Vaginal Estrogen Therapy for Recurrent UTIs in Postmenopausal Women

Mechanism and Effectiveness

• Menopause causes reduced vaginal estrogen, increased vaginal pH, and alteration in vaginal microbiota away from the protective lactobacillus-dominant environment, making the vagina more susceptible to colonization by gram-negative uropathogens 1
• Vaginal estrogen therapy reduces vaginal pH 1
• Vaginal estrogen therapy restores lactobacillus colonization while reducing gram-negative bacterial colonization 1

Treatment Recommendations

• Diagnose recurrent UTI via urine culture before initiating treatment, as recommended by the European Urology guidelines 2, 3
• Use vaginal estrogen replacement as the primary non-antimicrobial intervention, as recommended by the European Urology guidelines 2, 4, 5

Important Considerations

• Vaginal estrogen does not significantly increase serum estrogen levels 1
• Data do not show increased risk of breast cancer recurrence, endometrial hyperplasia, or carcinoma in women using vaginal estrogen for urogenital symptoms 1
• Common side effects of vaginal estrogen therapy include vaginal irritation, which may affect adherence 1

Additional Management Strategies

• If vaginal estrogen therapy fails, consider other non-antimicrobial interventions, such as immunoactive prophylaxis, methenamine hippurate, or probiotics, as recommended by the European Urology guidelines 2, 3
• Antimicrobial prophylaxis should be reserved for cases where non-antimicrobial interventions have failed, as recommended by the European Urology guidelines 2, 3

Vaginal Estrogen Therapy for Recurrent UTI Prevention

Introduction to Vaginal Estrogen Therapy

• The American Urological Association recommends vaginal estrogen cream for the prevention of recurrent UTIs in postmenopausal women, as it demonstrates superior efficacy compared to vaginal estrogen rings with a relative risk of 0.25 (75% reduction) compared to placebo 6, 7

Product Selection and Efficacy

• Vaginal estrogen cream is preferred over vaginal estrogen rings for UTI prevention due to its superior efficacy, with a 75% reduction in recurrent UTIs compared to a 36% reduction with vaginal rings 6, 7

Mechanism of Action and Implementation

• The European Urology guidelines recommend confirming UTI diagnosis before initiating vaginal estrogen therapy, with documentation of recurrent UTI (≥2 UTIs in 6 months or ≥3 in 12 months) 8
• Vaginal estrogen should be the first-line non-antimicrobial therapy for postmenopausal women with recurrent UTIs, as recommended by European Urology guidelines 8

Alternative and Adjunct Therapies

• If vaginal estrogen fails, sequential non-antimicrobial options include methenamine hippurate, immunoactive prophylaxis with OM-89 (Uro-Vaxom), and lactobacillus-containing probiotics 6, 8, 9
• Continuous antimicrobial prophylaxis (nitrofurantoin 50 mg, TMP-SMX 40/200 mg, or trimethoprim 100 mg nightly for 6-12 months) should be reserved for cases where non-antimicrobial interventions have failed, with antibiotic choice guided by prior organism susceptibility patterns and drug allergies 8

Recommendation for Vaginal Estrogen in Postmenopausal Women with Recurrent UTIs

Primary Recommendation

• Vaginal estrogen therapy is the first-line non-antimicrobial intervention for postmenopausal women with recurrent UTIs, with a Grade B evidence level and moderate recommendation strength from the AUA/CUA/SUFU guidelines 10, 11

Why the Uterus Doesn't Matter

• Vaginal estrogen has minimal systemic absorption, making systemic risks (including endometrial effects) negligible 10, 11
• The guidelines explicitly state there is no substantially increased risk of adverse events with vaginal estrogen therapy 10, 11

Important Safety Considerations

• Systemic estrogen therapy should NOT be recommended for recurrent UTI treatment, as oral estrogen has not been shown to reduce UTI risk and carries different risks 10, 11

Common Pitfalls to Avoid

• Do not withhold vaginal estrogen due to presence of uterus—this is a common misconception, as vaginal estrogen has minimal systemic absorption and does not require progesterone co-administration 10
• Do not use oral/systemic estrogen for UTI prevention, as it is ineffective and carries unnecessary risks 10, 11

Vaginal Estrogen for UTI Prevention in Postmenopausal Women

Introduction to Vaginal Estrogen Therapy

• The American Urological Association recommends vaginal estrogen as first-line non-antimicrobial therapy for preventing recurrent UTIs in postmenopausal women, as it is highly effective 12

Route-Specific Efficacy

• Vaginal estrogen cream reduces recurrent UTIs by 75% (RR 0.25, 95% CI 0.13-0.50) compared to placebo, according to the European Urology guidelines 12
• Vaginal estrogen rings show a more modest benefit with a 36% reduction (RR 0.64, 95% CI 0.47-0.86) 12
• Oral estrogen does NOT reduce UTI risk compared to placebo (RR 1.08, 95% CI 0.88-1.33), as stated by the American College of Obstetricians and Gynecologists 12, 13

Dosing Recommendations

• The European Urology guidelines recommend treatment duration of at least 6-12 months for optimal outcomes 12, 13

Clinical Algorithm for Postmenopausal Women with Recurrent UTIs

• Document recurrent UTI: ≥2 culture-positive UTIs in 6 months OR ≥3 in 12 months, as recommended by the Infectious Diseases Society of America 13
• Obtain urine culture before initiating treatment, according to the American Urological Association 13
• Initiate vaginal estrogen cream (preferred over ring) as first-line therapy, as recommended by the European Urology guidelines 13
• Consider adding lactobacillus-containing probiotics, as suggested by the American College of Obstetricians and Gynecologists 13

Step 3: If Vaginal Estrogen Fails

• Sequential non-antimicrobial options include methenamine hippurate 1 gram twice daily, as recommended by the American Urological Association 12, 13
• Immunoactive prophylaxis with OM-89 (Uro-Vaxom) may be considered, according to the European Urology guidelines 12
• Lactobacillus-containing probiotics may be added, as suggested by the American College of Obstetricians and Gynecologists 13

Critical Pitfalls to Avoid

• Do NOT withhold vaginal estrogen due to presence of uterus, as stated by the American College of Obstetricians and Gynecologists 12, 13
• Do NOT prescribe oral/systemic estrogen for UTI prevention, as it is ineffective and carries unnecessary risks, according to the American Urological Association 12, 13
• Do NOT treat asymptomatic bacteriuria, as this fosters antimicrobial resistance and increases recurrent UTI episodes, as recommended by the Infectious Diseases Society of America 13
• Do NOT classify patients with recurrent UTI as "complicated" unless they have structural/functional urinary tract abnormalities, immunosuppression, or pregnancy, according to the European Urology guidelines 13

Vaginal Estrogen Therapy for Recurrent UTIs

Introduction to Vaginal Estrogen Therapy

• The American Urological Association suggests that large prospective cohort studies of over 45,000 women found no increased risk of endometrial cancer, stroke, venous thromboembolism, invasive breast cancer, or colorectal cancer with vaginal estrogen 14

Specific Prescribing Instructions

• Estriol cream 0.5 mg is the most studied formulation for vaginal estrogen therapy, with an initial phase of applying 0.5 mg nightly for 2 weeks, followed by a maintenance phase of applying 0.5 mg twice weekly thereafter 15, 16
• The maintenance phase should continue for at least 6-12 months for optimal outcomes, with a duration of treatment dependent on patient response and recurrence of UTIs 14, 15, 16

Alternative Formulations and Delivery Methods

• Estradiol vaginal ring 2 mg (replaced every 12-24 weeks) is an alternative formulation, though less effective than estriol cream, with a relative risk reduction of 36% compared to 75% for estriol cream 15, 16
• Estriol vaginal pessary daily for 2 weeks, then every 2 weeks, is another option for patients who prefer this delivery method 15, 17

Diagnosis and Treatment Outcomes

• Documenting recurrent UTI is crucial, defined as ≥2 culture-positive UTIs in 6 months OR ≥3 in 12 months, with a urine culture obtained before initiating vaginal estrogen to confirm diagnosis 18, 14
• Vaginal estrogen restores lactobacilli colonization (61% vs 0% in placebo) and reduces vaginal pH, leading to a 51-75% reduction in UTI frequency depending on formulation used 15, 16

Critical Pitfalls to Avoid

• The American Urological Association recommends against prescribing oral/systemic estrogen for UTI prevention, as it is completely ineffective (RR 1.08, no benefit vs placebo) and carries unnecessary risks 15, 17, 14
• Treating asymptomatic bacteriuria is not recommended, as it fosters antimicrobial resistance and increases recurrent UTI episodes 18

If Vaginal Estrogen Fails

• A sequential algorithm for non-antimicrobial alternatives can be followed, including adding lactobacillus-containing probiotics (vaginal or oral), methenamine hippurate 1 gram twice daily, or immunoactive prophylaxis with OM-89 (Uro-Vaxom) if available 18, 14

Reserve Antimicrobial Prophylaxis as Last Resort

• Continuous antimicrobial prophylaxis should only be used when all non-antimicrobial interventions have failed, with preferred agents including nitrofurantoin 50 mg, trimethoprim-sulfamethoxazole 40/200 mg, or trimethoprim 100 mg nightly for 6-12 months 18, 14

Special Considerations for Breast Cancer History

• Recent evidence supports using vaginal estrogen for breast cancer patients with genitourinary symptoms when nonhormonal treatments fail, though systemic absorption is minimal and patients should discuss risks and benefits with their oncology team before initiation 14

Treatment of Postmenopausal Women with Ureaplasma-Dominant Vaginal Microbiome

Primary Intervention: Vaginal Estrogen Therapy

• Vaginal estrogen reduces vaginal pH, restores lactobacillus colonization (61% vs 0% in placebo), and reduces gram-negative bacterial colonization, with common side effect being vaginal irritation, which may affect adherence, in postmenopausal women with Ureaplasma-dominant vaginal microbiome 19

Adjunctive Probiotic Therapy

• Consider adding lactobacillus-containing probiotics (vaginal or oral) after initiating vaginal estrogen to help restore vaginal homeostasis, though they should be used as adjunctive therapy, not monotherapy, in postmenopausal women with Ureaplasma-dominant vaginal microbiome 20

Mechanism of Vaginal Estrogen in Preventing Recurrent UTIs

Pathophysiology and Treatment

• The European Association of Urology (2024) gives a strong recommendation for vaginal estrogen as first-line non-antimicrobial prophylaxis in postmenopausal women with recurrent UTIs 21, 22
• Atrophic vaginitis, caused by estrogen deficiency, is recognized as a key risk factor for recurrent UTIs in postmenopausal women 21

Clinical Impact

• Vaginal estrogen cream has been shown to reduce the incidence of UTIs, although the exact percentage reduction is not specified in the cited reference 21, 22

Vaginal Estrogen Therapy for Recurrent UTI Prevention

Introduction to Vaginal Estrogen Therapy

• The American Urological Association, Canadian Urological Association, and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction give a Moderate Recommendation with Grade B evidence for using vaginal estrogen as first-line therapy for recurrent UTI prevention in postmenopausal women 23

Clinical Considerations

• The European Association of Urology provides a Strong recommendation for vaginal estrogen therapy, although the specific details of this recommendation are not provided in the article 23
• Patients with a history of breast cancer should discuss vaginal estrogen use with their oncology team, as it is not an absolute contraindication due to minimal systemic absorption, but rather a consideration that requires careful evaluation 23
• Vaginal estrogen therapy should not be withheld from patients with a history of breast cancer if nonhormonal treatments have failed, as the benefits may outweigh the risks 23

Diagnostic Considerations

• Asymptomatic bacteriuria should not be treated, as it fosters antimicrobial resistance and increases recurrent UTI episodes, according to guidelines from The Journal of Urology 24
• Symptom clearance is sufficient, and routine post-treatment cultures are not recommended, as stated in The Journal of Urology 23

Treatment Considerations

• Oral estrogen is completely ineffective for UTI prevention and carries unnecessary systemic risks, and patients already on systemic estrogen therapy should still receive vaginal estrogen for UTI prevention, as recommended by The Journal of Urology 23

Vaginal Estrogen Therapy for UTI Prevention

Efficacy and Safety

• The American Urological Association recommends vaginal estrogen therapy for postmenopausal women with recurrent UTIs, as it has minimal systemic absorption and negligible systemic risks, including endometrial effects 25
• Vaginal estrogen therapy is not associated with a substantially increased risk of adverse events, including endometrial cancer, stroke, venous thromboembolism, invasive breast cancer, or colorectal cancer 25

Treatment Guidelines

• The American College of Obstetricians and Gynecologists suggests that patients already on systemic estrogen therapy should still receive vaginal estrogen for UTI prevention, as oral estrogen is completely ineffective for UTI prevention 25

Indications for Urovaxom (OM-89)

Patient Selection

• The European Urological Association recommends Urovaxom as an immunactive prophylaxis option for patients with recurrent urinary tract infections (UTIs), defined as ≥2 infections in 6 months or ≥3 infections in 12 months, after non-antimicrobial first-line therapies have failed or are not available, with a strong recommendation for postmenopausal women after vaginal estrogen therapy 26
• Urovaxom should be used in postmenopausal women with recurrent UTIs only after vaginal estrogen therapy has failed or shown insufficient effect, as vaginal estrogen is the first-line therapy with a 75% reduction in UTI recurrences 26
• The European Urological Association gives a strong recommendation for immunactive prophylaxis across all age groups, positioning it after vaginal estrogen in postmenopausal women 26

Diagnostic Requirements

• Mandatory documentation of recurrent UTIs through positive urine cultures (≥2 in 6 months or ≥3 in 12 months) is required before starting Urovaxom therapy 26
• Exclusion of complicated UTIs through medical history (no structural/functional urinary tract anomalies, no immunosuppression, no pregnancy) is necessary before starting Urovaxom therapy 26

Therapeutic Positioning

• Urovaxom can be used as an immunactive prophylaxis option in premenopausal women with documented recurrent UTIs (≥2 in 6 months or ≥3 in 12 months) after behavioral measures have been exhausted 26
• The European Urological Association recommends Urovaxom as a second-line option or after failure/contraindication of vaginal estrogen in postmenopausal women 26

Vaginal Estrogen Therapy for Recurrent UTIs

Introduction to Vaginal Estrogen Therapy

• The American College of Radiology recommends adequate hydration to promote frequent urination, post-coital voiding, and avoiding spermicide-containing contraceptives for women with recurrent UTIs 27

Diagnostic Considerations

• The presence of gram-negative uropathogens, primarily E. coli, can colonize the vagina due to menopause-related changes, leading to recurrent UTIs 27

Behavioral Modifications

• Counseling on avoiding harsh vaginal cleansers that disrupt normal flora is recommended for women with recurrent UTIs, in addition to vaginal estrogen therapy 27

UTI Prevention in Older Women with Recurrent Infections

Non-Antimicrobial Prevention Strategies

• The American Urological Association recommends intravaginal probiotics containing Lactobacillus rhamnosus GR-1 or Lactobacillus reuteri RC-14 once or twice weekly as adjunctive therapy for UTI prevention 28
• Daily consumption of cranberry products providing a minimum of 36 mg/day proanthocyanidin A is effective in reducing recurrent UTIs, with a reduction in recurrence rate 28, 29

Antimicrobial Prophylaxis

• The American Urological Association suggests reserving continuous antimicrobial prophylaxis only after all non-antimicrobial interventions have failed, with the choice of antimicrobial guided by prior organism susceptibility patterns and drug allergies 28, 29
• Trimethoprim-sulfamethoxazole 40/200 mg (half tablet) daily at bedtime for 6-12 months is a preferred antimicrobial regimen for UTI prophylaxis, with a significant reduction in infection rates 28, 29

Behavioral Modifications

• Avoiding spermicide use and considering alternative contraception may help reduce UTI recurrence, especially in women with infection patterns related to sexual activity 28, 29

Prevention of Recurrent Urinary Tract Infections in Post‑menopausal Women

Diagnostic criteria

• Recurrent urinary tract infection (UTI) is defined as ≥ 2 culture‑confirmed infections within 6 months or ≥ 3 within 12 months in a post‑menopausal woman. 30

Behavioral and lifestyle measures

• Recommended non‑pharmacologic measures include adequate hydration to promote frequent voiding, voiding after intercourse, avoidance of spermicidal contraceptives, and tight glycemic control in diabetic patients. These recommendations are supported by clinical data. 30, 31

Cranberry supplementation

• Daily intake of cranberry products providing at least 36 mg of proanthocyanidin A has been shown to reduce recurrence risk. 30, 31

Antibiotic prophylaxis (last‑line option)

Preferred agents (ordered by recommendation)

These agents are recommended for continuous prophylaxis after failure of all non‑antibiotic strategies. 30

Duration of prophylaxis

• Continuous prophylaxis should be administered for 6–12 months. 30

Selection considerations

• Choice of antibiotic must be guided by prior urine‑culture results, antimicrobial susceptibility patterns, patient allergies, and principles of antimicrobial stewardship. 30, 31

Stewardship cautions

• Fluoroquinolones and cephalosporins should be avoided as first‑line prophylactic agents because of rising resistance and stewardship concerns. 30
• Rotating the prophylactic antibiotic every 3 months may be employed to lessen the selection pressure for resistant organisms. 30

Follow‑up before initiating prophylaxis

• Prior to starting any prophylactic regimen, obtain a negative urine culture 1–2 weeks after treatment of the most recent infection to confirm eradication. 30, 31

UTI Prevention in Postmenopausal Women: Vaginal Estrogen and Cranberry Adjuncts

First‑Line Hormonal Therapy

• Vaginal estrogen cream reduces recurrent urinary tract infections by 75 % (relative risk 0.25) compared with placebo, representing a strong recommendation for first‑line use. 32
• Vaginal estrogen rings achieve a smaller benefit, lowering infection risk by 36 % (RR 0.64) and are therefore considered less effective than cream formulations. 32

Adjunctive Cranberry Therapy

• Adding standardized cranberry tablets to ongoing vaginal estrogen therapy provides an additional 26 % risk reduction for UTIs (RR 0.74, 95 % CI 0.55‑0.98) in women with recurrent infections. 32
• The 2023 Cochrane review reports moderate‑certainty evidence that cranberry products are effective for prophylaxis in this population. 32
• The American Urological Association issues a conditional recommendation (Grade C) that clinicians may offer cranberry prophylaxis as an adjunct. 32

Guideline Recommendations (Societal Positions)

• The European Association of Urology (2024) gives a strong recommendation for vaginal estrogen and a weak recommendation for cranberry, noting contradictory findings across studies. 32

Evidence Quality and Limitations

• Most meta‑analyses of cranberry interventions are rated critically low to low quality because of heterogeneity and lack of product standardization. 32
• The 2012 Cochrane review found no significant reduction in symptomatic UTIs with cranberry (RR 0.74, 0.42‑1.31) and reported 55 % heterogeneity among trials. 32
• Commercial cranberry products often lack verified proanthocyanidin (PAC) content, making consistent dosing difficult. 32

Comparative Effectiveness

• In head‑to‑head comparisons, cranberry prophylaxis shows no meaningful difference from antibiotic prophylaxis (RR 1.03, 95 % CI 0.80‑1.33). 32
• Cranberry appears more effective than probiotic therapy, reducing UTI risk by 61 % (RR 0.39, 95 % CI 0.27‑0.56). 32

Subpopulation Findings

• Cranberry does not confer benefit in elderly institutionalized women (RR 0.93, no statistical benefit) or in women with neurogenic bladder (RR 0.97, no benefit). 32

Safety and Tolerability

• Gastrointestinal adverse events are unlikely to differ between cranberry and placebo (RR 1.33, 95 % CI 1.00‑1.77). 32
• Withdrawal rates in cranberry trials can be high (up to 55 %), suggesting challenges with long‑term adherence. 32

Vaginal Estrogen as First‑Line Non‑Antibiotic Prophylaxis for Recurrent UTIs in Postmenopausal Women

1. Guideline Recommendation & Efficacy

• The European Association of Urology (EAU) gives a strong recommendation that vaginal estrogen therapy be initiated as the first‑line non‑antimicrobial intervention for postmenopausal women ≥ 65 years with recurrent urinary tract infections (UTIs). The therapy reduces UTI recurrence by ≈ 75 % when delivered as a vaginal cream formulation. 33

• Comparative data show that vaginal estrogen cream achieves a 75 % reduction in recurrent UTIs (relative risk 0.25, 95 % CI 0.13–0.50), which is markedly superior to vaginal estrogen rings that provide a 36 % reduction (RR 0.64, 95 % CI 0.47–0.86). 33

2. Prescribing Regimen

• The most studied formulation is estriol cream 0.5 mg: apply nightly for 2 weeks (initial phase), then twice weekly for maintenance, continuing for 6–12 months to achieve optimal outcomes. 33

3. Safety Profile

• Large prospective cohort studies of > 45 000 women demonstrate no increased risk of endometrial cancer, stroke, venous thromboembolism, invasive breast cancer, or colorectal cancer with vaginal estrogen use. Systemic absorption is minimal, and progesterone co‑administration is unnecessary, even in women with an intact uterus. (Observational evidence) 34

• The most common adverse effect is mild vaginal irritation, which may affect adherence. 34

4. Diagnostic Requirements Before Initiation

• Confirm recurrent UTI by ≥ 2 culture‑positive episodes in 6 months or ≥ 3 in 12 months. Obtain a urine culture prior to starting therapy to ensure accurate diagnosis and to rule out complicated infection. 33

5. Classification of Infection

• Patients with recurrent uncomplicated UTIs should not be labeled as “complicated” unless they have structural/functional urinary tract abnormalities, immunosuppression, or are pregnant. 34

6. Management Algorithm When Vaginal Estrogen Fails

6.1 Second‑Line Non‑Antimicrobial Options (Strong Recommendation)

33

6.2 Adjunctive Cranberry Therapy

• Adding cranberry products delivering ≥ 36 mg/day proanthocyanidin A to vaginal estrogen yields an additional 26 % risk reduction (RR 0.74, 95 % CI 0.55–0.98). Evidence quality is low and findings are inconsistent across studies. 33

6.3 Reserve Antimicrobial Prophylaxis (Last Resort)

• If all non‑antimicrobial measures fail, use nitrofurantoin 50 mg nightly for 6–12 months (preferred), or trimethoprim‑sulfamethoxazole 40/200 mg (half tablet) nightly, or trimethoprim 100 mg nightly, guided by prior susceptibility patterns and allergies. Avoid fluoroquinolones and cephalosporins as first‑line prophylaxis due to resistance concerns. (Guideline recommendation) 33

7. Special Populations

• Women with a history of breast cancer may use vaginal estrogen because systemic absorption is negligible; decision should be individualized after discussion with oncology. (Observational data)

• Women already on systemic (oral) estrogen should still receive vaginal estrogen for UTI prevention, as oral estrogen does not confer protective benefit against recurrent UTIs. (Guideline statement)

Vaginal Estrogen Reduces Recurrent Urinary Tract Infections – Evidence Summary

Effectiveness of Vaginal Estrogen

Safety Profile of Vaginal Estrogen

Evidence Regarding D‑Mannose

Guideline Recommendations for Vaginal Estrogen in Preventing Recurrent UTIs in Postmenopausal Women

Guideline Recommendations

• The American Urological Association and the European Association of Urology give a strong recommendation to use vaginal estrogen as first‑line therapy for postmenopausal women with recurrent urinary tract infections. [37][38]

Diagnostic Criteria Before Initiation

• Prior to starting vaginal estrogen, clinicians should confirm recurrent UTI (≥ 2 culture‑positive episodes in 6 months or ≥ 3 in 12 months) and exclude complicated UTI (e.g., structural abnormalities, immunosuppression, pregnancy). 38

Clinical Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria; treating it promotes antimicrobial resistance and increases the risk of subsequent recurrent UTIs. 38

Adjunctive Therapies

• After initiating vaginal estrogen, adding lactobacillus‑containing probiotics (vaginal or oral) can help restore normal vaginal flora; probiotics should not be used as monotherapy. 38

Sequential Management Algorithm (If Vaginal Estrogen Fails)

• Second‑line non‑antimicrobial options (in order of preference):
• Antimicrobial prophylaxis is reserved for patients who have failed all non‑antimicrobial measures. Preferred agents are nitrofurantoin 50 mg nightly, trimethoprim‑sulfamethoxazole 40/200 mg (half tablet) nightly, or trimethoprim 100 mg nightly, administered for 6–12 months; fluoroquinolones and cephalosporins should be avoided as first‑line prophylaxis, and rotating antibiotics every 3 months can help limit resistance. 38

Behavioral Modifications to Recommend Concurrently

• Encourage adequate hydration to promote frequent voiding.
• Advise patients to void after intercourse.
• Recommend avoidance of spermicide‑containing contraceptives and harsh vaginal cleansers that disrupt normal flora.
• Emphasize glycemic control in diabetic patients.
• Counsel against prolonged (>5 days) or unnecessary broad‑spectrum antibiotic courses.
• All of the above lifestyle measures are supported by guideline societies. [37][38]