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Malde S, Belal M, Mohamed-Ahmed R, Gibson W, Padilla-Fernandez B, Rantell A, Selai C, Solomon E, Abrams P. Can we define the optimal postvoid residual volume at which intermittent catheterization should be recommended, and are there other measures that could guide an intermittent catheterization protocol: ICI-RS 2023. Neurourol Urodyn 2024; 43:1353-1362. [PMID: 37905437 DOI: 10.1002/nau.25324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023]
Abstract
AIMS The postvoid residual (PVR) volume of urine in the bladder is widely used in clinical practice as a guide to initiate treatment, including clean-intermittent self-catheterization (CISC). It is often believed that an elevated PVR causes complications such as recurrent urinary tract infections (UTI) and renal failure. However, evidence for this is limited and identifying alternative measures to guide treatment decisions may optimize patient care. At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2023 a Think Tank addressed the question of whether we can define the optimal PVR at which CISC should be recommended, and whether there are other measures that could guide a CISC protocol. METHODS The Think Tank conducted a literature review and expert consensus meeting focusing on current limitations in defining and measuring PVR, and highlighting other measures that may optimize selection for, and persistence with, CISC. RESULTS There is no consensus on the threshold value of PVR that is considered "elevated" or "significant." There is a lack of standardization on terminology, and the normal range of PVR in different populations of different ages remains to be well-studied. The measurement of PVR is influenced by several factors, including intraindividual variation, timing and method of measurement. Furthermore, the evidence linking an elevated PVR with complications such as UTI and renal failure is mixed. Other measures, such as bladder voiding efficiency or urodynamic parameters, may be better at predicting such complications, and therefore may be more relevant at guiding a CISC protocol. CONCLUSIONS There is a lack of high quality evidence to support PVR as a predictor for complications of UTI or renal failure. Threshold values for normal PVR in different populations are unknow, and so threshold values for "elevated" or "significant" PVR cannot be determined. Other factors, such as urodynamic findings, may be better at predicting complications and therefore guiding management decisions, and this remains to be studied. Areas for further research are proposed.
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Affiliation(s)
- Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mo Belal
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | | | - William Gibson
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Barbara Padilla-Fernandez
- Department of Urology, Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Angela Rantell
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Caroline Selai
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Eskinder Solomon
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Simoni A, Schwartz L, Junquera GY, Ching CB, Spencer JD. Current and emerging strategies to curb antibiotic-resistant urinary tract infections. Nat Rev Urol 2024:10.1038/s41585-024-00877-9. [PMID: 38714857 DOI: 10.1038/s41585-024-00877-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/23/2024]
Abstract
Rising rates of antibiotic resistance in uropathogenic bacteria compromise patient outcomes and prolong hospital stays. Consequently, new strategies are needed to prevent and control the spread of antibiotic resistance in uropathogenic bacteria. Over the past two decades, sizeable clinical efforts and research advances have changed urinary tract infection (UTI) treatment and prevention strategies to conserve antibiotic use. The emergence of antimicrobial stewardship, policies from national societies, and the development of new antimicrobials have shaped modern UTI practices. Future UTI management practices could be driven by the evolution of antimicrobial stewardship, improved and readily available diagnostics, and an improved understanding of how the microbiome affects UTI. Forthcoming UTI treatment and prevention strategies could employ novel bactericidal compounds, combinations of new and classic antimicrobials that enhance bacterial killing, medications that prevent bacterial attachment to uroepithelial cells, repurposing drugs, and vaccines to curtail the rising rates of antibiotic resistance in uropathogenic bacteria and improve outcomes in people with UTI.
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Affiliation(s)
- Aaron Simoni
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA
| | - Laura Schwartz
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA
- Department of Pediatrics, Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Guillermo Yepes Junquera
- Department of Pediatrics, Division of Infectious Diseases, Nationwide Children's, Columbus, OH, USA
| | - Christina B Ching
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA
- Department of Urology, Nationwide Children's, Columbus, OH, USA
| | - John David Spencer
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA.
- Department of Pediatrics, Division of Nephrology and Hypertension, Nationwide Children's, Columbus, OH, USA.
- The Ohio State University College of Medicine, Columbus, OH, USA.
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Sawant NV, Chang SS, Pandit KA, Khekare P, Warner WR, Zimmern PE, De Nisco NJ. VesiX cetylpyridinium chloride is rapidly bactericidal and reduces uropathogenic Escherichia coli bladder epithelial cell invasion in vitro. Microbiol Spectr 2024; 12:e0271223. [PMID: 38240572 PMCID: PMC10913388 DOI: 10.1128/spectrum.02712-23] [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: 06/29/2023] [Accepted: 12/11/2023] [Indexed: 03/06/2024] Open
Abstract
Management of urinary tract infection (UTI) in postmenopausal women can be challenging. The recent rise in resistance to most of the available oral antibiotic options together with high recurrence rate in postmenopausal women has further complicated treatment of UTI. As such, intravesical instillations of antibiotics like gentamicin are being investigated as an alternative to oral antibiotic therapies. This study evaluates the efficacy of the candidate intravesical therapeutic VesiX, a solution containing the cationic detergent Cetylpyridinium chloride, against a broad range of uropathogenic bacterial species clinically isolated from postmenopausal women with recurrent UTI (rUTI). We also evaluate the cytotoxicity of VesiX against cultured bladder epithelial cells and find that low concentrations of 0.0063% and 0.0125% provide significant bactericidal effect toward diverse bacterial species including uropathogenic Escherichia coli (UPEC), Klebsiella pneumoniae, Enterococcus faecalis, Pseudomonas aeruginosa, and Proteus mirabilis while minimizing cytotoxic effects against cultured 5637 bladder epithelial cells. Lastly, to begin to evaluate the potential utility of using VesiX in combination therapy with existing intravesical therapies for rUTI, we investigate the combined effects of VesiX and the intravesical antibiotic gentamicin. We find that VesiX and gentamicin are not antagonistic and are able to reduce levels of intracellular UPEC in cultured bladder epithelial cells. IMPORTANCE When urinary tract infections (UTIs), which affect over 50% of women, become resistant to available antibiotic therapies dangerous complications like kidney infection and lethal sepsis can occur. New therapeutic paradigms are needed to expand our arsenal against these difficult to manage infections. Our study investigates VesiX, a Cetylpyridinium chloride (CPC)-based therapeutic, as a candidate broad-spectrum antimicrobial agent for use in bladder instillation therapy for antibiotic-resistant UTI. CPC is a cationic surfactant that is FDA-approved for use in mouthwashes and is used as a food additive but has not been extensively evaluated as a UTI therapeutic. Our study is the first to investigate its rapid bactericidal kinetics against diverse uropathogenic bacterial species isolated from postmenopausal women with recurrent UTI and host cytotoxicity. We also report that together with the FDA-approved bladder-instillation agent gentamicin, VesiX was able to significantly reduce intracellular populations of uropathogenic bacteria in cultured bladder epithelial cells.
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Affiliation(s)
- Namrata V. Sawant
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas, USA
| | - Samuel S. Chang
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas, USA
| | - Krutika A. Pandit
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas, USA
| | - Prachi Khekare
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas, USA
| | | | - Philippe E. Zimmern
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole J. De Nisco
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas, USA
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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4
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Churchill K. The management of recurrent urinary tract infections within a nurse-led urology team. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S6-S12. [PMID: 37173081 DOI: 10.12968/bjon.2023.32.9.s6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The aim of this article is to share experience and learning of managing recurrent urinary tract infections (UTIs) within a specialist urology nurse-led team based at a district general hospital. It looks at current practice and supporting evidence for how to manage and treat recurrent UTIs in both male and female patients. Two case studies are presented to illustrate the management strategies and outcomes, demonstrating a planned approach that informs the design of a local management guideline to organise patients' care.
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Affiliation(s)
- Kevin Churchill
- Clinical Nurse Specialist, Bladder and Bowel Care Team, Royal Devon University Healthcare NHS Trust, Exeter
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Neugent ML, Hulyalkar NV, Kumar A, Xing C, Zimmern PE, Shulaev V, De Nisco NJ. Urinary Glycosaminoglycans Are Associated with Recurrent UTI and Urobiome Ecology in Postmenopausal Women. ACS Infect Dis 2023; 9:1022-1032. [PMID: 36942838 PMCID: PMC10111421 DOI: 10.1021/acsinfecdis.3c00027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Glycosaminoglycans (GAGs) are linear, negatively charged polysaccharides composed of repeating disaccharide units of uronic acid and amino sugars. The luminal surface of the bladder epithelium is coated with a GAG layer. These urothelial GAGs are thought to provide a protective barrier and serve as a potential interaction site with the urinary microbiome (urobiome). Previous studies have profiled urinary GAG composition in mixed cohorts, but the urinary GAG composition in postmenopausal women remains undefined. To investigate the relationship between GAGs and recurrent urinary tract infection (rUTI), we profiled urinary GAGs in a controlled cohort of postmenopausal women. We found that chondroitin sulfate (CS) is the major urinary GAG in postmenopausal women and that urinary CS was elevated in women with active rUTI. We also associated urinary GAGs with urobiome composition and identified bacterial species that significantly associated with urinary GAG concentration. Corynebacterium amycolatum, Porphyromonas somerae, and Staphylococcus pasteuri were positively associated with heparin sulfate or hyaluronic acid, and bacterial species associated with vaginal dysbiosis were negatively correlated with urinary CS. Altogether, this work defines changes in urinary GAG composition associated with rUTI and identifies new associations between urinary GAGs and the urobiome that may play a role in rUTI pathobiology.
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Affiliation(s)
- Michael L Neugent
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas 75080, United States
| | - Neha V Hulyalkar
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas 75080, United States
| | - Ashwani Kumar
- Eugene McDermott Center for Human Growth and Development, The University of Texas Southwestern Medical Center, Dallas, Texas 75390, United States
| | - Chao Xing
- Eugene McDermott Center for Human Growth and Development, The University of Texas Southwestern Medical Center, Dallas, Texas 75390, United States
- Department of Bioinformatics, The University of Texas Southwestern Medical Center, Dallas, Texas 75390, United States
| | - Philippe E Zimmern
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas 75390, United States
| | - Vladimir Shulaev
- Department of Biological Sciences, The University of North Texas, Denton, Texas 76203, United States
- Advanced Environmental Research Institute, The University of North Texas, Denton, Texas 76203, United States
| | - Nicole J De Nisco
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, Texas 75080, United States
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas 75390, United States
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Morris CJ, Rohn JL, Glickman S, Mansfield KJ. Effective Treatments of UTI—Is Intravesical Therapy the Future? Pathogens 2023; 12:pathogens12030417. [PMID: 36986339 PMCID: PMC10058863 DOI: 10.3390/pathogens12030417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Urinary tract infection (UTI) afflicts millions of patients globally each year. While the majority of UTIs are successfully treated with orally administered antibiotics, the impact of oral antibiotics on the host microbiota is under close research scrutiny and the potential for dysbiosis is a cause for concern. Optimal treatment of UTI relies upon the selection of an agent which displays appropriate pharmacokinetic-pharmacodynamic (PK-PD) properties that will deliver appropriately high concentrations in the urinary tract after oral administration. Alternatively, high local concentrations of antibiotic at the urothelial surface can be achieved by direct instillation into the urinary tract. For antibiotics with the appropriate physicochemical properties, this can be of critical importance in cases for which an intracellular urothelial bacterial reservoir is suspected. In this review, we summarise the underpinning biopharmaceutical barriers to effective treatment of UTI and provide an overview of the evidence for the deployment of the intravesical administration route for antibiotics.
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Affiliation(s)
- Chris J. Morris
- School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Jennifer L. Rohn
- Division of Medicine, University College London, Royal Free Hospital Campus, Rowland Hill Street, London NW3 2PF, UK
| | | | - Kylie J. Mansfield
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
- Correspondence: ; Tel.: +61-242-215-851
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Zimmern PE, Sawant NV, Chang SS, Warner RW, De Nisco NJ. Intravesical VesiX as a Last Resort Therapy in Women With Antibiotic-Refractory Recurrent Urinary Tract Infections Contemplating Bladder Removal: A Preliminary Report. Ann Pharmacother 2023; 57:350-351. [PMID: 35838251 DOI: 10.1177/10600280221112111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Neugent ML, Hulyalkar NV, Kumar A, Xing C, Zimmern PE, Shulaev V, De Nisco NJ. Urinary Glycosaminoglycans are Associated with Recurrent UTI and Urobiome Ecology in Postmenopausal Women. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.11.523678. [PMID: 36711817 PMCID: PMC9882061 DOI: 10.1101/2023.01.11.523678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Glycosaminoglycans (GAGs) are linear, negatively charged polysaccharides composed of repeating disaccharide units of uronic acid and amino sugars. The luminal surface of the bladder epithelium is coated with a GAG layer. These urothelial GAGs are thought to provide a protective barrier and serve as a potential interaction site with the urinary microbiome (urobiome). Previous studies have profiled urinary GAG composition in mixed cohorts, but the urinary GAG composition in postmenopausal women remains undefined. To investigate the relationship between GAGs and recurrent UTI (rUTI), we profiled urinary GAGs in a controlled cohort of postmenopausal women. We found that chondroitin sulfate (CS) is the major urinary GAG in postmenopausal women and that urinary CS was elevated in women with active rUTI. We also associated urinary GAGs with urobiome composition and identified bacterial species that significantly associated with urinary GAG concentration. Corynebacterium amycolatum, Porphyromonas somerae , and Staphylococcus pasteuri were positively associated with heparin sulfate or hyaluronic acid and bacterial species associated with vaginal dysbiosis were negatively correlated to urinary CS. Altogether, this work defines changes in urinary GAG composition associated with rUTI and identifies new associations between urinary GAGs and the urobiome that may play a role in rUTI pathobiology.
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Intraoperative Gentamicin Intravesical Instillation for Prevention of Urinary Tract Infection After Urogynecologic Surgery: A Randomized Controlled Trial. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:825-833. [PMID: 36409639 DOI: 10.1097/spv.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Currently available evidence for efficacy of postoperative antibiotics to prevent postoperative urinary tract infection (UTI) conflicts. Oral antibiotics rely on patient adherence and can cause unwanted systemic effects. Gentamicin is a broad-spectrum antibiotic with rapid bactericidal activity and, when administered intravesically, has no systemic absorption through intact urothelium. OBJECTIVE We aimed to determine whether a single intravesical instillation of gentamicin at the conclusion of urogynecologic surgery would reduce the proportion of women treated for UTI within 6 weeks postoperatively compared with sham instillation. STUDY DESIGN This was a multicenter, randomized (stratified by study site, route of prolapse repair ±suburethral sling, with balanced 1:1 randomization), participant-masked, sham-controlled, study. The primary outcome was the proportion of participants treated with antibiotics for UTI within 6 weeks postoperatively. An adjusted multivariable logistic regression model was constructed to determine predictors of postoperative UTI treatment. RESULTS Three hundred seventy participants were randomized (gentamicin, 185; sham, 185), and data from 363 participants were analyzed (gentamicin, 183; sham, 180). Nineteen women in the gentamicin group and 20 women in the sham group were treated for UTI within 6 weeks postoperatively (10.4% vs 11.1%, P = 0.87). There were no adverse events related to the instillations. Increasing age (odds ratio, 1.028 [1.000-1.057]) and number of intraoperative transurethral instrumentations (odds ratio, 1.342 [1.080-1.668]) were independent predictors of postoperative UTI treatment. CONCLUSIONS In women undergoing urogynecologic surgery, postoperative intravesical gentamicin did not reduce the incidence of postoperative UTI. The number of intraoperative transurethral instrumentations is an important, potentially modifiable risk factor for postoperative UTI treatment.
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Finney EL, Pagura EJ, MacLachlan LS. Efficacy and Safety of Alternative Treatments for the Prevention of Recurrent Urinary Tract Infections. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00678-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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Andretta E, Longo R, Balladelli M, Sgarabotto C, Sgarabotto D. Intravesical Gentamicin: An Option for Therapy and Prophylaxis against Recurrent UTIs and Resistant Bacteria in Neurogenic Bladder Patients on Intermittent Catheterization. Antibiotics (Basel) 2022; 11:1335. [PMID: 36289993 PMCID: PMC9598998 DOI: 10.3390/antibiotics11101335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/14/2022] [Accepted: 08/10/2022] [Indexed: 08/01/2023] Open
Abstract
This is a retrospective study of our experience with Gentamicin intravesical instillation as therapy and prophylaxis in patients with lower urinary tract infections (UTIs) undergoing clean intermittent catheterization because of a neurogenic bladder. It is an alternative therapy when all other systemic treatments have failed as it is still an off-label prescription.
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Affiliation(s)
| | | | | | | | - Dino Sgarabotto
- Abano Infectious Diseases Outpatient Clinic, 35031 Padova, Italy
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