Recurrent UTIs- The way forward

A recurrent urinary tract infection (UTI) is defined as having multiple episodes of UTIs over a specific period.  Specifically, it means experiencing either two or more symptomatic lower UTIs within six months or three or more symptomatic lower UTIs within one year. These infections can be due to re-infection or bacterial persistence, where the same bacteria cause frequent relapsing infections. Symptoms typically include frequency, dysuria (painful urination), urgency, and suprapubic pain.

Recurrent urinary tract infections (UTIs) are relatively common, especially among women. Approximately 25-30% of women who experience an initial UTI will have a second infection, and about 2.7% will experience a third. The incidence of UTIs increases with age and is more common in women than in men.

Traditional treatment involves use of antibiotics and preventative measures such as ample hydration, use of cranberry juice, and topical oestrogens. 

There have been several advances in the management of recurrent urinary tract infections (UTIs):

1. Pulsed Antibiotic Therapy: Recent studies have shown that pulsed antibiotic therapy with intracellular activity can be effective in treating recurrent UTIs. This approach targets bacterial persistence and intracellular bacterial communities.
2. Methenamine Hippurate: The NICE guidelines have updated their recommendations to include methenamine hippurate as a preventative treatment for recurrent UTIs. This aims to optimize antibiotic use and reduce antibiotic resistance: antimicrobial prescribing 
3.  Vaccines: Uro Vaxom® for example involves an oral administration of immunologically active bacterial lysates of 18 E coli strains and has have shown promise. Better than placebo in several RCTs. UROMUNE®, Urovac® are newer vaccines being trialled.
4. Understanding Pathogenesis: Advances in understanding the pathogenesis of recurrent UTIs, particularly the role of bacterial persistence and intracellular bacterial communities, have led to more targeted treatment strategies.  This includes use of Intracellularly Active Antibiotics which are antibiotics designed to penetrate cells and target bacteria that hide within them.
5. Intravesical Treatments such as Cystistat® (HA), Hyacyst® (HA), Gepan® (CS), iAluril are compounds that contain Glycosaminoglycan hyaluronic acid (HA) and chondroitin sulphate (CS) which enhance the natural protective barrier of the urothelium.
6. Bacteriophages - obligate intracellular viruses that solely infect and kill bacteria. 

These advances aim to improve the management and outcomes for patients suffering from recurrent UTIs.