Primary Care Physician Comfort with Non-antibiotic Prophylaxis for Recurrent UTI

Objectives: Non-antibiotic prophylaxis for recurrent UTI (rUTI) has been shown to be effective and is an essential component of antibiotic stewardship. However, there is a paucity of literature on how primary care physicians have adopted these therapies in practice. The goal of this study is to explore provider comfort with non-antibiotic prevention of rUTI with vaginal estrogen (VET), methenamine hippurate (MH), and D-mannose.

Methods: Physicians who provide primary care to adult women at an academic institution were invited to complete an online survey regarding their management of rUTI. This survey included a series of questions on comfort with prescribing VET, MH, and D-mannose in both healthy and complex patients, and their perceptions of medication affordability and patient adherence. Responses were stratified between physicians who received “focused” training in sequelae of menopause (geriatric medicine and general obstetrics and gynecology) and “other” physicians (general internal medicine and family medicine); those who saw < 6 or ≥6 rUTI patients/month; rural vs urban practice; gender; and < 10 or ≥10 years in practice. Differences in categorical variables were determined using Chi-2 or Fisher’s exact test.

Results: A total of 40 surveys were completed out of an estimated 146 invited physicians (27%). A mix of specialties and experience was observed (Table 1). Most participants have prescribed VET for rUTI: 58% reported prescribing VET “often” and 38% reported prescribing VET “sometimes.” Those in the “Focused” group were more comfortable than the “Other” group with prescribing VET to patients with a first-degree family history or personal history of breast cancer, patients with a history of endometrial cancer, and BRCA positive patients (Figure 1). There were no differences among specialties regarding perception of affordability of vaginal estrogen or patient adherence to therapy. There were no other differences in VET prescribing patterns when comparing between groups. Most participants had never prescribed MH (78%) or D-mannose (85%) for rUTI prophylaxis. Providers who saw ≥6 rUTI patients/month were more likely to prescribe MH (54% vs 7.4%, p=0.001) and more likely to prescribe MH to patients with mild renal disease (86% vs 0%, p=0.083). There were no differences in perception of MH affordability, or patient adherence between groups. There were no differences in D-mannose prescribing patterns or perceptions of use between groups.

Data presented as mean (standard deviation) or number (percentage)
* Fisher’s exact test

Conclusions: While most primary care physicians were comfortable with prescribing VET to healthy postmenopausal patients with rUTI, those with more specialized training were more comfortable prescribing VET for patients with risk factors for estrogen-mediated diseases. MH and D mannose were underutilized in prevention of rUTI. There is further opportunity to improve antibiotic stewardship by educating primary care physicians on the use of VET, MH, and D mannose.