Recurrent Urinary Tract Infection Care

Integrating Complementary and Alternative Medicine

Feng Feng; Jane Hokanson Hawks; Jeanine Kernen; Eric Kyle


Urol Nurs. 2018;38(5):231-235. 

In This Article

Abstract and Introduction


Recurrent urinary tract infection is more common in postmenopausal women, pregnant women, immunocompromised patients, and patients with catheters. Several complementary and alternative approaches in the prevention and treatment of urinary tract infection recurrence are evaluated in this review.


One in three women who are older than 20 years are likely to experience clinically significant urinary tract infections (UTIs). Postmenopausal women, pregnant women, immunocompromised patients, and patients with catheters are more susceptible to recurrent urinary tract infections (rUTIs). rUTIs are defined as having at least three UTI episodes in 12 months or at least two episodes in six months due to incomplete treatment or reinfection (Beerepoot & Geerlings, 2016). UTIs are more common in women because the female urethra is shorter and closer to the anus. UTIs are commonly caused by bacteria, especially Escherichia coli (E. coli). Biologic and genetic risk factors, such as a patient's immune system and the bacterial flora of the introitus (vaginal vestibule and urethral mucosa), also contribute to UTIs. Bergamin and Kiosoglous (2017) reported on the role of virulence factors, such as adhesins, aerobactin, haemolysin, K-capsule, and resistance to serum killing. Virulence factors, such as aerobactin and haemolysin expression, are more common among certain genetically related groups of E. coli, which constitute virulent clones within the larger E. coli population. In general, the more virulence factors a strain expresses, the more severe an infection it can cause (Johnson, 1991).

Clinical manifestations may include frequency, urgency, dysuria, suprapubic, and/or low back pain. Hematuria, cloudy urine, and flank pain are more serious symptoms. Over 10% of women older than age 65 years reported having a UTI within the past 12 months. This number increases to almost 30% in women over the age of 85 years, this result also reflects in men over 85 years old. Older adutls with rUTIs and other concurrent illnesses have an elevated risk of mortality (Rowe & Juthani-Mehta, 2014).

In 2010, the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases issued an update to treatment guidelines for acute, uncomplicated cystitis and pyelonephritis in women to recommend three first-line therapies for uncomplicated cystitis: nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), and fosfomycin (Gupta et al., 2011). Fluoroquinolones (FQs) remain as second-line agents (Gupta et al., 2011). If left untreated, severe complications, such as renal fibrosis and renal failure, can occur. Antibiotics remain as first line treatment for UTIs.

Rising antibiotic resistance and side effects from antibiotic utilization have become challenges for providers (Edlin, Shapiro, Hersh, & Copp, 2013; Lange, Buerger, Stallmach, & Bruns, 2016; Malik, Wu, Christie, Alhalabi, & Zimmern, 2017). In addition, data reveal an increase in hospitalizations for UTIs and associated costs in the United States, especially in women and older adults. From 1998 to 2011, there was a 52% increase in hospitalizations for UTIs, with approximately 400,000 hospitalizations for UTIs at an estimated cost of $2.8 billion (Simmering, Tang, Cavanaugh, Polgreen, & Polgreen, 2017). There is a need for the development of new oral and intravenous antibiotics that may be resistant to first-line antibiotics and can be easily administered, ideally one time, in outpatient settings to treat rUTIs to minimize hospitalizations associated with UTIs and rUTIs and decrease costs (Simmering et al., 2017). Findings by Simmering and colleagues (2017) prompted the authors of this article to review literature on complementary and alternative medicine (CAM) therapies as a means to decrease hospitalizations and costs associated with UTIs and rUTIs.

The interest in CAM among patients is high, and the number of effective treatments available for rUTIs are few (Beerepoot & Geerlings, 2016; Bergamin & Kiosoglous, 2017; Caretto, Giannini, Russo, & Simoncini, 2017; Genovese et al., 2017; Liu, Guo, We, Chen, & Zhang, 2017). More than 30% of adults and about 12% of children in the United States use CAM. CAM is defined as a non-mainstream practice used together with conventional medicine (complementary medicine), or in place of conventional medicine (alternative medicine) (National Center for Complementary and Integrative Health [NCCIH], 2017). Three major types of CAM are widely used in modern medical practice: natural products, manual healing, and mind, body, and spirit practices. Other complementary approaches have also been used, such as Ayurvedic medicine, traditional Chinese medicine, homeopathy, and naturopathy (NCCIH, 2017). The following literature review of CAM treatments for UTIs and rUTIs is not intended to be an extensive review, but rather, an evaluation of the effectiveness and limitations of CAM treatments in the prevention and treatment of rUTI relapse and recurrence.