New medication for urinary tract infections: will it really help?

For the first time in 20 years, doctors have a new antibiotic for urinary tract infections (UTIs) in women. The FDA approved pivmecillinam (Pivya) in April 2024 - an encouraging step, since the germs behind UTIs have grown more resistant to existing medications, making them less effective. Here is how pivmecillinam could change treatment.

What is it?

Pivmecillinam is a type of penicillin taken by mouth. European doctors have prescribed it more than 30 million times over the past 40 years as a first-line treatment for "uncomplicated" UTIs - infections confined to the bladder.

The drug reached the United States after a company, Utility Therapeutics, acquired the U.S. rights and won FDA approval to sell it. The FDA based its decision on three clinical trials showing effectiveness ranging from 62% to 72%. The most common side effects were nausea and diarrhea.

Will it make a difference?

Pivmecillinam joins the existing lineup of first-line UTI treatments: fosfomycin, nitrofurantoin, and trimethoprim/sulfamethoxazole.

And more options are better. "A large portion of my patients have recurrent UTIs and come in with infection after infection. We often have to cycle through treatment options when we see evidence of antibiotic resistance. I also see a lot of women who experience reactions to certain medications. So it will be nice to be able to turn to another drug on the same tier, instead of jumping to stronger antibiotics. We want to reserve those for more advanced UTIs that ascend into the upper urinary tract," says a urogynecologist.

Why do we get UTIs?

Avoiding UTIs altogether would be ideal, but that gets harder with age.

UTIs develop when harmful bacteria start growing anywhere in the urinary tract: the kidneys, bladder, ureters (the tubes carrying urine from kidneys to bladder), or urethra (the tube carrying urine out of the body).

Women are particularly susceptible because the female urethra - opening just above the vagina - is only about an inch and a half long, so bacteria from the rectum can easily travel the short distance to the bladder. The risk grows after menopause, when lower estrogen leaves the vaginal tissue near the urethra more vulnerable to infection.

Men rarely get UTIs thanks to a longer urethra. But later in life, an enlarged prostate can block urine flow from the bladder, leaving pooled urine where bacteria breed.

Fighting back

Fortunately, several approaches help ward off UTIs.

For women, vaginal estrogen after menopause helps restore protection. "It's available as a cream applied twice a week, tablets, or an estrogen ring inserted into the vagina every three months," the specialist says. "Estrogen increases lubrication and healthy bacteria. And preventing UTIs is often about balancing unhealthy bacteria. In extreme cases, some medications can be taken long-term to make the bladder inhospitable to harmful bacteria."

For men with an enlarged prostate, certain prescription medications can improve urine flow and prevent the urine buildup that invites infection.

Drug-free approaches

What about drug-free prevention, like cranberry extract supplements or emptying the bladder soon after intercourse? "The evidence that those approaches help is mixed," the specialist says. "It won't hurt to try them, and many of my patients have benefited from these interventions, but some people are just more prone to UTIs than others."

Watch for UTI symptoms - burning with urination, urgent or frequent need to go, bloody or cloudy urine, fever, or confusion - and report them to your doctor promptly.