Methenamine in a Non-antibiotic, Multimodal Approach to UTI Prevention
Methenamine in a Non-antibiotic, Multimodal Approach to UTI Prevention
Urinary tract infections (UTIs) are the most common bacterial infection and are especially
 common in postmenopausal women, who often experience recurrent UTIs. Women with recurrent
 UTIs are commonly treated with antibiotics, but side effects, collateral damage to commensal
 bacteria, and antimicrobial resistance result from frequent antibiotic use. It is paramount
 that researchers develop non-antibiotic treatment strategies for UTIs.

 Several non-antibiotic strategies may be successful in preventing recurrent UTIs in
 postmenopausal women, including low-dose vaginal estrogen, d-mannose, and methenamine
 hippurate. Methenamine hippurate (MH) is interesting as it causes few side effects, kills
 bacteria by denaturing bacterial proteins, RNA, and DNA, and does not develop resistance.
 Several studies have demonstrated the efficacy of daily methenamine on the incidence of UTI.
 However, women often require multiple therapies in order to prevent recurrence. There are
 currently few guidelines to help clinicians identify optimal treatment regimens for
 non-antibiotic prevention of UTI.

 The purpose of this pilot study is to examine the feasibility of developing a sequential,
 multiple assignment, randomization trial (SMART); and examine the treatment effect of MH in
 combination with vaginal estrogen (VET) and D-mannose on prevention of UTI. The investigators
 plan to examine the efficacy of the addition of MH to low dose VET and d-mannose in the UTI
 prevention through randomization to MH + VET + D-mannose vs continuing VET + D-mannose alone.
 The primary outcome will be the proportion of patients who have symptomatic, culture-proven
 UTI during a 3 month treatment period. The investigators hypothesize that women on low dose
 VET, d-mannose, and MH will be less likely to have recurrent UTI than those with VET and
 d-mannose alone.

 This study uses a pragmatic, longitudinal approach that mimics patients' clinical experiences
 and physicians' decision points during management of UTI prophylaxis. Through this
 randomized, controlled pilot study, this proposal would allow the investigators to examine
 the feasibility of conducting a larger-scale, adaptive study trial, and estimate the
 treatment effect of a non-antibiotic regimen augmented with MH in women who continue to
 develop recurrence.
Urinary tract infections (UTIs) are the most common bacterial infection and are especially
 common in postmenopausal women, who often experience recurrent UTIs. Women with recurrent
 UTIs are commonly treated with antibiotics, but side effects, collateral damage to commensal
 bacteria, and antimicrobial resistance result from frequent antibiotic use. The Centers for
 Disease Control and Prevention estimate that drug resistance contributes to 23,000 deaths,
 2,049,442 illnesses, and $20 billion dollars in excess direct healthcare costs in the United
 States annually. Thus, it is paramount that researchers develop non-antibiotic treatment
 strategies for UTIs.

 Several non-antibiotic strategies may be successful in preventing recurrent UTIs in
 postmenopausal women. One is low-dose vaginal estrogen, which may decrease the rate of
 recurrent UTIs by decreasing inflammation, promoting bladder repair, and promoting retention
 of lactobacilli. Another is d-mannose, a natural sugar that may decrease bacterial adherence
 to the urothelium. Methenamine hippurate has regained interest recently. First, it causes few
 side effects. Second, it functions by producing formaldehyde in the urine, which kills
 bacteria by denaturing bacterial proteins, RNA, and DNA. Thus far, no methenamine-resistant
 bacteria have been reported to develop in vivo. Lastly, several studies have demonstrated
 that 2 grams daily of methenamine reduces the incidence of UTI and is likely comparable to
 the antibiotic nitrofurantoin for UTI prophylaxis. However, in the investigators' clinical
 experience, women often require multiple therapies in order to prevent recurrence. There are
 currently few guidelines to help clinicians identify optimal treatment regimens for
 prevention of UTI. The clinical challenge is to optimize individual treatment regimens by
 maximizing efficacy and minimizing the number of medications, cost, side effects, and
 nonadherence for each individual.

 The purpose of this pilot study is to 1) examine the feasibility of developing a sequential,
 multiple assignment, randomization trial (SMART) and 2) examine the treatment effect of
 methenamine hippurate in combination with vaginal estrogen and D-mannose on prevention of
 UTI. This adaptive study design allows the investigators to examine the efficacy of
 non-antibiotic prophylaxis and initiation of subsequent preventative therapies based on
 individual responses. It is a pragmatic, longitudinal approach that mimics patients' clinical
 experiences and physicians' decision points during management of UTI prophylaxis. Given the
 efficacy and relative safety of methenamine hippurate, the investigators are particularly
 interested in its efficacy among those who have had suboptimal response to vaginal estrogen
 and D-mannose. The timing of this study is ideal, as the investigators are also currently
 conducting a trial of vaginal estrogen plus D-mannose in postmenopausal women. Through this
 randomized, controlled pilot study, this proposal would allow the investigators to examine
 the feasibility of conducting a larger-scale, adaptive study trial on the use of methenamine
 hippurate in combination with vaginal estrogen plus D-mannose, and estimate the treatment
 effect of a non-antibiotic regimen augmented with methenamine hippurate in women who continue
 to develop recurrence.

 This study is a planned extension of a previously proposed clinical trial on d-mannose and
 vaginal estrogen (IRB#:201711120); however, any postmenopausal women with a history of
 recurrent UTI, who then develop UTI while on a combined prophylaxis regimen of d-mannose and
 vaginal estrogen will be eligible for the randomized controlled trial on methenamine
 augmentation. The investigators plan to examine the efficacy of the addition of methenamine
 hippurate to low dose vaginal estrogen and d-mannose in the UTI prevention through
 randomization to methenamine + vaginal estrogen + D-mannose vs continuing vaginal estrogen +
 D-mannose alone. Patients will be randomized to either the addition of methenamine hippurate
 or continuing with vaginal estrogen + D-mannose alone. The primary outcome will be the
 proportion of patients who have symptomatic, culture-proven UTI during a 3 month treatment
 period. The investigators hypothesize that women on low dose vaginal estrogen, d-mannose, and
 methenamine hippurate will be less likely to have recurrent UTI than those with low dose
 vaginal estrogen and d-mannose alone. As part of the study, baseline information and vaginal,
 urine, and fecal samples may be taken. Additionally, as part of examining feasibility of a
 larger study, recruitment, retention, refusal, non-compliance, and adherence rates will be
 collected. Patients who decline or drop out of the study will be contacted to answer
 questions on reasons for refusal or withdrawal. Subjects who undergo randomization will
 either add methenamine to their ongoing vaginal estrogen + D-mannose, or continue on vaginal
 estrogen + D-mannose alone. They will receive weekly calls or text reminders to record study
 diaries and to take their medications. Patients will follow up at the end of 3 months, at
 their usual follow up appointment, for routine examination, questionnaires, and urine and
 possible vaginal and fecal samples. Follow up may be extended up to 1 month prior or 6 months
 afterward their baseline visit (2-6 months after the baseline visit) for those who do not
 make their 3 months appointment. The investigators also plan to describe the uropathogen
 profile and antibiotic resistance of UTIs that occur during prophylaxis with vaginal estrogen
 + d-mannose, with or without methenamine hippurate. Lastly, the investigators hope to examine
 the impact of a non-antibiotic prophylaxis regimen that includes methenamine hippurate on the
 bladder microenvironment as well as the urinary, vaginal, and intestinal microbiomes.
Inclusion Criteria:

 -  Postmenopausal women

 -  History of recurrent UTI (>=3 culture proven UTIs in one year or >=2 in 6 months)

 -  Recurrent, culture proven UTI while on vaginal estrogen for at least 4 weeks +
 d-mannose prophylaxis

 -  English speaker

 Exclusion Criteria:

 -  Not postmenopausal

 -  Complicated UTIs

 -  Known renal tract anomaly

 -  Liver dysfunction

 -  Neurogenic bladder

 -  Incomplete bladder emptying (PVR > 150 cc when voided volume >150 cc)

 -  Self-catheterization or use of indwelling catheter

 -  Contraindication to vaginal estrogen, methenamine hippurate, or d-mannose, including
 allergic reactions

 -  History of or current endometrial cancer

 -  History of estrogen sensitive breast cancer without approval of patient, patient's
 oncologist, oncologic surgeon, or primary care physician to use vaginal estrogen after
 counseling

 -  History of interstitial cystitis/painful bladder syndrome

 -  Urothelial cancer

 -  Enrolled in other clinical trials for UTIs other than Washington University study IRB#
 201711120

 -  Currently on daily antibiotic prophylaxis and unwilling to stop this intervention