CEimpact Podcast

Prevention of Recurrent UTIs

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On this week's GameChangers episode, we discuss prevention of recurrent UTIs, including whether use of d-mannose or antibiotics are effective.
 
The GameChanger
Recurrent urinary tract infections plague some women throughout their lives. There are ways to prevent recurrent UTIs, however a recent study determined that d-mannose is not effective. We discuss what is effective.
 
Guest
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
 
Reference
d-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women
A Randomized Clinical Trial

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CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe non-pharmacologic strategies proven to decrease recurrent UTIs.
2. Discuss selection of an antibiotic and a selected patient for continuous prophylaxis.

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-220-H01-P
Initial release date: 07/08/2024
Expiration date: 07/08/2025
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Plan members From CE Impact. This is Game Changers. I'm Jen Moulton and I have with me today our resident expert, jeff Wall. Hi, jeff.

Speaker 2:

How are you doing?

Speaker 1:

Great, great Thanks for being with us today. So I know you've been on the podcast for four years now. We just had our fourth anniversary, which is super exciting. But before we get started today, can you take just a quick minute to tell our any new listeners that we have a little bit about yourself and your practice?

Speaker 2:

Absolutely, you don't know me. My name is Jeff Wall. I've been a pharmacist now for 32 years, and 25 of those 32 years I've been a professor of pharmacy practice at Drake University here in Des Moines, iowa. My specialty practice is in internal medicine and critical care, and so I actually work in a large tertiary care hospital where I split my time between an internal medicine teaching service and a critical care teaching service, so kind of jack of all trades, master of none. But I do enjoy almost all areas of medicine, and so we've been doing this podcast for a long time, I think, really trying to give our listeners the latest and, I think, most practical information that's evidence-based, about new studies, new guidelines, just controversial topics they may get asked about or try to implement in their practice. Myself, I have two lovely daughters. They're both finishing either high school or college. Because I'm that, old.

Speaker 2:

And as far as what I like to do outside, I'm a big bike rider, a big cyclist, so that's a lot of fun. I'm also a music producer. The music that you heard that was intro and outro in our podcast is actually music I compose. I'm an electronic music producer under the name Prophet of Jupiter. Again, prophet of Jupiter is my producer name. I have been fortunate enough to have several tracks that have been picked up by mid-sized electronic dance music labels, and so I'm on all platforms you may want to look under. Instead of Prophet of Jupiter, look under some of the different labels. One is Electronic Eden Label, the other is Cafe de Antolina Records Again, all kind of mid-sized labels that hopefully get me played some places. And I'm actually getting into DJing as well. I actually am practicing on a DJ controller and hopefully, hopefully they get to play some gigs here coming up, so that's kind of me so fun.

Speaker 1:

I love it. I love that other side of you. Who would have guessed? A pharmacist turned DJ.

Speaker 2:

Yes, indeed yeah, trying to use both sides of my brain if at all possible. Right, we all should take note of that.

Speaker 1:

That's for sure. Love the creativity. Well, I personally love working with you on this podcast. I think it's super fun, I think you are so smart and I always learn something from you, so I'm excited to get into our topic today, thank you. So today we're going to talk about the prevention of recurrent UTIs, and why is this topic important right now.

Speaker 2:

Well, you know, I mean, this is something I deal with almost every day, and I suspect that many of both are the providers who listen, the pharmacists who listen. We have patients who, unfortunately, suffer from recurrent urinary tract infections their whole lives, and it ends up being costly for the health system, it ends up being, you know, disruptive to patients' lives and in some cases it ends up being deadly. I mean, you know, people do die from uriceps, especially older patients, and and so you know, I think it's very frustrating for providers, for pharmacists and for patients when patients are having multiple urinary tract infections a year. And so the question is you know, rather than just you know, being, you know, retroactive about it and saying, okay, well, you know, they, you know, yep, sorry, mrs Jones, this is your seventh urinary tract infection this year. I mean, I don't know what we're going to do. You know, to say, is there anything we can do to keep that number down?

Speaker 2:

I think is cost saving and improves quality of life and in, like I said, some cases may save somebody's life. So it's an important thing, it's a common issue and we actually have a new study that just came out about six weeks ago in JAMA. They kind of looked at one of the kind of upcoming strategies for preventing urinary tract infections called D-MANose that we're actually going to get into at the end of the end of this podcast.

Speaker 1:

So Great, well, let's, let's get into it.

Speaker 2:

All right.

Speaker 1:

About what, what, what, how can we support our patients, and what works, what doesn't work Absolutely.

Speaker 2:

Yeah, so you know again. You know UTIs are common primarily in women, as we all know, and in fact more than 50% of women will be diagnosed with a urinary tract infection in their lifetime. And recurrent urinary tract infection is actually there's actually a formal definition it's a patient who has more than two urinary tract infections in six months, or more than three urinary tract infections in six months, or more than three urinary tract infections in one year. And when you use that definition, I suspect a lot more patients have recurrent UTIs than I think we would previously think. Again, in my world, where I deal with primarily, you know, older patients, again, primarily older postmenopausal women, especially those who have you know with postmenopausal women, especially those who have, you know, foley catheters in or super pubic catheters in you know three seems pretty low to me because, again, a lot of these patients have to have a lot more urinary tract infections.

Speaker 2:

But I think when you use that definition, there's a lot of premenopausal women who also may have meet that definition for recurrent urinary tract infection. Incidents, again, not uncommon a hundred per a and 200 and 100,000 women age 55 to 64. So, again, up to 25% of women who are 18 will go on to meet the definition of recurrent urinary tract infection sometime during their life. So, again, pretty common, if you notice, I keep saying biologic women. That's because that's you know who gets urinary tract infections. You know, again, not fair. I totally agree. Men almost never get urinary tract infections and in fact when we do, it's so rare that they're automatically considered complicated urinary tract infections. The joke I tell students when I, when I'm teaching this to them is that you know it's one of the many reasons I'm grateful that I'm a guy. You know so. So you know it is. It's something that unfortunately very, very disproportionately affects women, particularly postmenopausal women. Now, in premenopausal women the factors related to sexual behavior are the major risk factors for current urinary tract infections. But in postmenopausal women, which is again where I tend to see patients, it's less about that and much more about things they have no control over, such as age, hormonal and disease related gynecologic and immune factors. That play a prominent role and in fact, one of the biggest ones is the change in vaginal flora that occurs in women as they reach postmenopausal state and that's been shown now in multiple studies to increase the risk of uh, uh urinary tract infections in women, because that alteration uh decreases the pH, so it's less acidic and also allows uh, uh, it also kills off some of the normal vaginal flora. So now you know, pathogenic organisms now have a place to kind of to, to kind of, you know, form a base, if you will, and then and then get patients put patients at risk for urinary tract infections.

Speaker 2:

Also, things like cystic seals, which are bladder prolapses, urinary incontinence, which unfortunately is, is common in women as they age, and then the, the whole genital urinary syndrome of menopause again, this, this thought about a vaginal changes, which is now the new term for atrophic vaginitis all have been thought to predispose to urinary tract infections and drugs and you know, one of the biggies, of course now in the last 10 years is the SGL-2 drugs and, as we know, sgl-2 drugs have been shown to be vastly beneficial in a wide array of patients diabetic patients, patients with chronic kidney disease, heart failure patients, now gout. It looks like it seems to decrease the risk of gout. You know, it is a drug class that seems to be incredibly beneficial, but the trade-off for that is definitely, especially in women, an increased risk of general urinary infections. And then the other big drug that has been associated with increased risk of urinary tract infections are anticholinergic drugs.

Speaker 2:

So patients, particularly elderly, women who are on anticholinergic drugs are at increased risk of UTIs. It's worth noting that, that you know a lot of these drugs of course we kind of use for overactive bladder right and and anticholinergic drugs are of course we kind of use for overactive bladder right and anticholinergic drugs are one of the mainstays of therapy for overactive bladder. I've always thought it kind of weird that you know again, the drugs we use to treat overactive bladder in patients may be the very drugs that cause urinary tract infections. I have always been a nihilist when it comes to those medications. I think the evidence has always shown they don't work that well anyway and I think it just adds to the anticoagulant burden that a lot of elderly patients have. That has a lot of other problems far beyond just overactive bladder issues. So you know getting off my soapbox on that, but I think anyone who knows me knows I'm not a big fan of those drugs overactive bladder drugs for that reason.

Speaker 2:

So again, bottom line drugs. It's very common, something you're going to see over and over again, particularly in postmenopausal women. So what can we do as pharmacists and providers to help decrease this risk? Well, there are several non-pharmacologic or quasi-pharmacologic things we can do. The first and most important is increased fluid intake, and I think that just stands to reason, and certainly it's pretty rare nowadays for me to see someone who is not walking around the hospital with you know, a big Stanley cup or one of the other you know gigantic water bottles that people are walking around days.

Speaker 2:

And I don't know whether in the actual, you know person that actually does anything. I think the evidence suggests no. But in patients who have recurrent urinary tract infections, the answer is yes, it does and in fact we have a decent randomized control trial data, believe it or not, that shows that randomizing patients to drink less than 1.5 liters of extra water, so this is a fluid on top of what they would normally drink, right? So it doesn't count the water they have in the morning or the coffee they have in the afternoon.

Speaker 2:

Just adding an extra 1.5 liters to someone's fluid compared to people who don't, actually showed a 50% decrease incidence of cystitis in women. So I think that's actually quite interesting. And a fairly easy thing to recommend to patients is that. You know, yes, especially in postmenopausal women, it's probably a reasonable thing to try and increase fluid intake. Again, I'm not really particularly sure if you know they have to drink tons and tons of fluid, but again, 1.5 liters actually isn't, you know. I mean it's a lot, but it isn't that much.

Speaker 2:

So I think I think it's certainly reasonable to consider, and I think we should probably recommending that to all postmenopausal women who have a complaint of recurrent urinary tract infections. Complaint of recurrent urinary tract infections. Of course, the reason why it works would be, you know, basically diluting the urine and getting the bugs out of the bladder before they have a chance to find purchase in the bladder wall and actually develop an infection. It is worth noting that this was studied primarily in premenopausal women, but there's again, absolutely no reason to think why it wouldn't work for postmenopausal women as well. The other thing that works really well in postmenopausal women, though there's some data in premenopausal women as well, is vaginal estrogen therapy. And if you are a big social media person, we have, there are several big social media physicians out there who are in OBGYN or urology and they, you know tout this to the ceiling, and they are right to do so. Vaginal estrogen therapy actually has solid evidence for reduction of urinary tract in episodes and that data is not new.

Speaker 2:

We've known this now for more than a quarter of a century. But more recent studies have really increased the evidence showing that it's beneficial. There has been several randomized control trials that have now actually been done. That has shown, you know, fewer urinary tract infections at six months.

Speaker 2:

There was a large multi-center retrospective review of over 5,600 post-menopausal women who received vaginal estrogen, prevention of your current urinary tract infection and again, I found a 50% reduction in UTIs observed in the following year. So you know, obviously I think I think we have solid data showing that, that that vaginal estrogen is beneficial in these patients and, an additional benefit, it also helps with some of these again, these genital urinary symptoms of menopause, the itching, the burning symptoms that many patients complain about you're actually treating that as well.

Speaker 2:

So it's it seems to be, you know, pretty beneficial in most postmenopausal women. Now for the pharmacist listening, I think there's some important counseling issues that I think we need to talk about. One is that this isn't going to work tomorrow, right?

Speaker 2:

Obviously, it's going to take some time for vaginal floor to be restored for the atropic vaginitis to kind of be treated officially, and they need to take it for months, maybe even years, you know, and as you might imagine, it's not the easiest thing to apply. Anything topical in that area is probably not going to be too fun to apply. So I you know I totally get that as well.

Speaker 2:

It's also worth noting that even though we have fewer women today than certainly when I came out of school, who are on systemic estrogen. So again, I'm old enough to remember when Premarin was one of the biggest movers in any community pharmacy and now you hardly ever see anybody on it. That's probably an overreaction to the Women's Health Initiative study, which we could certainly talk about at some future date. But you know, it's interesting to note that if someone were to be taking, you know, premarin or even oral contraceptive therapy with estrogen, that is not enough estrogen to deal with this. You need to have high topical concentrations of estrogen at the site for it to really have this benefit. So that's kind of interesting that systemic estrogen is not enough. You'd really need to have local estrogen application. It comes as three formulations the cream, which is what most people use, an intervaginal tablet, an intervaginal ring. Certainly women can prefer one over the other, but again, cream is by far the most common use.

Speaker 2:

And, as any community pharmacist will tell you, the biggest problem they run into. And probably the biggest barrier to using this is cost. You know all these creams are very expensive in the hundreds of dollars a month.

Speaker 2:

And because this is not an FDA approved indication, most insurance companies will not pay for it and so out-of-pocket costs can be can be basically prohibitive for patients as well. The other question that I think a lot of people get asked about, both providers and pharmacists, is the cancer risk in these patients. It is worth noting that that that topical or even intravaginal estrogen actually has a very, very low risk of of of uh increasing the risk of of cancer in in patients, even those who have a like a family history and stuff like that, and in fact the American college of clinical oncology actually has a a whole supporting position paper that basically says that that you know, yeah, on the whole, vaginal estrogen therapy is is safe and effective. A caution is warranted, obviously, in a patient if she herself has estrogen-dependent breast cancer or a history of that. But just a family history in and of itself actually would not be a contraindication, and it's worth noting that a recent observational cohort study of women did show an increase in recurrence in women who were on aromatase inhibitors like anastronol, but not tamoxifen in patients who received systemic estrogen therapy. So not, again, topical estrogen therapy, but I think, after an abundance of caution, yes, if a woman had a personal history of estrogen positive breast cancer. Probably not a great idea to, or at least use with caution. But just a family history apparently does not seem to increase that risk.

Speaker 2:

So you know, I totally agree with with the, the, the OBGYNs and urologists out there who really really push this, and I think again, as pharmacists we need to do a better job of trying to make this more affordable for patients. I've heard compounding pharmacies are trying their best to do this as well and can maybe offer these products at a less cash price cost. So an old drug that I see is making a bit of a comeback is methamine. Methenamine literally could have been one of the very, very first drugs I studied in pharmacy school a long, long time ago. It's been around now for about 80 years. It has a long history in being used for the prevention of urinary tract infections and in the pre-antibiotic era was one of our few treatments for urinary tract infections, but it's not an antibiotic, those of you who remember.

Speaker 2:

It works by basically dramatically acidifying the urine and so that's where it's thought that it may treat but most importantly, prevent the rate of urinary tract infections. We don't really have at least any large scale randomized control trials that show the methamine is beneficial. There's been some, certainly some retrospective studies that have suggested that. There has been a couple of more recent studies, but they're relatively small but they are randomized control trials. But they do know that that one in fact was a study that compared methamine to nitroferantoin, trimethperine or cephalexin in prevention of urinary tract infections and found that it was probably less effective than antibiotics. But the study itself was a non-inferiority study and they did meet the non-inferiority margin of the study, but it didn't reach. The numerics were lower with methamine compared to traditional antibiotics that are used continuously.

Speaker 2:

So I think that, again, methamine is probably not an unreasonable thing to consider in patients who have had recurrent urinary tract infections, particularly men. I think this may be beneficial in those patients. The problem is they need to take it two or three times a day and if you've ever seen the methamphetamine tablets, they're pretty like they're horse tablets, they're big, so some patients may have a difficult time uh swallowing them as well. Um, and so that's. That's something uh that interestingly and I didn't know this happened before doing research on this that uh patients often uh um a complaint, have note when they look on the internet that apparently methamine has a concern by carcinogenicity. I never heard that One of the reasons is that methamine, one of its byproducts, is converted to a spermaldehyde. I did not know that.

Speaker 2:

But, as you might imagine, they have not seen an actual increased risk of bladder or colorectal cancer.

Speaker 2:

So you know I'm sure someone may get asked about that, but I'm not sure it's something that anyone really needs to worry about. Also, remember that it should not be used with other antibiotics at the same time, because it may inactivate the use of this time, because it may inactivate the use of this. And remember also that if patients' creatinine clearance is low, it may not get to the bladder. And something to watch out for Kind of a cousin of that, or another way to consider acidifying the urethra, of course, is cranberries, cranberry juice, cranberry tablets. I mean, you can go on and on and on and I get asked this even now, probably once or twice a year.

Speaker 2:

It's worth noting that there's not a lot of studies out there, but the ones that are out there have not shown a particular benefit. I think the reason why is really the only studies that I'm aware of that have shown that high levels of cranberry juice or cranberry tablets seems to be beneficial is in proteus urinary tract infections, and that's probably because proteus, of all the gram negatives that cause UTIs, is the one that that really requires a basic medium to live right. It needs an alkaline medium to live and if you acidify the urine then they're going to have more difficult time attaching to the bladder. Unfortunately, proteases not one of our top drugs excuse me, top organisms for causing UTIs obviously E coli, and it didn't seem to have real effect on E coli.

Speaker 2:

So I kind of agree with this Cochrane review that there really is no data showing that that cranberry is beneficial, can't hurt anybody. I'm sure to take if they'd like to, but I'm not really sure it's particularly beneficial in preventing recurrent urinary tract infections. So then, the thing that's been done, I think for the last 25 years, in patients again who you know keep having urinary tract infections despite some of the stuff we've talked about, is antibiotics. Is you know, do we use some sort of prophylactic antibiotic regimen? Uh to uh, to to um, prevent urinary tract infections?

Speaker 2:

It's worth noting that the infectious disease society of America, guidelines for the treatment of UTIs actually comes right out and says this is probably not a great idea. And you know, um, we don't have a lot of solid data showing it's beneficial. And of course, you increase the risk of resistance, you increase the risk of C, diff, colitis and all those sort of things. But I also have worked with many, many physicians over the years who, in kind of desperation, are like look, I can't. You know, this is the sixth, seventh, eighth, tenth urinary tract infection, this patient has had, I got to do something you know, and so I think that's not an unreasonable to think about.

Speaker 2:

But I, when my physicians asked me about this, I always say well, you know, idsa doesn't recommend this, but sort of right, you know there's really two kind of ways to consider this. The first is post coital prophylaxis. Unfortunately, there's some women who, after sexual activity, are at high risk developing urinary tract infections. Now, of course, before you consider post-coital prophylaxis, it is important to make sure that patients get ruled out for things like sexually transmitted diseases, like chlamydia, atrial trichomoniasis and things like that.

Speaker 2:

But, once that's done and we suspect that it's literally just because of sexual activity that the patient is developing urinary tract infections like within that time period. There actually are some placebo-controlled studies that have looked at this and have found that in fact it does decrease the risk of either ED visits or hospitalization for urinary tract infections about 30% decrease, which is kind of interesting. There's been no specific recommended regimen but basically you take one dose of either nitroferantoin, trimethoprim or Bactrim or cephalexin and seems to decrease this risk. You know the the. The time period about exactly when to take it and does that, you know, is how long it the protection is is is really unknown, but again, it seems like a single dose seems to be beneficial with this offset.

Speaker 2:

Offset increased risk of of of resistance and and C diff diarrhea. So, just kind of you know again I would be cautious in in recommending this, but again in premenop. So just kind of you know again I would be cautious in in recommending this.

Speaker 2:

But again in premenopausal women who say you know, gee, really around sexual activity is really when I get urinary tract infections. It is something to at least consider in these patients, I think. And then you have continuous prophylaxis, and again, this is probably mostly in postmenopausal women or men who have multiple urinary tract infections for whatever reason. Again, very little data showing that this is beneficial, but but and most of this data comes from the 1970s and 80s. But again, I get where providers are like we have no choice, I've got to do something here. So again, when, when, when physicians ask me about this, I tend to say, okay, well, again, there's not a lot of data and I would only do it for six months and then stop and kind of see where you're at.

Speaker 2:

But several regimens have been recommended nitroferantoin at bedtime, bactrim at bedtime, cefalexin at bedtime. I'm going to come right out and say right now, I am not a fan of long-term nitroferantoin use. Long-term nitroferantoin can actually lead to pulmonary fibrosis and I actually have in my world seen several cases of pulmonary fibrosis due to nitroferantoin, at least one resulting in death. And so it seems to me that long-term use of nitroferantoin probably isn't a great idea. Again, when my docs asked me what to do on this, I usually just recommend playing trimethyloprim without the sulfamethoxazole component. Yeah, 200 milligrams at bedtime it's dirt cheap, you don't get the the sulfaside effects that you would get. And again, old, old data from from the 70s and 80s does suggest that for prevention of urinary tract infections, trimethyloprim is actually pretty effective, so I think that that's reasonable to use.

Speaker 2:

Then finally and this is kind of where the idea for this podcast kind of came about was D-mannose and I have seen my physicians using D-mannose more and more frequently for this, if D-mannose, as the name suggests, is a sugar that may prevent adhesion of E coli to the bladder epithelium, which is kind of interesting. So again the thought that you know, again, if you're taking this D-mannose regularly, it keeps E coli from adhering to the bladder and then you just don't get E coli urinary tract infections. There is not, until recently, been a whole lot of studies looking at this as most of an open label studies or small studies that have seemed to find a benefit. A 2022 Cochrane review, you know, kind of reflected this and said you know there's little to no evidence to support or refute the use of D-mannose to prevent urinary tract infection prevention. But the thought has always been.

Speaker 2:

It's a sugar, can't really hurt anybody, it's not very expensive, so why not give it a shot?

Speaker 2:

up until a paper that just came out in April 8th in JAMA. In JAMA we have the largest randomized controlled trial of looking at D-mannose in premenopausal women who have frequent urinary tract infections. So this study was done in these patients. You had to be 18 or older. You had to have that standard definition of urinary tract infections, again, three or more in the last year, two or more in the last six months. They were not eligible if they were pregnant, lactating, planning pregnancy during the study, had a formal diagnosis of overactive bladder interstitial cystitis, had any sort of urinary tract instrumentation, like catheterized patients and nursing home patients as well. They were also ineligible if they were on prophylactic antibiotics for some other reason or if they were already on D-mannose coming into the study. Basically, it was interesting how they blinded the study. They randomized patients to take a daily scoop of about two grams of D-mannose powder a day mixed with whatever they wanted to mix it with, or a similar daily scoop of fructose powder. So I guess that either way they got some sweet, some sweet sugar going on. Both products are white powders with a similar sweet taste, but the difference, of course, is fructose is absorbed almost entirely in the small intestine and almost completely metabolized by the liver and so almost none of it gets to the bladder or the urine. So in and of itself it would not increase the risk of urinary tract infections.

Speaker 2:

They were starting to continue taking the study product, even when they were symptomatic and taking an advex for urinary tract infection. Primary outcome of the study was how many urinary tract infections the patient had a year and they actually considered the drug effective. So this was a binary study where they actually considered a go, no go and in this case it was a go if the woman had at least one fewer urinary tract infection per year. Right, and this was bad enough that they had to contact some sort of ambulatory care, including clinic, ed, hospital or urgent care sort of situations within six months of randomization. So, and they chose this outcome because they had a patient panel of women who had recurrent urinary tract infections and I think they came to consensus that one less urinary tract infection a year was a clinically significant endpoint, that women would improve their quality of life and things along those lines.

Speaker 2:

They did do a host of secondary outcomes number of days with symptoms of UTIs and they did symptom diaries for that a number of microbiologically proven urinary tract infections, number of antibiotic courses the patients had, and then things like C diff, colitis incidents, quality of life scores and things along those lines. The study went on from March 28, 2019 to January 31, 2020. And in that period of time, march 28, 2019 to January 31, 2020. And in that period of time, they randomized about 600 women to both either D-mannose or the fructose.

Speaker 2:

Taking a look at the baseline characteristics of mean age in these patients was 58. So even though I think they tended to target premenopausal women, I think perimenopausal women were actually probably the most common type of patient who was enrolled in the study as far as had they gone through menopause. In fact the majority of patients had said they had. 64% of patients said they had. The vast majority did not use any sort of hormonal treatment for their menopause and the mean number of urinary tract infections they had in the last 12 months was 5, 4.4,. So 5, basically, so definitely meeting the criteria of having recurrent urinary tract infections. And for the primary outcome, what they found? Again, the number of women who had at least one less urinary tract infection in six months, infection in six months.

Speaker 2:

In the 294 women in the D-Mannose group, 51% of them had a decreased risk or a decreased number of urinary tract infections compared to the placebo, which was 55%. So just one versus 55%, and that did not reach statistical significance. And neither did anything else of quality of life scores, antibiotic courses, hospitalizations, clinic visits. Nothing was different between the D-mannose and the fruit dose. And so what the authors kind of came away with in the study was that, at least when it comes to clinically relevant endpoints that I think patients actually care about, there was not a difference between either D-mannose and placebo in the number of urinary tract infections women experience, so again showing that, you know, we really always need large randomized control studies to show a benefit or show a risk. In this case it did not. So I'm probably not going to be recommending D-mannose now for prevention of urinary tract infections. So you know, that's kind of where we're at, I think, as pharmacist providers. You know, I think there's a lot we can do here, but apparently D-mannose is not something we should be recommending. Jen.

Speaker 1:

Yeah, thanks, jeff, and I think you know we talk a lot about supplements and you know natural products, and so I think you know, to establish some credibility, I think it's good to know what the data is. So you know. In this case, I mean, there are lots of things that do work for other things, so I think you know. In this case, I think it is important to call that out and to provide the evidence. I mean, none of us want to be spending money on something that isn't going to work, and obviously we need something to work in this case. So right, right, yeah.

Speaker 2:

And and I you know again, it's not like we don't have good therapies in this I again, I know, in postmenopausal women we really, really need to be making sure that if you have recurrent UTIs you should be on vaginal estrogen and we should really do everything we can to make sure that they in fact have access to that. And I think, again, pharmacists play a big role there in making sure patients have access to it. And then, you know again, telling women, especially premenopausal women, to really push fluids and that will decrease their risk.

Speaker 2:

And then you know this might be something embarrassing that women may not be interested in discussing with a lot of their providers. But you know again, you know the, the, the patient who comes to you and says, yeah, I'm having a lot of UPIs, it seems like every time they're at their sexual activity. You know again that that that post-coital um antibiotics seem to be beneficial as well.

Speaker 1:

Yeah, and we did um a podcast not too long ago on perimenopause and menopause and estrogen and I think it's such an important topic and you know, this gives us another avenue to discuss that. Absolutely, yeah, so good. This, this information was so good and I think it was prompted, obviously, by that study on D-mannose, but I think it's such a good reminder of what we can do for prevention of recurrent UTIs and many, many women experience that. So this is a great topic. Do you have any final comments about how we, as pharmacists, can best support our patients?

Speaker 2:

You know, listening, you know, and again, I get it. You know. You know, community pharmacists, you know are, are bombarded, you know, with 12 million things to do every day, and there's a new metric. There's a new to do every day and there's a new metric, there's a new, you know, vaccine. There's a new thing we've got to do. And you know, while I am 100% supportive and want and hope that pharmacists are able to expand their practices and really improve care, that you know, just basically showing what the studies have always shown that pharmacists can do this, I get that. You know, I can hear the groan over the ether about from some community pharmacists going oh, one more thing I got to watch out for, you know, and I get that.

Speaker 2:

But this is, I think, a relatively simple intervention really, 30 to 60 seconds of talking to somebody can really make the difference in this. Again, you know pushing fluids, making sure women are uh, who are uh are eligible, or on a topical estrogen. I think that those are some simple things to do.

Speaker 1:

Yeah, great points, great points. Thank you so much, jeff. Uh, as always, we appreciate you sharing your expertise, and this was another, um really good reminder of what we need to do for our patients, so I greatly appreciate it, thank you. And that's it for this week. If you're a CE plan member, be sure to claim your CE credit for this episode by logging in at CEimpactcom and, as always, have a great week and keep learning. We'll talk to you next week.

Speaker 3:

Thanks for listening in. Claim your CE credit by clicking on the link in the show notes and check out CE Impact's other education at CEImpactcom, where we curate the most important information in pharmacy and medicine to deliver straight to you. Join today to connect your learning to practice.