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Ashmore S, Geynisman-Tan J, Ehimiaghe E, Cheeks M, Arteaga R, Sarkar P, Das D. Adherence to Non-Antibiotic Prophylactic Regimens in Women with Recurrent Urinary Tract Infections. Int Urogynecol J 2024:10.1007/s00192-024-05928-8. [PMID: 39316113 DOI: 10.1007/s00192-024-05928-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 08/13/2024] [Indexed: 09/25/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Non-antibiotic regimens such as methenamine hippurate, D-mannose, and vaginal estrogen are often prescribed as prevention for recurrent urinary tract infections (rUTIs). The objective of our study was to describe adherence rates in women prescribed non-antibiotic prophylaxis for rUTI and to explore factors associated with adherence. METHODS This was an ambispective cohort study describing and comparing adherence to non-antibiotic prophylactic regimens for rUTIs. Adult women who sought care from a Urogynecology clinic at a tertiary care center for rUTIs or frequent UTIs between January 2020 and December 2021 were included if they were prescribed a non-antibiotic prophylactic regimen. The Medication Adherence Questionnaire (MAQ) was administered to all eligible patients prospectively and then their charts were reviewed retrospectively for demographic and clinical factors. A score of 0 on the MAQ defined medication adherence. Any score ≥ 1 defined medication non-adherence. RESULTS A total of 90 patients met the inclusion criteria and completed the MAQ, with 33 (37%) in the adherent group and 57 (63%) in the non-adherent group. Mean age was 64.7 (± 14.7) years. Vaginal estrogen (81.1%) was the most commonly prescribed prophylactic regimen, followed by methenamine hippurate (26.7%). 73.3% of patients met criteria for rUTI at the index visit as per the American Urogynecologic Society best-practice statement. No demographic or clinical factors were associated with adherence to non-antibiotic prophylactic regimens. CONCLUSIONS Non-antibiotic prophylactic rUTI regimens are commonly prescribed; however, adherence remains low at 37%. There were no predictors associated with patient compliance. Clinicians should therefore inquire about adherence prior to escalating treatment.
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Affiliation(s)
- Sarah Ashmore
- Section of Urogynecology and Reconstructive Pelvic Surgery, University of Chicago, Chicago, IL, USA.
| | - Julia Geynisman-Tan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Eseohi Ehimiaghe
- Division of Obstetrics and Gynecology, Northwestern Medicine, Chicago, IL, USA
| | - Morgan Cheeks
- Division of Obstetrics and Gynecology, Northwestern Medicine, Chicago, IL, USA
| | - Rebecca Arteaga
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Prottusha Sarkar
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Deepanjana Das
- Urogynecology and Reconstructive Pelvic Surgery, OB/GYN and Women's Institute, Cleveland Clinic, Cleveland, OH, USA
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Han Z, Yi X, Li J, Liao D, Ai J. Nonantibiotic prophylaxis for urinary tract infections: a network meta-analysis of randomized controlled trials. Infection 2024:10.1007/s15010-024-02357-z. [PMID: 39095666 DOI: 10.1007/s15010-024-02357-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/16/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE Recent guidelines indicated that, in addition to antibiotics, nonantibiotic interventions serve as available preventive options for urinary tract infections (UTIs). This study aimed to compare the efficacy and safety of various nonantibiotic interventions in preventing UTIs. METHODS The authors systematically searched databases for eligible studies. The inclusion criteria encompassed randomized controlled trials (RCTs) focusing on one or more nonantibiotic interventions for UTI prevention, with the incidence of UTIs being a key outcome measure. Subgroup analyses were performed according to age, sex, and follow-up. RESULTS 50 RCTs comprising 10,495 subjects and investigating 14 interventions, were included. Nearly 80% of the RCTs utilized double-blind or triple-blind designs. In the whole group, D-mannose (risk ratio [RR] 0.34, 0.21 to 0.56), vaccine (RR 0.65, 0.52 to 0.82), probiotics (RR 0.69, 0.50 to 0.94), cranberry (RR 0.72, 0.60 to 0.87), and triple therapy (cranberry plus probiotics plus vitamin A) (RR 0.27, 0.09 to 0.87), exhibited a significant reduction in UTI incidence compared to the placebo. Probiotics (RR 0.50, 0.28 to 0.89) were the most effective in the nonadult group, while vitamin D (RR 0.46, 0.27 to 0.81) showed the highest efficacy in the long follow-up group (≥ 1 year). There was no significant difference in the incidence of adverse events between the interventions and the placebo group. CONCLUSIONS D-mannose, triple therapy, vaccine, probiotics, and cranberry serve as potential nonantibiotic intervention options for clinical UTI prevention.
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Affiliation(s)
- Zeyu Han
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, 88 South Keyuan Road, Chengdu, 610041, China
| | - Xianyanling Yi
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, 88 South Keyuan Road, Chengdu, 610041, China
| | - Jin Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, 88 South Keyuan Road, Chengdu, 610041, China
| | - Dazhou Liao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, 88 South Keyuan Road, Chengdu, 610041, China
| | - Jianzhong Ai
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, 88 South Keyuan Road, Chengdu, 610041, China.
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Ioannou P, Baliou S. The Molecular Mechanisms and Therapeutic Potential of Cranberry, D-Mannose, and Flavonoids against Infectious Diseases: The Example of Urinary Tract Infections. Antibiotics (Basel) 2024; 13:593. [PMID: 39061275 PMCID: PMC11273536 DOI: 10.3390/antibiotics13070593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/22/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
The treatment of infectious diseases typically includes the administration of anti-infectives; however, the increasing rates of antimicrobial resistance (AMR) have led to attempts to develop other modalities, such as antimicrobial peptides, nanotechnology, bacteriophages, and natural products. Natural products offer a viable alternative due to their potential affordability, ease of access, and diverse biological activities. Flavonoids, a class of natural polyphenols, demonstrate broad anti-infective properties against viruses, bacteria, fungi, and parasites. Their mechanisms of action include disruption of microbial membranes, inhibition of nucleic acid synthesis, and interference with bacterial enzymes. This review explores the potential of natural compounds, such as flavonoids, as an alternative therapeutic approach to combat infectious diseases. Moreover, it discusses some commonly used natural products, such as cranberry and D-mannose, to manage urinary tract infections (UTIs). Cranberry products and D-mannose both, yet differently, inhibit the adhesion of uropathogenic bacteria to the urothelium, thus reducing the likelihood of UTI occurrence. Some studies, with methodological limitations and small patient samples, provide some encouraging results suggesting the use of these substances in the prevention of recurrent UTIs. While further research is needed to determine optimal dosages, bioavailability, and potential side effects, natural compounds hold promise as a complementary or alternative therapeutic strategy in the fight against infectious diseases.
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Affiliation(s)
- Petros Ioannou
- School of Medicine, University of Crete, 71003 Heraklion, Greece
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Hayward G, Mort S, Hay AD, Moore M, Thomas NPB, Cook J, Robinson J, Williams N, Maeder N, Edeson R, Franssen M, Grabey J, Glogowska M, Yang Y, Allen J, Butler CC. d-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:619-628. [PMID: 38587819 PMCID: PMC11002776 DOI: 10.1001/jamainternmed.2024.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/12/2023] [Indexed: 04/09/2024]
Abstract
Importance Recurrent urinary tract infection (UTI) is a common debilitating condition in women, with limited prophylactic options. d-Mannose has shown promise in trials based in secondary care, but effectiveness in placebo-controlled studies and community settings has not been established. Objective To determine whether d-mannose taken for 6 months reduces the proportion of women with recurrent UTI experiencing a medically attended UTI. Design, Setting, and Participants This 2-group, double-blind randomized placebo-controlled trial took place across 99 primary care centers in the UK. Participants were recruited between March 28, 2019, and January 31, 2020, with 6 months of follow-up. Participants were female, 18 years or older, living in the community, and had evidence in their primary care record of consultations for at least 2 UTIs in the preceding 6 months or 3 UTIs in 12 months. Invitation to participate was made by their primary care center. A total of 7591 participants were approached, 830 responded, and 232 were ineligible or did not proceed to randomization. Statistical analysis was reported in December 2022. Intervention Two grams daily of d-mannose powder or matched volume of placebo powder. Main Outcomes and Measures The primary outcome measure was the proportion of women experiencing at least 1 further episode of clinically suspected UTI for which they contacted ambulatory care within 6 months of study entry. Secondary outcomes included symptom duration, antibiotic use, time to next medically attended UTI, number of suspected UTIs, and UTI-related hospital admissions. Results Of 598 women eligible (mean [range] age, 58 [18-93] years), 303 were randomized to d-mannose (50.7%) and 295 to placebo (49.3%). Primary outcome data were available for 583 participants (97.5%). The proportion contacting ambulatory care with a clinically suspected UTI was 150 of 294 (51.0%) in the d-mannose group and 161 of 289 (55.7%) in the placebo group (risk difference, -5%; 95% CI, -13% to 3%; P = .26). Estimates were similar in per protocol analyses, imputation analyses, and preplanned subgroups. There were no statistically significant differences in any secondary outcome measures. Conclusions and Relevance In this randomized clinical trial, daily d-mannose did not reduce the proportion of women with recurrent UTI in primary care who experienced a subsequent clinically suspected UTI. d-Mannose should not be recommended for prophylaxis in this patient group. Trial Registration isrctn.org Identifier: ISRCTN13283516.
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Affiliation(s)
- Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Sam Mort
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, England, United Kingdom
| | - Michael Moore
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, England, United Kingdom
| | - Nicholas P. B. Thomas
- Windrush Medical Practice, Witney, England, United Kingdom
- NIHR Clinical Research Network Thames Valley and South Midlands, Oxford, England, United Kingdom
| | - Johanna Cook
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Jared Robinson
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Nicola Williams
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Nicola Maeder
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Rebecca Edeson
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Marloes Franssen
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, England, United Kingdom
| | - Jenna Grabey
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England, United Kingdom
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Scaglione F, Minghetti P, Ambrosio F, Ernst B, Ficarra V, Gobbi M, Naber K, Schellekens H. Nature of the Interaction of Alpha-D-Mannose and Escherichia coli Bacteria, and Implications for its Regulatory Classification. A Delphi Panel European Consensus Based on Chemistry and Legal Evidence. Ther Innov Regul Sci 2023; 57:1153-1166. [PMID: 37578736 PMCID: PMC10579141 DOI: 10.1007/s43441-023-00548-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/05/2023] [Indexed: 08/15/2023]
Abstract
The nature of alpha-D-mannose-natural aldohexose sugar, C-2 glucose epimer, whose intended use is for preventing urinary tract infections-in the interaction with E. coli is addressed in order to drive the issue of its regulatory classification as a medicinal product or medical device. PRISMA systematic review approach was applied; Delphi Panel method was used to target consensus on statements retrieved from evidence. Based on regulatory definitions and research evidence, the mechanism of D-mannose does not involve a metabolic or immunological action while there is uncertainty regarding the pharmacological action. Specific interaction between the product and the bacteria within the body occurs, but its nature is inert: it does not induce a direct response activating or inhibiting body processes. Moreover, the action of D-mannose takes place, even if inside the bladder, outside the epithelium on bacteria that have not yet invaded the urothelial tissue. Therefore, its mechanism of action is not directed to host structures but to structures (bacteria) external to the host's tissues. On the basis of current regulation, the uncertainty as regard a pharmacological action of alpha-D-mannose makes possible its medical device classification: new regulations and legal judgments can add further considerations. From a pharmacological perspective, research is driven versus synthetic mannosides: no further considerations are expected on alpha-D-mannose.
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Affiliation(s)
- Francesco Scaglione
- Clinical Pharmacology and Toxicology Unit -GOM Niguarda, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Paola Minghetti
- Department of Pharmaceutical Sciences, University of Milan, Via Mangiagalli 25, 20133 Milan, Italy
| | | | - Beat Ernst
- Group Molecular Pharmacy Pharmacenter, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland
| | - Vincenzo Ficarra
- Department of Human and Pediatric Pathology “Gaetano Barresi”, Urologic Section, University of Messina, Piazza Pugliatti, 1, Messina, Italy
| | - Marco Gobbi
- Laboratory of Pharmacodynamics and Pharmacokinetics, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156 Milan, MI Italy
| | - Kurt Naber
- Department of Urology, Technical University of Munich, Munich, Germany
- Department of Urology, Technical University of Munich, Karl-Bickleder Str. 44C, 94315 Straubing, Germany
| | - Huub Schellekens
- Faculty of Sciences, Utrecht University, PO Box 80125, 3508 TC Utrecht, The Netherlands
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Dhanalakshmi M, Sruthi D, Jinuraj KR, Das K, Dave S, Andal NM, Das J. Mannose: a potential saccharide candidate in disease management. Med Chem Res 2023; 32:391-408. [PMID: 36694836 PMCID: PMC9852811 DOI: 10.1007/s00044-023-03015-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023]
Abstract
There are a plethora of antibiotic resistance cases and humans are marching towards another big survival test of evolution along with drastic climate change and infectious diseases. Ever since the first antibiotic [penicillin], and the myriad of vaccines, we were privileged to escape many infectious disease threats. The survival technique of pathogens seems rapidly changing and sometimes mimicking our own systems in such a perfect manner that we are left unarmed against them. Apart from searching for natural alternatives, repurposing existing drugs more effectively is becoming a familiar approach to new therapeutic opportunities. The ingenious use of revolutionary artificial intelligence-enabled drug discovery techniques is coping with the speed of such alterations. D-Mannose is a great hope as a nutraceutical in drug discovery, against CDG, diabetes, obesity, lung disease, and autoimmune diseases and recent findings of anti-tumor activity make it interesting along with its role in drug delivery enhancing techniques. A very unique work done in the present investigation is the collection of data from the ChEMBL database and presenting the targetable proteins on pathogens as well as on humans. It shows Mannose has 50 targets and the majority of them are on human beings. The structure and conformation of certain monosaccharides have a decisive role in receptor pathogen interactions and here we attempt to review the multifaceted roles of Mannose sugar, its targets associated with different diseases, as a natural molecule having many success stories as a drug and future hope for disease management. Graphical abstract
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Affiliation(s)
- M. Dhanalakshmi
- Research and Development Centre, Bharathiar University, Coimbatore, 641046 Tamil Nadu India
| | - D. Sruthi
- Department of Biochemistry, Indian Institute of Science, Bengaluru, 560012 India
| | - K. R. Jinuraj
- OSPF-NIAS Drug Discovery Lab, NIAS, IISc Campus, Bengaluru, 560012 India
| | - Kajari Das
- Department of Biotechnology, College of Basic Science and Humanities, Odisha University of Agriculture and Technology, Bhubaneswar-3, Odisha India
| | - Sushma Dave
- Department of Applied Sciences, JIET, Jodhpur, Rajasthan India
| | - N. Muthulakshmi Andal
- Department of Chemistry, PSGR Krishnammal College for Women, Coimbatore, 641004 Tamil Nadu India
| | - Jayashankar Das
- Valnizen Healthcare, Vile Parle West, Mumbai, 400056 Maharashtra India
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7
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Fan E, Dashti M, Fuentes J, Reitzer L, Christie AL, Zimmern PE. d-mannosuria levels measured 1 h after d-mannose intake can select out favorable responders: A pilot study. Neurourol Urodyn 2023; 42:49-55. [PMID: 36183388 DOI: 10.1002/nau.25059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND d-mannose is used as preventive measure against recurrent urinary tract infections (RUTIs). We studied d-mannosuria after a challenge test to identify favorable responders that could be targeted for long-term preventive therapy. MATERIAL AND METHODS Following institutional review board approval, women attending a specialized tertiary care center urology clinic with a history of RUTIs were invited to participate by providing a urine sample (baseline), followed by the intake of home-dose d-mannose, and a second urine sample 1 h later (post). Urine samples were processed according to a d-mannosuria assay technique reported previously by our group. d-mannose concentrations were normalized to urinary creatinine. RESULTS From July 2020 to March 2021, 26 patients met study criteria. Thirteen had a lower or unchanged ratio of baseline to post d-mannose, whereas 13 were responders. Among 19 taking 2 g, 12 had a lower or unchanged trend and 7 were responders with >20% increase in the d-mannose/creatinine ratio. Comparison of urinary baseline d-mannose/creatinine ratios was significantly different between the responder (mean = 0.337 ± 0.158) and nonresponder (mean = 0.692 ± 0.444; p = 0.016) groups. Urinary post d-mannose/creatinine ratios did not significantly differ between the two groups (p = 0.46). d-mannose-naïve patients had few responders, and age and urinary creatinine did not affect the findings. CONCLUSION This preliminary study on d-mannose challenge tests indicates a urine response if urinary d-mannose/creatinine ratio is low, which it was in some women with a history of RUTIs.
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Affiliation(s)
- Ethan Fan
- Department of Urology, University of Texas Southwestern Medical Centerm, Dallas, Texas, USA
| | - Marjan Dashti
- Department of Biology, The University of Texas at Dallas, Richardson, Texas, USA
| | - Jorge Fuentes
- Department of Urology, University of Texas Southwestern Medical Centerm, Dallas, Texas, USA
| | - Larry Reitzer
- Department of Biology, The University of Texas at Dallas, Richardson, Texas, USA
| | - Alana L Christie
- Simmons Comprehensive Cancer Center Biostatistics Southwestern Medical Center, University of Texas, Dallas, Texas, USA
| | - Philippe E Zimmern
- Department of Urology, University of Texas Southwestern Medical Centerm, Dallas, Texas, USA
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The Clinical Trial Outcomes of Cranberry, D-Mannose and NSAIDs in the Prevention or Management of Uncomplicated Urinary Tract Infections in Women: A Systematic Review. Pathogens 2022; 11:pathogens11121471. [PMID: 36558804 PMCID: PMC9788503 DOI: 10.3390/pathogens11121471] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/09/2022] Open
Abstract
The use of antibiotics in the treatment of UTIs is contributing to resistance. Hence, the outcome of human clinical trials of nonantibiotic remedies for preventing or treating UTI is of significant interest. This systematic review aimed to identify, summarise and evaluate the evidence for the outcomes of different nonantibiotic options including cranberry, D-mannose and non-steroidal anti-inflammatory drugs (NSAIDs). PubMed, Embase and Scopus were searched for manuscripts relating to nonantibiotic treatment of UTI including cranberry, mannose and NSAIDs. After title and abstract screening, data were extracted from 21 papers that were published in English and related to the treatment or prevention of uncomplicated UTI in adult women. We identified twelve papers examining the effects of cranberry, two papers examining D-mannose, two papers examining combination treatments (cranberry and D-mannose) and five manuscripts investigating the effects of NSAIDs. There is low-level evidence, from a small number of studies, supporting the use of D-mannose or combination treatments for potentially preventing UTIs in adult women without producing burdening side effects. However, larger and more randomised double-blinded trials are needed to confirm this. In comparison, the multiple studies of cranberry and NSAIDs produced conflicting evidence regarding their effectiveness.
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Butler D, Ambite I, Wan MLY, Tran TH, Wullt B, Svanborg C. Immunomodulation therapy offers new molecular strategies to treat UTI. Nat Rev Urol 2022; 19:419-437. [PMID: 35732832 PMCID: PMC9214477 DOI: 10.1038/s41585-022-00602-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/13/2022]
Abstract
Innovative solutions are needed for the treatment of bacterial infections, and a range of antibacterial molecules have been explored as alternatives to antibiotics. A different approach is to investigate the immune system of the host for new ways of making the antibacterial defence more efficient. However, the immune system has a dual role as protector and cause of disease: in addition to being protective, increasing evidence shows that innate immune responses can become excessive and cause acute symptoms and tissue pathology during infection. This role of innate immunity in disease suggests that the immune system should be targeted therapeutically, to inhibit over-reactivity. The ultimate goal is to develop therapies that selectively attenuate destructive immune response cascades, while augmenting the protective antimicrobial defence but such treatment options have remained underexplored, owing to the molecular proximity of the protective and destructive effects of the immune response. The concept of innate immunomodulation therapy has been developed successfully in urinary tract infections, based on detailed studies of innate immune activation and disease pathogenesis. Effective, disease-specific, immunomodulatory strategies have been developed by targeting specific immune response regulators including key transcription factors. In acute pyelonephritis, targeting interferon regulatory factor 7 using small interfering RNA or treatment with antimicrobial peptide cathelicidin was protective and, in acute cystitis, targeting overactive effector molecules such as IL-1β, MMP7, COX2, cAMP and the pain-sensing receptor NK1R has been successful in vivo. Furthermore, other UTI treatment strategies, such as inhibiting bacterial adhesion and vaccination, have also shown promise. Hyperactivation of innate immunity is a disease determinant in urinary tract infections (UTIs). Modulation of innate immunity has promise as a therapy for UTIs. In this Review, the authors discuss potential mechanisms and immunomodulatory therapeutic strategies in UTIs. Excessive innate immune responses to infection cause symptoms and pathology in acute pyelonephritis and acute cystitis. Innate immunomodulation therapy is, therefore, a realistic option for treating these conditions. Targeting excessive innate immune responses at the level of transcription has been successful in animal models. Innate immunomodulation therapy reduces excessive inflammation and tissue pathology and accelerates bacterial clearance from infected kidneys and bladders in mice. Innate immunomodulation therapy also accelerates the clearance of antibiotic-resistant bacterial strains.
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Affiliation(s)
- Daniel Butler
- Department of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - Ines Ambite
- Department of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - Murphy Lam Yim Wan
- Department of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - Thi Hien Tran
- Department of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - Björn Wullt
- Department of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - Catharina Svanborg
- Department of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden.
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Non-antibiotic Approaches to Preventing Pediatric UTIs: a Role for D-Mannose, Cranberry, and Probiotics? Curr Urol Rep 2022; 23:113-127. [PMID: 35441976 DOI: 10.1007/s11934-022-01094-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW While antibiotics have been a staple in the management and even prevention of urinary tract infections (UTIs), it is not without significant consequences due to intolerance and development of antibiotic resistant bacteria. These concerns necessitate alternatives to antibiotic use in the management of pediatric UTIs. This review seeks to evaluate non-antibiotic means of preventing UTI in the pediatric population. RECENT FINDINGS The search for preventative alternatives to antibiotics has included D-mannose, cranberry, and probiotics. These products similarly work through competitive inhibition of uropathogens in the urinary tract. Pediatric studies exist highlighting the use of cranberry extract/juice and probiotics in UTI prevention, although significant heterogeneity amongst studies have limited overarching recommendations for their use. Data of D-mannose use is extrapolated from adult literature. More studies are required in the utility of each treatment, with some emphasis on larger sample sizes and clarifications regarding dosing and formulation.
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Ala-Jaakkola R, Laitila A, Ouwehand AC, Lehtoranta L. Role of D-mannose in urinary tract infections - a narrative review. Nutr J 2022; 21:18. [PMID: 35313893 PMCID: PMC8939087 DOI: 10.1186/s12937-022-00769-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 12/27/2022] Open
Abstract
Urinary tract infections (UTIs) are one of the most prevalent bacterial diseases worldwide. Despite the efficacy of antibiotics targeted against UTI, the recurrence rates remain significant among the patients. Furthermore, the development of antibiotic resistance is a major concern and creates a demand for alternative treatment options. D-mannose, a monosaccharide naturally found in fruits, is commonly marketed as a dietary supplement for reducing the risk for UTIs. Research suggests that supplemented D-mannose could be a promising alternative or complementary remedy especially as a prophylaxis for recurrent UTIs. When excreted in urine, D-mannose potentially inhibits Escherichia coli, the main causative organism of UTIs, from attaching to urothelium and causing infection. In this review, we provide an overview of UTIs, E. coli pathogenesis and D-mannose and outline the existing clinical evidence of D-mannose in reducing the risk of UTI and its recurrence. Furthermore, we discuss the potential effect mechanisms of D-mannose against uropathogenic E.coli.
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Affiliation(s)
- Reeta Ala-Jaakkola
- Health & Biosciences, International Flavors & Fragrances, Sokeritehtaantie 20, FIN-02460, Kantvik, Finland
| | - Arja Laitila
- Health & Biosciences, International Flavors & Fragrances, Sokeritehtaantie 20, FIN-02460, Kantvik, Finland
| | - Arthur C Ouwehand
- Health & Biosciences, International Flavors & Fragrances, Sokeritehtaantie 20, FIN-02460, Kantvik, Finland.
| | - Liisa Lehtoranta
- Health & Biosciences, International Flavors & Fragrances, Sokeritehtaantie 20, FIN-02460, Kantvik, Finland
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Hwang D, Boehm A, Rostami A, Zhang GX, Ciric B. Oral D-mannose treatment suppresses experimental autoimmune encephalomyelitis via induction of regulatory T cells. J Neuroimmunol 2022; 362:577778. [PMID: 34814011 PMCID: PMC8724449 DOI: 10.1016/j.jneuroim.2021.577778] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 01/17/2023]
Abstract
D-mannose (D-m) is a glucose epimer found in natural products, especially fruits. In mouse models of diabetes and airway inflammation, D-m supplementation via drinking water attenuated pathology by modifying cellular energy metabolism, leading to the activation of latent transforming growth factor beta (TGF-β), which in turn induced T regulatory cells (Tregs). Given that Tregs are important in controlling neuroinflammation in experimental autoimmune encephalomyelitis (EAE) and likely in multiple sclerosis (MS), we hypothesized that D-m could also suppress EAE. We found that D-m delayed disease onset and reduced disease severity in two models of EAE. Importantly, D-m treatment prevented relapses in a relapsing-remitting model of EAE, which mimics the most common clinical manifestation of MS. EAE suppression was accompanied by increased frequency of CD4+FoxP3+ Tregs in the central nervous system, suggesting that EAE suppression resulted from Treg cell induction by D-m. These findings suggest that D-m has the potential to be a safe and low-cost complementary therapy for MS.
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Affiliation(s)
- Daniel Hwang
- Department of Neurology, Jefferson Hospital for Neuroscience, Thomas Jefferson University, Philadelphia, PA
| | - Alexandra Boehm
- Department of Neurology, Jefferson Hospital for Neuroscience, Thomas Jefferson University, Philadelphia, PA
| | - Abdolmohamad Rostami
- Department of Neurology, Jefferson Hospital for Neuroscience, Thomas Jefferson University, Philadelphia, PA
| | - Guang-Xian Zhang
- Department of Neurology, Jefferson Hospital for Neuroscience, Thomas Jefferson University, Philadelphia, PA
| | - Bogoljub Ciric
- Department of Neurology, Jefferson Hospital for Neuroscience, Thomas Jefferson University, Philadelphia, PA.,Corresponding author at: Department of Neurology, Jefferson Hospital for Neuroscience, Thomas Jefferson University, 900 Walnut Street, Suite 300, Philadelphia, PA, 19107.
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13
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Zhang W, Cheng H, Gui Y, Zhan Q, Li S, Qiao W, Tong A. Mannose Treatment: A Promising Novel Strategy to Suppress Inflammation. Front Immunol 2021; 12:756920. [PMID: 34646279 PMCID: PMC8502929 DOI: 10.3389/fimmu.2021.756920] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/09/2021] [Indexed: 02/05/2023] Open
Abstract
High glucose and fructose intake have been proven to display pro-inflammatory roles during the progression of inflammatory diseases. However, mannose has been shown to be a special type of hexose that has immune regulatory functions. In this review, we trace the discovery process of the regulatory functions of mannose and summarize some past and recent studies showing the therapeutic functions of mannose in inflammatory diseases. We conclude that treatment with mannose can suppress inflammation by inducing regulatory T cells, suppressing effector T cells and inflammatory macrophages, and increasing anti-inflammatory gut microbiome. By summarizing all the important findings, we highlight that mannose treatment is a safe and promising novel strategy to suppress inflammatory diseases, including autoimmune disease and allergic disease.
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Affiliation(s)
- Wei Zhang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Cheng
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanyuan Gui
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qipeng Zhan
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Si Li
- Discovery Project Unit, HitGen Inc. Tianfu International Bio-Town, Chengdu, China
| | - Wenliang Qiao
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Aiping Tong
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Marei MM, Jackson R, Keene DJB. Intravesical gentamicin instillation for the treatment and prevention of urinary tract infections in complex paediatric urology patients: evidence for safety and efficacy. J Pediatr Urol 2021; 17:65.e1-65.e11. [PMID: 33309610 DOI: 10.1016/j.jpurol.2020.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 06/29/2020] [Accepted: 08/12/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Little has been reported to date on the instillation of antimicrobials directly into the bladder in children. Children with complex urinary tract anomalies struggle frequently with recurrent urinary tract infections (UTI), with frequent emergence of antibiotic resistance. Gentamicin bladder instillation to treat and prevent UTI was described in children since 2006. OBJECTIVE We adopted gentamicin bladder instillation in 2016 and evaluate herein our intermediate-term experience with it. STUDY DESIGN AND METHODS This study is a retrospective review of a prospectively initiated database and a clinical audit of our practice. The gentamicin bladder instillation was employed in 24 cases. A treatment regime was initiated for symptomatic documented UTI when resistance patterns precluded an oral alternative (14 cases), avoiding hospitalisation for parenteral antibiotics. A prophylaxis regime (19 cases-including 9 of the 14 who received an initial treatment regime) followed at least one breakthrough UTI while receiving oral prophylactic antibiotics. Two instillation volumes (8 mg gentamicin in 20 mL 0.9% NaCl or 20 mg gentamicin in 50 mL 0.9% NaCl) were used to suit different bladder capacities. The irrigation is given twice a day for 7 days in the treatment regime or once a day, every other day, in the prophylactic regime. Gentamicin serum levels (all cases) and audiology/audiometry testing (17/24 cases) were checked to assess the safety of this method. RESULTS The median age when either the treatment course or prophylaxis regime was started was 3.8 years. The treatment regime was 86% successful (12/14) to suppress an acute UTI. The mean duration of prophylaxis was 252 days (median: 256 days). The percentage of patients on the prophylactic regime who had no breakthrough UTI was 58%. No serum gentamicin was detectable secondary to the intravesical instillation. No attributable cases of sensorineural hearing loss were detected. Gentamicin resistance emerged in one case (4.16%). DISCUSSION Intravesical administration was feasible via various routes for a spectrum of complex lower urinary tract abnormalities (see Summary Figure). Concerns regarding systemic absorption, nephrotoxicity or ototoxicity were investigated and safety ensured. Limitations include being a small series of non-identical pathologies, albeit categorically similar and being a single-arm study, however, statistical significance was proven descriptively and analytically. CONCLUSION In selected cases and with the appropriate specialist support and logistics, intravesical gentamicin instillation is well-tolerated and safe to treat and/or prevent urinary tract infections in pateints with complex bladder conditions and lower urinary tract pathologies.
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Affiliation(s)
- Mahmoud Marei Marei
- Department of Paediatric Urology and Bladder Exstrophy, The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Cairo University, Faculty of Medicine (Kasr Alainy), Department of Paediatric Surgery, Cairo University Children's Hospitals, Cairo, Egypt.
| | - Raef Jackson
- Department of Paediatric Urology and Bladder Exstrophy, The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
| | - David J B Keene
- Department of Paediatric Urology and Bladder Exstrophy, The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
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15
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Franssen M, Cook J, Robinson J, Williams N, Glogowska M, Yang Y, Allen J, Butler CC, Thomas N, Hay A, Moore M, Hayward G. D-MannosE to prevent Recurrent urinary tract InfecTions (MERIT): protocol for a randomised controlled trial. BMJ Open 2021; 11:e037128. [PMID: 33441350 PMCID: PMC7812098 DOI: 10.1136/bmjopen-2020-037128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 11/06/2020] [Accepted: 11/26/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Recurrent urinary tract infections (RUTIs) have a significant negative impact on quality of life and healthcare costs. To date, daily prophylactic antibiotics are the only treatment which have been shown to help prevent RUTIs. D-mannose is a type of sugar which is believed to inhibit bacterial adherence to uroepithelial cells, and is already being used by some women in an attempt to prevent RUTIs. There is currently insufficient rigorous evidence on which to base decisions about its use. The D-mannose to prevent recurrent urinary tract infections (MERIT) study will evaluate whether D-mannose is clinically and cost-effective in reducing frequency of infection and symptom burden for women presenting to UK primary care with RUTI. METHODS AND ANALYSIS MERIT will be a two-arm, individually randomised, double blind placebo controlled, pragmatic trial. Participants will be randomised to take D-mannose powder or placebo powder daily for 6 months. The primary outcome will be the number of medical attendances attributable to symptoms of RUTI. With 508 participants we will have 90% power to detect a 50% reduction in the chance of a further clinically suspected UTI, assuming 20% lost to follow-up. Secondary outcomes will include: number of days of moderately bad symptoms of UTI; time to next consultation; number of clinically suspected UTIs; number of microbiologically proven UTIs; number of antibiotic courses for UTI; quality of life and healthcare utilisation related to UTI. A within trial economic evaluation will be conducted to examine cost-effectiveness of D-mannose in comparison with placebo. A nested qualitative study will explore participants' experiences and perceptions of recruitment to, and participation in a study requiring a daily treatment. ETHICS AND DISSEMINATION Ethical approval has been obtained from South West-Central Bristol Research Ethics Committee. Publication of the MERIT study is anticipated to occur in 2021. TRIAL REGISTRATION NUMBER ISRCTN 13283516.
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Affiliation(s)
- Marloes Franssen
- Nuffield Department of Orthopaedics, Rheumathology and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Johanna Cook
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Jared Robinson
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Nicola Williams
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Nick Thomas
- Windrush Medical Practice, Witney, Oxfordshire, UK
| | - Alastair Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, Bristol, UK
| | - Michael Moore
- Primary Care Medical Group, University of Southampton, Southampton, Hampshire, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
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Sihra N, Malde S, Greenwell T, Pakzad M, Kujawa M, Sinclair A. Management of recurrent urinary tract infections in women. JOURNAL OF CLINICAL UROLOGY 2020. [DOI: 10.1177/2051415820939456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Urinary tract infections are highly prevalent and result in significant patient morbidity as well as large financial costs to healthcare systems. Recurrent urinary tract infections can be challenging for many healthcare professionals, and the repeated use of antibiotics in this patient cohort inevitably contributes to the growing issue of antimicrobial resistance and superbugs. It is essential that these patients are appropriately diagnosed and managed to ensure rapid resolution of symptoms and the prevention of chronic or recurrent urinary tract infections. There are several antibiotic-based options available for the prophylaxis of recurrent urinary tract infections however, in the current era of rising antimicrobial resistance, an awareness of antibiotic stewardship and the use of non-antibiotic alternatives for the treatment and prevention of urinary tract infections is of critical importance. We present a case-based multidisciplinary team discussion to highlight how women with recurrent urinary tract infections should be managed, encouraging the use of non-antibiotic prophylactic measures when suitable. Level of evidence: Level 5
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17
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Yu D, Wang Y, Yu C, Song M, Zhou Q, Liu S. High-throughput serum metabolomics analysis of gouty arthritis rat treated by total saponins of Rhizoma Dioscoreae Makino by UPLC-Q/TOF-MS. Biomed Chromatogr 2020; 34:e4867. [PMID: 32330320 DOI: 10.1002/bmc.4867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 04/04/2020] [Accepted: 04/20/2020] [Indexed: 12/27/2022]
Abstract
Rhizoma Dioscoreae Makino (RDM) is effective in treating gouty arthritis (GA) and hyperuricacidemia, especially in promoting uric acid excretion and reducing the inflammatory reaction. Bioactive constituents in RDM are mainly steroidal saponins such as dioscin, trillin, protodioscin and protogracillin. However, the mechanism of its anti-GA action is still unclear, owing to the complex pathological and physiological characteristics of GA, and integration of RDM with multiple components, multiple targets and multiple pathways. Herein, a GA rat model was induced with monosodium urate (MSU), and RDM reduced inflammation of rat synovium tissue. Through metabolomics analysis, 35 potential biomarkers with significant changes involved in the pathogenesis of GA induced by MSU were identified, and perturbations were restored after RDM treatment. The most correlated pathways involved in d-galactose, d-mannose, d-glucose, myoinositol, Phosphatidylcholine (PC) (16:0/16:0), LysoPC (15:0), phosphatidic acid (PA) [18:1(9Z)/18:1(11Z)] and glutathione induced by MSU were galactose metabolism, inositol phosphate metabolism, glycerophospholipid metabolism and glutathione metabolism, and the derivations of all those biomarkers could be regulated by RDM treatment. RDM has a therapeutic effect on GA by intervening in changes in endogenous metabolisms and the related metabolic pathways.
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Affiliation(s)
- Donghua Yu
- Institute of Traditional Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Yu Wang
- Institute of Traditional Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Chunmiao Yu
- College of Pharmacy, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Mingyang Song
- Institute of Traditional Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Qi Zhou
- Institute of Traditional Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Shumin Liu
- Institute of Traditional Chinese Medicine, Heilongjiang University of Chinese Medicine, Harbin, China
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Scribano D, Sarshar M, Prezioso C, Lucarelli M, Angeloni A, Zagaglia C, Palamara AT, Ambrosi C. d-Mannose Treatment neither Affects Uropathogenic Escherichia coli Properties nor Induces Stable FimH Modifications. Molecules 2020; 25:E316. [PMID: 31941080 PMCID: PMC7024335 DOI: 10.3390/molecules25020316] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 11/17/2022] Open
Abstract
Urinary tract infections (UTIs) are mainly caused by uropathogenic Escherichia coli (UPEC). Acute and recurrent UTIs are commonly treated with antibiotics, the efficacy of which is limited by the emergence of antibiotic resistant strains. The natural sugar d-mannose is considered as an alternative to antibiotics due to its ability to mask the bacterial adhesin FimH, thereby preventing its binding to urothelial cells. Despite its extensive use, the possibility that d-mannose exerts "antibiotic-like" activity by altering bacterial growth and metabolism or selecting FimH variants has not been investigated yet. To this aim, main bacterial features of the prototype UPEC strain CFT073 treated with d-mannose were analyzed by standard microbiological methods. FimH functionality was analyzed by yeast agglutination and human bladder cell adhesion assays. Our results indicate that high d-mannose concentrations have no effect on bacterial growth and do not interfere with the activity of different antibiotics. d-mannose ranked as the least preferred carbon source to support bacterial metabolism and growth, in comparison with d-glucose, d-fructose, and l-arabinose. Since small glucose amounts are physiologically detectable in urine, we can conclude that the presence of d-mannose is irrelevant for bacterial metabolism. Moreover, d-mannose removal after long-term exposure did not alter FimH's capacity to bind to mannosylated proteins. Overall, our data indicate that d-mannose is a good alternative in the prevention and treatment of UPEC-related UTIs.
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Affiliation(s)
- Daniela Scribano
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (D.S.); (C.P.); (C.Z.)
- Dani Di Giò Foundation-Onlus, 00193 Rome, Italy
| | - Meysam Sarshar
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Laboratory Affiliated to Institute Pasteur Italia-Cenci Bolognetti Foundation, 00185 Rome, Italy; (M.S.); (A.T.P.)
- Microbiology Research Center (MRC), Pasteur Institute of Iran, Tehran 1316943551, Iran
| | - Carla Prezioso
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (D.S.); (C.P.); (C.Z.)
| | - Marco Lucarelli
- Department of Experimental Medicine, Sapienza University of Rome, 00185 Rome, Italy; (M.L.); (A.A.)
- Pasteur Institute Cenci Bolognetti Foundation, 00161 Rome, Italy
| | - Antonio Angeloni
- Department of Experimental Medicine, Sapienza University of Rome, 00185 Rome, Italy; (M.L.); (A.A.)
| | - Carlo Zagaglia
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (D.S.); (C.P.); (C.Z.)
| | - Anna Teresa Palamara
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Laboratory Affiliated to Institute Pasteur Italia-Cenci Bolognetti Foundation, 00185 Rome, Italy; (M.S.); (A.T.P.)
- IRCCS San Raffaele Pisana, Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, 00166 Rome, Italy
| | - Cecilia Ambrosi
- IRCCS San Raffaele Pisana, Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, 00166 Rome, Italy
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Yang B, Blick C, Foley S. Avoiding antibiotics in the management of recurrent UTIs in women: What are our options? JOURNAL OF CLINICAL UROLOGY 2020. [DOI: 10.1177/2051415819854912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Urinary tract infections are one of the most common infections worldwide, accounting in the United Kingdom for 1–3% of all medical consultations. Fifty per cent of women will experience one episode of urinary tract infection in their lifetimes and of these, up to 30% will develop recurrent urinary tract infections. Such women often rely on long-term low dose antibiotics. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
- Bob Yang
- Department of Urology, Royal Berkshire Hospital, UK
| | | | - Steve Foley
- Department of Urology, Royal Berkshire Hospital, UK
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20
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Abstract
Urinary tract infections (UTIs) are highly prevalent, lead to considerable patient morbidity, incur large financial costs to health-care systems and are one of the most common reasons for antibiotic use worldwide. The growing problem of antimicrobial resistance means that the search for nonantibiotic alternatives for the treatment and prevention of UTI is of critical importance. Potential nonantibiotic measures and treatments for UTIs include behavioural changes, dietary supplementation (such as Chinese herbal medicines and cranberry products), NSAIDs, probiotics, D-mannose, methenamine hippurate, estrogens, intravesical glycosaminoglycans, immunostimulants, vaccines and inoculation with less-pathogenic bacteria. Some of the results of trials of these approaches are promising; however, high-level evidence is required before firm recommendations for their use can be made. A combination of these agents might provide the optimal treatment to reduce recurrent UTI, and trials in specific population groups are required.
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Genovese C, Davinelli S, Mangano K, Tempera G, Nicolosi D, Corsello S, Vergalito F, Tartaglia E, Scapagnini G, Di Marco R. Effects of a new combination of plant extracts plus d-mannose for the management of uncomplicated recurrent urinary tract infections. J Chemother 2017; 30:107-114. [PMID: 29078739 DOI: 10.1080/1120009x.2017.1393587] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Urinary tract infections (UTIs) are an economic burden for public health. The increasing prevalence of resistant bacteria which cause UTIs may be related to the inappropriate prescription of antibiotics. The aim of this preliminary study was to evaluate whether three different combinations of plant extracts plus d-mannose are effective in preventing the recurrence of UTIs. Three groups of patients received three combinations of plant extracts in conjunction with d-mannose. These were: berberine, arbutin and birch (group A); berberine, arbutin, birch and forskolin (group B); and proanthocyanidins (group C). The clinical recurrence of cystitis at the end of treatment and during follow-up was determined by comparison with baseline measurements using the microbiological assessment of urine samples, vaginal swabs and vaginal smear slides. Patients in groups A and B had a lower incidence of episodes of recurrent cystitis during treatment and follow-up, samples with a significantly lower median bacterial load and a reduction of the grade of lactobacillary flora compared to patients in group C.
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Affiliation(s)
- Carlo Genovese
- a Department of Biomedical and Biotechnological Sciences , University of Catania , Catania , Italy
| | - Sergio Davinelli
- b Department of Medicine and Health Sciences , University of Molise , Campobasso , Italy
| | - Katia Mangano
- a Department of Biomedical and Biotechnological Sciences , University of Catania , Catania , Italy
| | - Gianna Tempera
- a Department of Biomedical and Biotechnological Sciences , University of Catania , Catania , Italy
| | - Daria Nicolosi
- a Department of Biomedical and Biotechnological Sciences , University of Catania , Catania , Italy
| | - Salvatore Corsello
- c Obstetrics & Gynecology Division , "Castiglione Prestianni" Hospital , Bronte , Italy
| | - Franca Vergalito
- b Department of Medicine and Health Sciences , University of Molise , Campobasso , Italy
| | - Edoardo Tartaglia
- b Department of Medicine and Health Sciences , University of Molise , Campobasso , Italy
| | - Giovanni Scapagnini
- b Department of Medicine and Health Sciences , University of Molise , Campobasso , Italy
| | - Roberto Di Marco
- b Department of Medicine and Health Sciences , University of Molise , Campobasso , Italy
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D-mannose induces regulatory T cells and suppresses immunopathology. Nat Med 2017; 23:1036-1045. [DOI: 10.1038/nm.4375] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/19/2017] [Indexed: 12/11/2022]
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Phé V, Pakzad M, Haslam C, Gonzales G, Curtis C, Porter B, Chataway J, Panicker JN. Open label feasibility study evaluating D-mannose combined with home-based monitoring of suspected urinary tract infections in patients with multiple sclerosis. Neurourol Urodyn 2016; 36:1770-1775. [PMID: 27813195 DOI: 10.1002/nau.23173] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/14/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the feasibility of using D-mannose, a natural food supplement, in patients with multiple sclerosis (MS) reporting recurrent urinary tract infections (UTIs) as a preventative. METHODS A single-center, open-label, feasibility study enrolled patients with MS, using and not using urinary catheters, experiencing recurrent UTIs (≥3/year or ≥2/6 months). Participants were given D-mannose powder 1.5 grams twice daily for 16-weeks and were instructed to monitor suspected UTIs at home using urine dipsticks. Diaries were used to record compliance, number of prescriptions of antibiotics received for UTIs, results of urine dipsticks and cultures. RESULTS Overall, 22 patients with MS, median age 50 years (46-59) were enrolled: 10 were not using catheters and 12 were using catheters. The compliance rates for using D-mannose and dipsticks for testing suspected UTIs were 100% and 90.2%, respectively. Sixty-one episodes of suspected UTIs were recorded, 19/61 (31.1%) were confirmed UTIs and 29/61 (47.5%) prescriptions of antibiotics were made. The number of monthly proven UTIs decreased both in catheter users and non-users (P < 0.01). No adverse effects were reported. CONCLUSION Using D-mannose in patients with MS experiencing recurrent UTIs and self-monitoring for infections is feasible and safe. Further studies are required to establish efficacy. CinicalTrials.gov (identifier NCT02490046).
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Affiliation(s)
- Véronique Phé
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, United Kingdom.,Pitié-Salpêtrière Academic Hospital, Department of Urology, Assistance Publique-Hôpitaux de Paris, Pierre and Marie Curie Medical School, Paris 6 University, Paris, France
| | - Mahreen Pakzad
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, United Kingdom
| | - Collette Haslam
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, United Kingdom
| | - Gwen Gonzales
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, United Kingdom
| | - Carmel Curtis
- Department of Clinical Microbiology, University College London Hospital, London, United Kingdom
| | - Bernadette Porter
- Queen Square Multiple Sclerosis Centre, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, United Kingdom
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, United Kingdom
| | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, United Kingdom
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Cystoman® and calculi: a good alternative to standard therapies in preventing stone recurrence. Urolithiasis 2014; 42:285-90. [PMID: 24972556 DOI: 10.1007/s00240-014-0675-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 05/10/2014] [Indexed: 10/25/2022]
Abstract
To assess the efficacy and tolerability of D-mannose-containing product (Cystoman(®)) in preventing recurrence in patients who underwent surgical treatment for infection related urinary stones. From January 2011 to February 2013 we have enrolled all consecutive patients affected by staghorn calculi and recurrent urinary tract infections (UTIs). All patients recommended for surgery were scheduled for percutaneous nephrolithotomy. The study agent was administered daily for 5 months after surgical procedure. At baseline and 5-month follow-up all patients underwent abdominal Computed Tomography (CT) scan and they also completed Medical Outcomes Study short-form, 36-item questionnaire (SF-36). They performed urine and urine culture monthly. The primary endpoints were the assessment of the efficacy with regard to infection-related urinary stone recurrence and the tolerability of Cystoman(®). The secondary endpoint was the evaluation of quality-of-life symptoms. During the study period, a total of 27 patients were included in the study. The data from 25 patients were analyzable. Seventeen patients (68%) did not report UTIs during follow-up. Eight patients (32%) remained infected and the average number of UTIs was 2.6 ± 1.6 in 5 months. At 5-month follow-up 17 (68%) patients were free from stones recurrence; in 8 (32%) cases CT scan revealed stone recurrence with an average stone diameter of 1.1 ± 0.4 cm. In nonrecurring patients, 2 (11.7%) reported an average of 1.5 ± 0.7 UTIs episodes; in recurring patients, 6 (75%) showed 3 ± 1.67 of UTIs episodes. Statistically significant differences were seen in the occurrence of UTIs episodes were detected between nonrecurring stone patients and recurring patients (p < 0.05). Moreover, statistically significant changes were detected in SF-36 scores from baseline to month 5 in the categories of physical functioning and energy/fatigue (p < 0.05). Cystoman(®) is effective in preventing infection-related urinary stones.
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Porru D, Parmigiani A, Tinelli C, Barletta D, Choussos D, Di Franco C, Bobbi V, Bassi S, Miller O, Gardella B, Nappi RE, Spinillo A, Rovereto B. Oral D-mannose in recurrent urinary tract infections in women: a pilot study. JOURNAL OF CLINICAL UROLOGY 2014. [DOI: 10.1177/2051415813518332] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In recurrent urinary tract infections (UTIs) usual prophylactic antibiotic regimes do not change the long-term risk of recurrence. Our aim was to evaluate the efficacy of D-mannose in the treatment and prophylaxis of recurrent UTIs. Methods: In this randomized cross-over trial female patients were eligible for the study if they had an acute symptomatic UTI and three or more recurrent UTIs during the preceding 12 months. Suitable patients were randomly assigned to antibiotic treatment with trimethoprim/sulfamethoxazole or to a regimen of oral D-mannose 1 g 3 times a day, every 8 hours for 2 weeks, and subsequently 1 g twice a day for 22 weeks. They received the other intervention in the second phase of the study, with no further antibiotic prophylaxis. The primary endpoint was evaluation of the elapsed time to recurrence; secondary endpoints were evaluation of bladder pain (VASp) and urinary urgency (VASu). Results: The results for quantitative variables were expressed as mean values and SD as they were all normally distributed (Shapiro–Wilk test). In total, 60 patients aged between 22 and 54 years (mean 42 years) were included. Mean time to UTI recurrence was 52.7 days with antibiotic treatment, and 200 days with oral D-mannose ( p < 0.0001). Conclusions: Mean VASp, VASu score, and average numbers of 24-hour voidings decreased significantly. D-mannose appeared to be a safe and effective treatment for recurrent UTIs in adult women. A significant difference was observed in the proportion of women remaining infection free versus antibiotic treatment.
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Affiliation(s)
- D Porru
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A Parmigiani
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - C Tinelli
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - D Barletta
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - D Choussos
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - C Di Franco
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - V Bobbi
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - S Bassi
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - O Miller
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - B Gardella
- Obstetrics and Gynecologic Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - RE Nappi
- Obstetrics and Gynecologic Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A Spinillo
- Obstetrics and Gynecologic Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - B Rovereto
- Urology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Altarac S, Papeš D. Use of d-mannose in prophylaxis of recurrent urinary tract infections (UTIs) in women. BJU Int 2013; 113:9-10. [DOI: 10.1111/bju.12492] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Silvio Altarac
- Department of Surgery and Urology; Zabok General Hospital; Zabok Croatia
| | - Dino Papeš
- Department of Paediatric Surgery and Urology; Clinical Hospital Center Zagreb; Zagreb Croatia
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Hill TC, Baverstock R, Carlson KV, Estey EP, Gray GJ, Hill DC, Ho C, McGinnis RH, Moore K, Parmar R. Best practices for the treatment and prevention of urinary tract infection in the spinal cord injured population: The Alberta context. Can Urol Assoc J 2013; 7:122-30. [PMID: 23671527 DOI: 10.5489/cuaj.337] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this review of clinical guidelines and best practices literature is to suggest prevention options and a treatment approach for intermittent catheter users that will minimize urinary tract infections (UTI). Recommendations are based both on evidence in the literature and an understanding of what is currently attainable within the Alberta context. This is done through collaboration between both major tertiary care centres (Edmonton and Calgary) and between various professionals who regularly encounter these patients, including nurses, physiatrists and urologists.
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Kranjčec B, Papeš D, Altarac S. D-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial. World J Urol 2013; 32:79-84. [PMID: 23633128 DOI: 10.1007/s00345-013-1091-6] [Citation(s) in RCA: 212] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 04/20/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To test whether D-mannose powder is effective for recurrent urinary tract infection (UTI) prevention. MATERIALS AND METHODS After initial antibiotic treatment of acute cystitis, 308 women with history of recurrent UTI and no other significant comorbidities were randomly allocated to three groups. The first group (n = 103) received prophylaxis with 2 g of D-mannose powder in 200 ml of water daily for 6 months, the second (n = 103) received 50 mg Nitrofurantoin daily, and the third (n = 102) did not receive prophylaxis. RESULTS Overall 98 patients (31.8%) had recurrent UTI: 15 (14.6) in the D-mannose group, 21 (20.4) in Nitrofurantoin group, and 62 (60.8) in no prophylaxis group, with the rate significantly higher in no prophylaxis group compared to active groups (P < 0.001). Patients in D-mannose group and Nitrofurantoin group had a significantly lower risk of recurrent UTI episode during prophylactic therapy compared to patients in no prophylaxis group (RR 0.239 and 0.335, P < 0.0001). In active groups, 17.9% of patients reported side effects but they were mild and did not require stopping the prophylaxis. Patients in D-mannose group had a significantly lower risk of side effects compared to patients in Nitrofurantoin group (RR 0.276, P < 0.0001), but the clinical importance of this finding is low because Nitrofurantoin was well tolerated. CONCLUSIONS In our study, D-mannose powder had significantly reduced the risk of recurrent UTI which was no different than in Nitrofurantoin group. More studies will be needed to validate the results of this study, but initial findings show that D-mannose may be useful for UTI prevention.
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Affiliation(s)
- Bojana Kranjčec
- Department of Medical Biochemistry, Zabok General Hospital, Zabok, Croatia
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Kusema BT, Tönnov T, Mäki-Arvela P, Salmi T, Willför S, Holmbom B, Murzin DY. Acid hydrolysis of O-acetyl-galactoglucomannan. Catal Sci Technol 2013. [DOI: 10.1039/c2cy20314f] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Locke AB. Urinary Tract Infection. Integr Med (Encinitas) 2012. [DOI: 10.1016/b978-1-4377-1793-8.00020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lim JK, Gunther NW, Zhao H, Johnson DE, Keay SK, Mobley HL. In vivo phase variation of Escherichia coli type 1 fimbrial genes in women with urinary tract infection. Infect Immun 1998; 66:3303-10. [PMID: 9632599 PMCID: PMC108346 DOI: 10.1128/iai.66.7.3303-3310.1998] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/1997] [Accepted: 04/21/1998] [Indexed: 02/07/2023] Open
Abstract
Type 1 fimbriae, expressed by most Escherichia coli strains, are thought to attach to human uroepithelium as an initial step in the pathogenesis of urinary tract infections (UTI). Numerous reports using both in vitro and murine models support this role for type 1 fimbriae in colonization. Unfortunately, only a limited number of studies have directly examined the expression of fimbriae in vivo. To determine whether type 1 fimbrial genes are transcribed during an acute UTI, we employed a modification of an established method. The orientation (ON or OFF) of the invertible promoter element, which drives transcription of type 1 fimbrial genes, was determined by PCR amplification using primers that flank the invertible element, followed by SnaBI digestion. The orientation of the type 1 fimbrial switch was determined under three experimental conditions. First, E. coli strains from different clinical sources (acute pyelonephritis patients, cystitis patients, and fecal controls) were tested under different in vitro culture conditions (agar versus broth; aerated versus static). The genes in the more-virulent strains (those causing acute pyelonephritis) demonstrated a resistance, in aerated broth, to switching from OFF to ON, while those in fecal strains readily switched from OFF to ON. Second, bladder and kidney tissue from CBA mice transurethrally inoculated with E. coli CFT073 (an established murine model of ascending UTI) was assayed. The switches directly amplified from infected bladder and kidney tissues were estimated to be 33 and 39% ON, respectively, by using a standard curve. Finally, bacteria present in urine samples collected from women with cystitis were tested for type 1 fimbria switch orientation. For all 11 cases, an average of only 4% of the switches in the bacteria in the urine were ON. In 7 of the 11 cases, we found that all of the visible type 1 fimbrial switches were in the OFF position (upper limit of detection of assay, 98% OFF). Strains recovered from these urine samples, however, were shown after culture in vitro to be capable of switching the fimbrial gene to the ON position and expressing mannose-sensitive hemagglutinin. The results from experimental infections and cases of cystitis in women suggest that type 1 fimbrial genes are transcribed both in the bladder and in the kidney. However, those bacteria found in the urine and not attached to the uroepithelium are not transcriptionally active for type 1 fimbrial genes.
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Affiliation(s)
- J K Lim
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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Future Approaches to the Management of Urinary Tract Infections. Emerg Med Clin North Am 1991. [DOI: 10.1016/s0733-8627(20)30494-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Dellamonica P, Drugeon H, Bernard E, Beziau H. Bases pharmacologiques et expérimentales de l'utilisation en clinique. Résultats thérapeutiques des nouvelles bêta-lactamines dans les infections urinaires. Med Mal Infect 1986. [DOI: 10.1016/s0399-077x(86)80012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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