Non-antibiotic vs antibiotic prophylaxis for recurrent urinary tract infections

Suzanne Geerlings, MD, PhD, of the Academic Medical Center, in Amsterdam, Netherlands, and colleagues performed two interlinked trials in the Non-antibiotic versus Antibiotic Prophylaxis for Recurrent Urinary Tract Infections (NAPRUTI) Study.

In the first, they included 252 postmenopausal women with recurrent urinary tract infections (rUTIs): 127 received trimethoprim-sulfamethoxazole (TMP/SMX) and 125 oral lactobacilli, and compared 12-months prophylaxis with either TMP/SMX 480 mg once daily or oral capsules containing Lactobacillus rhamnosus GR-1 and L. reuteri RC-14 twice daily for the prevention of rUTIs. The mean cumulative number of symptomatic UTIs after 12 months was 2.9 for TMP/SMX and 3.3 for lactobacilli prophylaxis. The percentage of patients with at least one symptomatic UTI at 12 months and the median time to first recurrence were also in favor of TMP/SMX (P=0.02). However, development of antibiotic resistance of the normal bacterial flora was considerably lower in women on lactobacilli. Therefore, lactobacilli may be an acceptable alternative for prevention of UTIs, especially in women who dislike taking antibiotics.

In the investigators’ other double-blind, double-dummy non-inferiority trial, 221 premenopausal women with rUTIs were randomized to 12-months prophylaxis with TMP/SMX 480 mg once-daily (n=110) or cranberry capsules 500 mg twice-daily (n=111). After 12 months the mean number and the proportion of patients with at least one symptomatic UTI were higher in the cranberry than in the TMP/SMX group (4.0 and 1.8, P=0.02; 78% and 71%, respectively). Median times to the first symptomatic UTI were 4 and 8 months for the cranberry and TMP/SMX group, respectively.

But after one month Dr. Geerlings and colleagues found increased resistance rates for trimethoprim, TMP/SMX, amoxicillin, and ciprofloxacin in E. coli isolates of the normal flora. After discontinuation of TMP/SMX, resistance reached baseline levels after three months, they noted. Antibiotic resistance did not increase on cranberries. Cranberries and TMP/SMX were equally well tolerated.