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ILLUSTRATIVE CASE
A 23-year-old nonpregnant woman, whom you treated 3 times in the past year for cystitis, comes to you for follow-up. She wants to know what she can do to prevent another urinary tract infection other than taking prophylactic antibiotics. Should you recommend that this patient increase her daily water intake to prevent recurrent cystitis?
Urinary tract infection (UTI) is the most common bacterial infection encountered in the ambulatory setting. Half of all women report having had at least 1 UTI by the time they are 32 years old.2 Recurrence is also common, with 27% of women having 1 recurrence within 6 months of their first episode.2
Because of growing antimicrobial resistance, the World Health Organization has urged using novel antimicrobial-sparing approaches to infectious diseases.3 Physicians have long recommended behavioral, nonantimicrobial strategies for prevention of recurrent uncomplicated cystitis. Such behavioral recommendations include drinking fluids liberally, urinating after intercourse, not delaying urination, wiping front to back, and avoiding tight-fitting underwear. However, these behavior modification strategies have been studied largely in case-control trials that have yet to find an association between behavior modification and reduced risk of UTI.2 Although unproven as a prevention strategy, increasing daily fluid intake has long been a recommendation because of the belief that it helps to dilute and clear bactiuria.4 This study is the first non–case-control trial to examine the association between increased fluid intake and decreased UTIs.1
STUDY SUMMARY
RCT looks at whether more water leads to fewer UTIs
Hooton and colleagues1 conducted an open-label, randomized controlled trial (RCT) of premenopausal women with recurrent UTIs and low baseline fluid intake and compared increased fluid intake (an additional 1.5 L/d) with no additional fluids. Participants were provided three 500-mL bottles of water per day and were followed for 1 year. Screened women were included if they had 3 or more symptomatic UTIs in the previous year, 1 culture-confirmed UTI, self-reported fluid intake < 1.5 L /d, and were otherwise in good health. Fluid intake was verified by 24-hour urine collection, requiring a volume < 1.2 L and urine osmolality of ≥ 500 mOsm/kg. Exclusion criteria included a history of pyelonephritis within the past year, interstitial cystitis, pregnancy, or current symptoms of UTI.
The primary outcome was frequency of UTI during the study period, defined as 1 urinary symptom and at least 103 CFU/mL uropathogens in a urine culture. Secondary outcomes included the number of antimicrobial agents used, time to first UTI, mean time interval between cystitis episodes, and adverse events.1
A total of 140 participants were randomized with 70 in the water group and 70 in the control group. The mean age of the participants was 35.7 years, and the mean number of reported cystitis episodes was 3.3 in the 12 months prior to the study. By the end of the 12-month study period, mean daily fluid intake had increased by 1.7 L above baseline in the water group. During the 12-month study period, the mean (SD) number of cystitis episodes was 1.7 (95% confidence interval [CI], 1.5-1.8) in the water group compared with 3.2 (95% CI, 3-3.4) in the control group, with a difference in means of 1.5 (95% CI, 1.2-1.8; P < .001).
The mean number of antimicrobial agents used for UTI was 1.9 (95% CI, 1.7-2.2) in the water group and 3.6 (95% CI, 3.3-4) in the control group. The median time to first UTI episode was 148 days in the water group compared with 93.5 days in the control group (hazard ratio [HR] = 0.51; 95% CI, 0.36-0.74; P < .001) and the difference in means for the time interval between UTI episodes was 58.4 days (95% CI, 39.4-77.4; P < .001). No serious adverse events were reported.1
Continue to: WHAT'S NEW
WHAT’S NEW
Proof that increased fluid intake reduces the risk of recurrent UTI
Increasing daily fluid intake is a long-held but previously unproven recommendation. This is the first RCT to show increased daily water intake can reduce the risk of recurrent cystitis in premenopausal patients at high risk for UTI and with low fluid intake. No additional risk of adverse events was found.
CAVEATS
Is there a risk of overhydration?
The study did not address the effect of increasing water intake in women who do not have low-volume fluid intake. Case reports of overhydration emphasize the need to be cautious when making recommendations to hydrate.5 It is not known if physicians should screen for fluid intake at baseline to identify those (with low intake) who would be eligible for this intervention.
CHALLENGES TO IMPLEMENTATION
It’s unclear whether the strategy will work without monitoring
The intervention is both low-risk and low-cost to the patient. However, the intervention was supported by home delivery of water and monthly monitoring interventions that are not typical in normal care. Although the clinical intervention of drinking more fluids (primarily water) appears sound, it is not known whether a physician’s recommendation would result in the same adherence and risk reduction as water delivery and monitoring.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
1. Hooton TM, Vecchio M, Iroz A, et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: a randomized clinical trial. JAMA Intern Med. 2018;178:1509-1515.
2. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366:1028-1037.
3. WHO. Antimicrobial resistance: global report on surveillance. April 2014. www.who.int/drugresistance/documents/surveillancereport/en/. Accessed March 23, 2020.
4. Fasugba O, Mitchell BG, McInnes E, et al. Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review. J Hosp Infect. 2020;104:68-77.
5. Lee LC, Noronha M. When plenty is too much: water intoxication in a patient with a simple urinary tract infection. BMJ Case Rep. 2016. doi:10.1136/bcr-2016-216882.
ILLUSTRATIVE CASE
A 23-year-old nonpregnant woman, whom you treated 3 times in the past year for cystitis, comes to you for follow-up. She wants to know what she can do to prevent another urinary tract infection other than taking prophylactic antibiotics. Should you recommend that this patient increase her daily water intake to prevent recurrent cystitis?
Urinary tract infection (UTI) is the most common bacterial infection encountered in the ambulatory setting. Half of all women report having had at least 1 UTI by the time they are 32 years old.2 Recurrence is also common, with 27% of women having 1 recurrence within 6 months of their first episode.2
Because of growing antimicrobial resistance, the World Health Organization has urged using novel antimicrobial-sparing approaches to infectious diseases.3 Physicians have long recommended behavioral, nonantimicrobial strategies for prevention of recurrent uncomplicated cystitis. Such behavioral recommendations include drinking fluids liberally, urinating after intercourse, not delaying urination, wiping front to back, and avoiding tight-fitting underwear. However, these behavior modification strategies have been studied largely in case-control trials that have yet to find an association between behavior modification and reduced risk of UTI.2 Although unproven as a prevention strategy, increasing daily fluid intake has long been a recommendation because of the belief that it helps to dilute and clear bactiuria.4 This study is the first non–case-control trial to examine the association between increased fluid intake and decreased UTIs.1
STUDY SUMMARY
RCT looks at whether more water leads to fewer UTIs
Hooton and colleagues1 conducted an open-label, randomized controlled trial (RCT) of premenopausal women with recurrent UTIs and low baseline fluid intake and compared increased fluid intake (an additional 1.5 L/d) with no additional fluids. Participants were provided three 500-mL bottles of water per day and were followed for 1 year. Screened women were included if they had 3 or more symptomatic UTIs in the previous year, 1 culture-confirmed UTI, self-reported fluid intake < 1.5 L /d, and were otherwise in good health. Fluid intake was verified by 24-hour urine collection, requiring a volume < 1.2 L and urine osmolality of ≥ 500 mOsm/kg. Exclusion criteria included a history of pyelonephritis within the past year, interstitial cystitis, pregnancy, or current symptoms of UTI.
The primary outcome was frequency of UTI during the study period, defined as 1 urinary symptom and at least 103 CFU/mL uropathogens in a urine culture. Secondary outcomes included the number of antimicrobial agents used, time to first UTI, mean time interval between cystitis episodes, and adverse events.1
A total of 140 participants were randomized with 70 in the water group and 70 in the control group. The mean age of the participants was 35.7 years, and the mean number of reported cystitis episodes was 3.3 in the 12 months prior to the study. By the end of the 12-month study period, mean daily fluid intake had increased by 1.7 L above baseline in the water group. During the 12-month study period, the mean (SD) number of cystitis episodes was 1.7 (95% confidence interval [CI], 1.5-1.8) in the water group compared with 3.2 (95% CI, 3-3.4) in the control group, with a difference in means of 1.5 (95% CI, 1.2-1.8; P < .001).
The mean number of antimicrobial agents used for UTI was 1.9 (95% CI, 1.7-2.2) in the water group and 3.6 (95% CI, 3.3-4) in the control group. The median time to first UTI episode was 148 days in the water group compared with 93.5 days in the control group (hazard ratio [HR] = 0.51; 95% CI, 0.36-0.74; P < .001) and the difference in means for the time interval between UTI episodes was 58.4 days (95% CI, 39.4-77.4; P < .001). No serious adverse events were reported.1
Continue to: WHAT'S NEW
WHAT’S NEW
Proof that increased fluid intake reduces the risk of recurrent UTI
Increasing daily fluid intake is a long-held but previously unproven recommendation. This is the first RCT to show increased daily water intake can reduce the risk of recurrent cystitis in premenopausal patients at high risk for UTI and with low fluid intake. No additional risk of adverse events was found.
CAVEATS
Is there a risk of overhydration?
The study did not address the effect of increasing water intake in women who do not have low-volume fluid intake. Case reports of overhydration emphasize the need to be cautious when making recommendations to hydrate.5 It is not known if physicians should screen for fluid intake at baseline to identify those (with low intake) who would be eligible for this intervention.
CHALLENGES TO IMPLEMENTATION
It’s unclear whether the strategy will work without monitoring
The intervention is both low-risk and low-cost to the patient. However, the intervention was supported by home delivery of water and monthly monitoring interventions that are not typical in normal care. Although the clinical intervention of drinking more fluids (primarily water) appears sound, it is not known whether a physician’s recommendation would result in the same adherence and risk reduction as water delivery and monitoring.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
ILLUSTRATIVE CASE
A 23-year-old nonpregnant woman, whom you treated 3 times in the past year for cystitis, comes to you for follow-up. She wants to know what she can do to prevent another urinary tract infection other than taking prophylactic antibiotics. Should you recommend that this patient increase her daily water intake to prevent recurrent cystitis?
Urinary tract infection (UTI) is the most common bacterial infection encountered in the ambulatory setting. Half of all women report having had at least 1 UTI by the time they are 32 years old.2 Recurrence is also common, with 27% of women having 1 recurrence within 6 months of their first episode.2
Because of growing antimicrobial resistance, the World Health Organization has urged using novel antimicrobial-sparing approaches to infectious diseases.3 Physicians have long recommended behavioral, nonantimicrobial strategies for prevention of recurrent uncomplicated cystitis. Such behavioral recommendations include drinking fluids liberally, urinating after intercourse, not delaying urination, wiping front to back, and avoiding tight-fitting underwear. However, these behavior modification strategies have been studied largely in case-control trials that have yet to find an association between behavior modification and reduced risk of UTI.2 Although unproven as a prevention strategy, increasing daily fluid intake has long been a recommendation because of the belief that it helps to dilute and clear bactiuria.4 This study is the first non–case-control trial to examine the association between increased fluid intake and decreased UTIs.1
STUDY SUMMARY
RCT looks at whether more water leads to fewer UTIs
Hooton and colleagues1 conducted an open-label, randomized controlled trial (RCT) of premenopausal women with recurrent UTIs and low baseline fluid intake and compared increased fluid intake (an additional 1.5 L/d) with no additional fluids. Participants were provided three 500-mL bottles of water per day and were followed for 1 year. Screened women were included if they had 3 or more symptomatic UTIs in the previous year, 1 culture-confirmed UTI, self-reported fluid intake < 1.5 L /d, and were otherwise in good health. Fluid intake was verified by 24-hour urine collection, requiring a volume < 1.2 L and urine osmolality of ≥ 500 mOsm/kg. Exclusion criteria included a history of pyelonephritis within the past year, interstitial cystitis, pregnancy, or current symptoms of UTI.
The primary outcome was frequency of UTI during the study period, defined as 1 urinary symptom and at least 103 CFU/mL uropathogens in a urine culture. Secondary outcomes included the number of antimicrobial agents used, time to first UTI, mean time interval between cystitis episodes, and adverse events.1
A total of 140 participants were randomized with 70 in the water group and 70 in the control group. The mean age of the participants was 35.7 years, and the mean number of reported cystitis episodes was 3.3 in the 12 months prior to the study. By the end of the 12-month study period, mean daily fluid intake had increased by 1.7 L above baseline in the water group. During the 12-month study period, the mean (SD) number of cystitis episodes was 1.7 (95% confidence interval [CI], 1.5-1.8) in the water group compared with 3.2 (95% CI, 3-3.4) in the control group, with a difference in means of 1.5 (95% CI, 1.2-1.8; P < .001).
The mean number of antimicrobial agents used for UTI was 1.9 (95% CI, 1.7-2.2) in the water group and 3.6 (95% CI, 3.3-4) in the control group. The median time to first UTI episode was 148 days in the water group compared with 93.5 days in the control group (hazard ratio [HR] = 0.51; 95% CI, 0.36-0.74; P < .001) and the difference in means for the time interval between UTI episodes was 58.4 days (95% CI, 39.4-77.4; P < .001). No serious adverse events were reported.1
Continue to: WHAT'S NEW
WHAT’S NEW
Proof that increased fluid intake reduces the risk of recurrent UTI
Increasing daily fluid intake is a long-held but previously unproven recommendation. This is the first RCT to show increased daily water intake can reduce the risk of recurrent cystitis in premenopausal patients at high risk for UTI and with low fluid intake. No additional risk of adverse events was found.
CAVEATS
Is there a risk of overhydration?
The study did not address the effect of increasing water intake in women who do not have low-volume fluid intake. Case reports of overhydration emphasize the need to be cautious when making recommendations to hydrate.5 It is not known if physicians should screen for fluid intake at baseline to identify those (with low intake) who would be eligible for this intervention.
CHALLENGES TO IMPLEMENTATION
It’s unclear whether the strategy will work without monitoring
The intervention is both low-risk and low-cost to the patient. However, the intervention was supported by home delivery of water and monthly monitoring interventions that are not typical in normal care. Although the clinical intervention of drinking more fluids (primarily water) appears sound, it is not known whether a physician’s recommendation would result in the same adherence and risk reduction as water delivery and monitoring.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
1. Hooton TM, Vecchio M, Iroz A, et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: a randomized clinical trial. JAMA Intern Med. 2018;178:1509-1515.
2. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366:1028-1037.
3. WHO. Antimicrobial resistance: global report on surveillance. April 2014. www.who.int/drugresistance/documents/surveillancereport/en/. Accessed March 23, 2020.
4. Fasugba O, Mitchell BG, McInnes E, et al. Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review. J Hosp Infect. 2020;104:68-77.
5. Lee LC, Noronha M. When plenty is too much: water intoxication in a patient with a simple urinary tract infection. BMJ Case Rep. 2016. doi:10.1136/bcr-2016-216882.
1. Hooton TM, Vecchio M, Iroz A, et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: a randomized clinical trial. JAMA Intern Med. 2018;178:1509-1515.
2. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366:1028-1037.
3. WHO. Antimicrobial resistance: global report on surveillance. April 2014. www.who.int/drugresistance/documents/surveillancereport/en/. Accessed March 23, 2020.
4. Fasugba O, Mitchell BG, McInnes E, et al. Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review. J Hosp Infect. 2020;104:68-77.
5. Lee LC, Noronha M. When plenty is too much: water intoxication in a patient with a simple urinary tract infection. BMJ Case Rep. 2016. doi:10.1136/bcr-2016-216882.
PRACTICE CHANGER
Advise premenopausal women with recurrent urinary tract infections (UTIs) and low-volume fluid intake to increase their water intake by at least 1.5 liters daily to reduce the frequency of UTIs.1
STRENGTH OF RECOMMENDATION
A: Based on a single, high-quality randomized controlled trial.
Hooton TM, Vecchio M, Iroz A, et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: a randomized clinical trial. JAMA Intern Med. 2018;178:1509-1515.
