This multicenter retrospective review investigated the effect of vaginal estrogens on the incidence of recurrent urinary tract infections (UTIs) in 5638 women. Vaginal estrogen resulted in 51.9% fewer urinary tract infections (frequency, 3.9 vs. 1.8; P < 0.001). Interestingly, the high adherence group saw the smallest reduction in the number of urinary tract infections.
It is reasonable to add vaginal estrogen to the treatment plan for women with recurrent urinary tract infections. More research is needed to identify the exact regimen that is most effective in reducing UTIs.
Vaginal estrogen for the prevention of recurrent urinary tract infections
This multicenter retrospective cohort study sought to analyze the association between vaginal estrogen use and the frequency of culture-proven urinary tract infections (UTIs) in women with hypoestrogenism .
The urethra and distal vagina share similar concentrations of estrogen receptors. Conditions that result in estrogen deficiency can lead to a decrease in vaginal lactobacilli, an increase in pH level, and subsequent colonization by gram-negative uropathogens. Reintroduction of local estrogen may decrease vaginal pH and facilitate colonization by lactobacillus .
The cohort study included 5638 women with a mean age of 70.4 ± 11.9 years, a BMI of 28.5 ± 6.3 kg/m² and a baseline UTI frequency of 3.9 ± 1.3 per year (defined as at least one uropathogen with at least 1000 colony-forming units). per mL, separated by at least 14 days from another culture).
Key results
Women with recurrent UTIs who filled at least one vaginal estrogen prescription (including the ring, cream, and tablet) experienced a 52% reduction in the frequency of UTIs in the following year.
Baseline frequency of UTI, age over 75 years, urinary incontinence or retention, and diabetes were associated with an increased risk of UTI after prescription.
Participants with greater adherence to vaginal estrogen demonstrated the smallest relative reduction in UTI frequency, likely due to selection bias, unmeasured confounding, and attrition bias.
This study adds external validity to existing clinical practice guideline data and supports the use of vaginal estrogens as prophylactic therapy for women experiencing recurrent urinary tract infections, which may offer relief from the use of both therapeutic and prophylactic antibiotics.
Summary
Background
Vaginal estrogen is considered the standard treatment for the prevention of recurrent urinary tract infections in women with hypoestrogenism . However, the literature supporting its use is limited to small clinical trials with limited generalizability.
Aim
This study aimed to evaluate the association between vaginal estrogen prescription and the frequency of urinary tract infections over the following year in a diverse population of women with hypoestrogenism. Secondary objectives included assessment of medication adherence and predictors of post-prescription urinary tract infection.
Study design
This multicenter retrospective review included women who were prescribed vaginal estrogen for the indication of recurrent urinary tract infection from January 2009 to December 2019.
Recurrent urinary tract infection was defined as having ≥3 positive urine cultures (separated by at least 14 days) in the 12 months prior to the index vaginal estrogen prescription. Patients were asked to fill their prescriptions and continue care within the Kaiser Permanente Southern California system for at least 1 year.
Exclusion criteria included anatomical abnormalities, malignancy, or mesh erosion of the genitourinary tract.
Data on demographics, medical comorbidities, and surgical history were collected. Adherence was captured through refill data after the index prescription. Low adherence was defined as absence of refills; moderate adherence was defined as 1 refill; high adherence was defined as ≥2 refills.
Data were extracted from the electronic medical record system using the pharmacy database and diagnosis codes. A paired t test was used to compare pre- and post-prescription urinary tract infections during the year before and after vaginal estrogen prescription. Multivariate negative binomial regression was used to evaluate predictors of postprescription urinary tract infection.
Results
The cohort included 5,638 women with a mean (±standard deviation) age of 70.4 (±11.9) years, body mass index of 28.5 (±6.3) kg/m 2, and baseline frequency of infections. of the urinary tract of 3.9 (±1.3).
The majority of participants were white (59.9%) or Hispanic (29.7%) and postmenopausal (93.4%).
The mean frequency of urinary tract infections in the year following the index prescription decreased to 1.8 (p < 0.001) from 3.9 in the year before the prescription, representing a 51.9% reduction .
During the 12 months following the index prescription, 55.3% of patients experienced ≤1 urinary tract infection and 31.4% did not experience any urinary tract infection.
Significant predictors of urinary tract infection after prescription included age 75 to 84 years (incident rate ratio, 1.24; 95% confidence interval, 1.05–1.46) and >85 years ( 1.41; 1.17–1.68), higher initial frequency of urinary tract infection (1.22; 1.19-1.24), urinary incontinence (1.14; 1.07-1.21) , urinary retention (1.21; 1.10-1.33), diabetes mellitus (1.14; 1.07-1.21) and moderate adherence (1.32; 1.23-1.42) or high (1.33; 1.24–1.42).
Patients with high medication adherence demonstrated more frequent postprescription urinary tract infections than patients with low adherence (2.2 vs. 1.6; P < 0.0001).
Conclusion
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