accept slightly less success in an infection that’s really more of a nuisance than a health hazard than put everyone on a very expensive broad-spectrum antibiotic. It’s more important to have that drug in reserve if we need it, rather than overuse it, which has already happened with Cipro.
Now, if the patient says to me, “You know, I’m only getting an infection when I have sex, and I only have sex once a month or once every 2 weeks,” then, that’s a scenario where I might say, “Okay. Take a Macrobid just before or after intercourse.” However, if the patient is having sex two or three times a week or more, that’s a lot of antibiotics, and I’d rather treat her as needed. I’m not a big believer in the precoital antibiotics, except in certain circumstances.
If someone says, “You know, when I get one of these infections I get really sick, really fast, and I might get fever, flank pain, or I can’t work or it affects my job,” then maybe self-treatment at the first sign of infection isn’t the best way to go.
Dr. Nimeh: Is this a situation where you think about prophylaxis?
Dr. Hanno: One strategy that’s used in these unusual circumstances is long-term low-dose antibiotic prophylaxis, and that would be taking 1 trimethoprim or 1 Keflex every day or every other day for 6 months at a time, which can head off symptomatic infections. Then, we stop it after 6 months and see whether the patient is out of this period of recurrent infections, and if she develops more infections in the subsequent 6 months, we put her back on for 6 months.
I don’t like Macrobid for prophylaxis because there’s a very slight risk of pulmonary toxicity, pulmonary fibrosis, with long-term use. If someone has a site of bacterial persistence in the urinary tract, it’s best to attack that directly. If it’s an infection stone, that should be treated and gotten rid of. If it’s a urethral diverticulum, if it’s obstruction, that can be managed.
Dr. Nimeh: What do you do for patients on intermittent catheterization and for elderly patients with recurrent infections?
Dr. Hanno: That is a very interesting area. In elderly people, the incidence of asymptomatic bacteriuria is very high—10% in elderly men and 20% in elderly women in nursing homes. We can’t get rid of the bacteria, and we don’t really worry about it because it doesn’t cause any harm.
However, we need to do something for those patients who get recurrent infections that are symptomatic or patients who are on intermittent catheterization and getting symptomatic infections. I like to use a very old-fashioned drug called methenamine hippurate—Hiprex—or methenamine mandelate. Sometimes it’s hard for the patient to find a pharmacy that carries it. It’s actually not an antibiotic; it’s called an urinary antiseptic, and, when it sits in acid urine, it turns to a dilute solution of formaldehyde and prevents bacterial growth. It’s a fantastic treatment in someone on intermittent catheterization getting recurrent symptomatic infections because the urine sits in the bladder. If it’s taken with vitamin C, the urine becomes acidic, the medicine turns to formaldehyde and keeps the colony counts low so the patient doesn’t get symptomatic. I’ve had tremendous success with that.
Dr. Nimeh: In what situations do you have to treat asymptomatic bacteria?
Dr. Hanno: We have to treat it in pregnant women because it can lead to pyelonephritis, especially in the second and third trimester. That can present problems with the fetus as well. That’s why gynecologists and obstetricians are so careful in terms of screening for asymptomatic bacteria in pregnant patients.
We tend to worry about it more in patients with diabetes who have complicated urinary tracts, in patients who are going to have urologic surgery, and in patients who are going to have other types of surgery in which a foreign body, such as an implant, will be placed.
However, in healthy people who are not pregnant, and especially in the elderly, asymptomatic bacteria are not a major issue and recurrent infection is not a health hazard.