Effects of a new combination of plant extracts plus d-mannose for the management of uncomplicated recurrent urinary tract infections

Microbial lectins as a potential therapeutics for the prevention of certain human diseases

Lectins are protein or glycoprotein molecules with a specific ability to bind to carbohydrates. From viruses to mammals, they are found in various organisms and exhibit remarkable diverse structures and functions. They are significant contributors to defense mechanisms against microbial attacks in plants. They are also involved in functions such as controlling lymphocyte migration, regulating glycoprotein biosynthesis, cell-cell recognition, and embryonic development in animals. In addition, lectins serve as invaluable molecular tools in various biological and medical disciplines due to their reversible binding ability and enable the monitoring of cell membrane changes in physiological and pathological contexts. Microbial lectins, often referred to as adhesins, play an important role in microbial colonization, pathogenicity, and interactions among microorganisms. Viral lectins are located in the bilayered viral membrane, whereas bacterial lectins are found intracellularly and on the bacterial cell surface. Microfungal lectins are typically intracellular and have various functions in host-parasite interaction, and in fungal growth and morphogenesis. Although microbial lectin studies are less extensive than those of plants and animals, they provide insights into the infection mechanisms and potential interventions. Glycan specificity, essential functions in infectious diseases, and applications in the diagnosis and treatment of viral and bacterial infections are critical aspects of microbial lectin research. In this review, we will discuss the application and therapeutic potential of viral, bacterial and microfungal lectins.

SWOT and Root Cause Analyses of Antimicrobial Resistance to Oral Antimicrobial Treatment of Cystitis

Nearly 150 million cases of urinary tract infections (UTIs) are reported each year, of which uncomplicated cystitis triggers > 25% of outpatient prescriptions of oral antimicrobial treatment (OAT). OAT aids immune cells infiltrating the urothelium in eliminating uropathogens capable of invading the urothelium and surviving hyperosmotic urine. This self-evident adaptability of uropathogens and the short interval between the introduction of Penicillin and the first report of antimicrobial resistance (AMR) implicate AMR as an evolutionary conserved heritable trait of mutant strains selected by the Darwinian principle to survive environmental threats through exponential proliferation. Therefore, AMR can only be countered by antimicrobial stewardship (AMS) following the principle of the five Ds-drug, dose, duration, drug route, and de-escalation. While convenient to administer, the onset of the minimum inhibitory concentration (MIC) for OAT in urine leaves a window of opportunity for uropathogens to survive the first contact with an antimicrobial and arm their descendant colonies with AMR for surviving subsequent higher urine antimicrobial levels. Meanwhile, the initial dose of intravesical antimicrobial treatment (IAT) may be well above the MIC. Therefore, the widespread clinical use of OAT for cystitis warrants an analysis of the strengths, weaknesses, opportunity, and threats (SWOTs) and a root cause analysis of the AMR associated with OAT and IAT.

Natural Products in the Treatment of Lower Urinary Tract Dysfunction and Infection

The popularity of natural products for the treatment of lower urinary tract symptoms (LUTS) differs considerably between countries. Here we discuss the clinical evidence for efficacy in two indications, male LUTS suggestive of benign prostatic hyperplasia and urinary tract infections, and the mechanistic evidence from experimental studies. Most evidence for male LUTS is based on extracts from saw palmetto berries, stinging nettle roots, and pumpkin seeds, whereas most evidence for urinary tract infection is available for European golden rod and combined preparations although this field appears more fragmented with regard to extract sources. Based on differences in sample collection and extraction, extracts from the same plants are likely to exhibit at least quantitative differences in potential active ingredients, which makes extrapolation of findings with one extract to those of others potentially difficult. While only limited information is available for most individual extracts, some extracts have been compared to placebo and/or active controls in adequately powered trials.

Novel Key Ingredients in Urinary Tract Health-The Role of D-mannose, Chondroitin Sulphate, Hyaluronic Acid, and N-acetylcysteine in Urinary Tract Infections (Uroial PLUS®)

Urinary tract infections represent a common and significant health concern worldwide. The high rate of recurrence and the increasing antibiotic resistance of uropathogens are further worsening the current scenario. Nevertheless, novel key ingredients such as D-mannose, chondroitin sulphate, hyaluronic acid, and N-acetylcysteine could represent an important alternative or adjuvant to the prevention and treatment strategies of urinary tract infections. Several studies have indeed evaluated the efficacy and the potential use of these compounds in urinary tract health. In this review, we aimed to summarize the characteristics, the role, and the application of the previously reported compounds, alone and in combination, in urinary tract health, focusing on their potential role in urinary tract infections.

Promising natural products against SARS-CoV-2: Structure, function, and clinical trials

The corona virus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus type 2 (SARS-COV-2) poses a severe threat to human health and still spreads globally. Due to the high mutation ratio and breakthrough infection rate of the virus, vaccines and anti-COVID-19 drugs require continual improvements. Drug screening research has shown that some natural active products can target the critical proteins of SARS-CoV-2, including 3CLpro, ACE2, FURIN, and RdRp, which could produce great inhibitory effects on SARS-COV-2. In addition, some natural products have displayed activities of immunomodulation, antiinflammatory, and antihepatic failure in COVID-19 clinical trials, which may relate to their non-monomeric structures. However, further evaluation and high-quality assessments, including safety verification tests, drug interaction tests, and clinical trials, are needed to substantiate natural products' multi-target and multi-pathway effects on COVID-19. Here, we review the literature on several promising active natural products that may act as vaccine immune enhancers or provide targeted anti-COVID-19 drugs. The structures, mechanisms of action, and research progress of these natural products are analyzed, to hopefully provide effective ideas for the development of targeted drugs that possess better structure, potency, and safety.

D-mannose for preventing and treating urinary tract infections

BACKGROUND

Urinary tract infections (UTIs) are very common, affecting more than 7 million people worldwide. Whilst many people may only experience a single episode in their lifetime and are generally responsive to standard antibiotics, a significant proportion of adults and children (approximately 15% to 25%) are chronic symptomatic UTI sufferers. Certain population groups are at greater risk than others, such as immunosuppressed and people with chronic kidney disease. D-mannose is a sugar part of normal human metabolism found within most diets. The mechanism of action is to prevent bacterial adherence to the uroepithelial cells. The D-mannose-based inhibitors can block uropathogenic Escherichia coli adhesion and invasion of the uroepithelial cells. The bacteria are then understood to essentially be eliminated by urination. Early pilot studies on animals and humans have trialled concentrated forms of D-mannose (tablets or sachets) in doses ranging from 200 mg up to 2 to 3 g and found possible efficacy in reducing UTI symptoms or recurrence. Although the anti-adhesive effects of D-mannose have been well-established, only recently have we seen a small number of pilot studies and small clinical trials conducted.

OBJECTIVES

To assess the benefits and harms of D-mannose for preventing and treating UTIs in adults and children.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 22 February 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included RCTs measuring and reporting the effect of D-mannose, in any combination and any formulation, to prevent or treat UTIs in adults and children, females and males, in any setting (including perioperative). Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Data extraction was independently carried out by two authors using a standard data extraction form. Methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another author. The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included seven RCTs (719 participants) in adult females and males who had either acute cystitis or a history of recurrent (at least two episodes in six months or three episodes in 12 months) UTIs (symptomatic or asymptomatic). Two were prevention studies, four were prevention and treatment studies (two perioperative and one in people with multiple sclerosis), and one was a treatment study. Time periods ranged from 15 days to six months. No two studies were comparable (by dose or treatments), and we could not undertake meta-analyses. Individual studies reported no clear evidence to determine whether D-mannose is more or less effective in preventing or treating UTIs. D-mannose (2 g) had uncertain effects on symptomatic and bacteriuria-confirmed UTIs when compared to no treatment (1 study, 205 participants; very low certainty evidence) and antibiotics (nitrofurantoin 50 mg) (1 study, 206 participants; very low certainty evidence). D-mannose, in combination with herbal supplements, had uncertain effects on symptomatic and bacteria-confirmed UTI and pain when compared to no treatment (1 study, 40 participants; very low certainty evidence). D-mannose 500 mg plus supplements (N-acetylcysteine and Morinda citrifolia fruit extract) had uncertain effects on symptomatic and bacteriuria-confirmed UTIs when compared to an antibiotic (prulifloxacin 400 mg) (1 study, 75 participants; very low certainty evidence). Adverse events were very few and poorly reported; none were serious (mostly diarrhoea and vaginal burning). Overall, the quality of the evidence is poor. Most studies were judged to have unclear or high risk of bias across most domains. Data was sparse and addressed very few outcomes. The GRADE evaluation was rated as very low certainty evidence due to very serious limitations in the study design or execution (high risk of bias across all studies) and sparse data (single study data and small sample sizes).

AUTHORS' CONCLUSIONS

There is currently little to no evidence to support or refute the use of D-mannose to prevent or treat UTIs in all populations. This review highlights the severe lack of high-quality RCTs testing the efficacy of D-mannose for UTIs in any population. Despite UTIs being one of the most common adult infections (affecting 50% of women at least once in their lifetime) and the growing global antimicrobial resistance, we found very few studies that adequately test this alternative treatment. Future research in this field requires, in the first instance, a single adequately powered RCT comparing D-mannose with placebo.

Femistina versus Canephron as a prevention of urinary tract infections after midurethral sling surgery - Non-inferiority study

OBJECTIVE

Urinary tract infection (UTI) is relatively common post-operative complication following midurethral sling placement (MUS), even in cases where intraoperative antibiotic prophylaxis was given. The primary aim of this study was to investigate the non-inferiority of Femistina as compared with Canephron in reducing symptomatic UTI in first six months following surgery.

STUDY DESIGN

A sample size of 144 patients per group was established, to provide at least 90% power to demonstrate the non-inferiority of phytodrug Femistina versus Canephron as a prevention of post-MUS urinary tract infection.

RESULTS

Women suffering from stress urinary incontinence and mixed urinary incontinence (MUI) with predominant SUI symptoms as confirmed by urodymamics (n = 320) were randomized in a 1:1 ratio to Femistina (40 mg, oral, twice daily for 20 days) or Canephron (3 × 5 ml taken orally-three times daily for 4 weeks). Both groups were homogenous for age, type of operation (only TOT outside-in) and severity of illness as indicated by ICIQ-SF questionnaire. We found that symptoms of UTI were significantly lower in patients receiving Femistina. During first 6 months after surgery UTI was confirmed in only 10 patients receiving Femistina (6,25%) when compared to 25 (15,63%) subjects receiving Canephron, p < 0.007.

CONCLUSION

Femistina is not inferior to Canephron in preventing lower urinary tract infection after midurethral sling surgery.

Systematic review of the effect of D‑mannose with or without other drugs in the treatment of symptoms of urinary tract infections/cystitis (Review)

Several studies, reviews and meta-analyses have documented that D-mannose use lowers the risk of recurrent urinary tract infections (UTI), but its role in the treatment of UTI/cystitis-related symptoms is unclear. In particular, no systematic review has analyzed the role of treatment with D-mannose in acute UTI/cystitis. In this paper, we systematically reviewed the published data on the effect of D-mannose, alone or in association with other compounds, on the typical symptoms of UTI/cystitis. PubMed/Medline and EMBASE databases were searched, from 1990 to January 2022, using combinations of the following keywords: ‘urinary tract infections’, ‘cystalgia’, ‘recurrent next urinary tract infection’, ‘cystitis’, ‘mannose’, ‘mannoside’, ‘D-mannose’, ‘bacteriuria’, ‘pyuria’, ‘pyelocystitis’ with the appropriate Boolean modifiers (Limits: Human, English, full article). Studies were selected for the systematic review if they were clinical studies and reported original data, the number of patients using D-mannose alone or in association with other treatments, and the number of patients with symptoms of UTI/cystitis at trial entry and after the follow-up period. A total of seven studies were identified. D-mannose was given alone in two studies, and was associated with cranberry extract, Morinda citrifolia fruit extract, pomegranate extract, fructo-oligosaccharides, lactobacilli, and N-acetylcysteine in the others. All studies reported that symptoms decreased after treatment with D-mannose. Despite the limitations of the studies, the consistent results observed among all studies give support to the general findings that D-mannose may be useful in the treatment of UTI/cystitis symptoms.

Non-antibiotic Approaches to Preventing Pediatric UTIs: a Role for D-Mannose, Cranberry, and Probiotics?

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.

Role of D-mannose in urinary tract infections - a narrative review

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.

A Potential “Vitaminic Strategy” against Caries and Halitosis

Streptococcus mutans and Fusobacterium nucleatum are two key bacteria of the oral microbiota. Due to their ability to form biofilms on oral tissues, they are both involved in the onset of the most common oral diseases. F. nucleatum is also the principal producer of hydrogen sulfide (H2S), causative of the awkward bad breath of halitosis. In this study, the oral product Vea® Oris, made by vitamin E and capric/caprylic acid only, was evaluated as a potential treatment for the most common oral diseases. Different concentrations of the product were tested against both S. mutans and F. nucleatum. The effect on planktonic and biofilm growth was investigated for both strains, and for F. nucleatum, the influence on H2S production was evaluated. From our data, the product did not relevantly reduce the planktonic growth of both strains, whereas it validly counteracted biofilm assemblage. Moreover, an interesting trend of H2S reduction was highlighted. Overall, these results suggested, on the one hand, a synergistic antimicrobial–antibiofilm action of two Vea® Oris components and, together, potential modulation activity on H2S production. However, the study should be implemented to confirm these only preliminary findings, certainly extending the panel of tested bacteria and using alternative methods of detection.

Whole-Person, Urobiome-Centric Therapy for Uncomplicated Urinary Tract Infection

A healthy urinary tract contains a variety of microbes resulting in a diverse urobiome. Urobiome dysbiosis, defined as an imbalance in the microbial composition in the microenvironments along the urinary tract, is found in women with uncomplicated urinary tract infection (UTI). Historically, antibiotics have been used to address UTI. An alternative approach to uncomplicated UTI is warranted as the current paradigm fails to take urobiome dysbiosis into account and contributes to the communal problem of resistance. A whole-person, multi-modal approach that addresses vaginal and urinary tract dysbiosis may be more effective in reducing recurrent UTI. In this review, we discuss strategies that include reducing pathogenic bacteria while supporting commensal urogenital bacteria, encouraging diuresis, maintaining optimal pH levels, and reducing inflammation. Strategies for future research are suggested.

Naturopathic Management of Urinary Tract Infections: A Retrospective Chart Review

Introduction: Antibiotic overuse is a significant driver of bacterial resistance. Urinary tract infections (UTIs, cystitis) are the most common condition for which antibiotics are prescribed in the ambulatory setting. Many complementary and integrative approaches to cystitis have been proposed, including probiotics, D-mannose, and several herbal therapies. Trials comparing such therapies with placebo or antibiotics showed mixed, but promising, results. Naturopathy is a system of medicine that has potential to avoid antibiotic use for UTI because of its affinity for nonpharmacologic therapies and its theory that infection is a result of both the immune system's vulnerability and the pathogen's virulence. Methods: The authors conducted a retrospective chart review of cases treated at four naturopathic clinics in the Portland, OR, metro area, where naturopathic doctors (NDs) have a scope of practice consistent with their license as primary care providers. The primary aim was to characterize how NDs treat UTIs in a real-world setting. Secondary aims were to gather preliminary evidence on the types of patient cases receiving such treatments, outcomes of treatments, and associations between presentation and treatment prescriptions. Results: The authors found 82 distinct treatment regimens among 103 individual patients diagnosed with UTI. Most patients received a combination of herbal medicine and behavioral modification (e.g., increase fluid intake), whereas the most common monotherapeutic regimen was antibiotics. Of the 43 patients who were followed up, 15 had no success with nonpharmacologic therapies and required antibiotics. The sample was comparable with national data regarding composition of public versus private insurance, acute versus recurrent/chronic UTI, and percent of cases related to uropathogenic Escherichia coli. Conclusions: NDs practicing in a primary care context frequently prescribe antibiotic and nonantibiotic multimodal therapy for uncomplicated UTI. These results may guide future studies testing complementary and integrative therapies for uncomplicated UTI.

A Natural Alternative Treatment for Urinary Tract Infections: Itxasol©, the Importance of the Formulation

Genito-urinary tract infections have a high incidence in the general population, being more prevalent among women than men. These diseases are usually treated with antibiotics, but very frequently, they are recurrent and lead to the creation of resistance and are associated with increased morbidity and mortality. For this reason, it is necessary to develop new compounds for their treatment. In this work, our objective is to review the characteristics of the compounds of a new formulation called Itxasol© that is prescribed as an adjuvant for the treatment of UTIs and composed of β-arbutin, umbelliferon and n-acetyl cysteine. This formulation, based on biomimetic principles, makes Itxasol© a broad-spectrum antibiotic with bactericidal, bacteriostatic and antifungal properties that is capable of destroying the biofilm and stopping its formation. It also acts as an anti-inflammatory agent, without the adverse effects associated with the recurrent use of antibiotics that leads to renal nephrotoxicity and other side effects. All these characteristics make Itxasol© an ideal candidate for the treatment of UTIs since it behaves like an antibiotic and with better characteristics than other adjuvants, such as D-mannose and cranberry extracts.

Comparative Study of ESBL Production Among Uropathogenic Escherichia coli Clinical Isolates from Pre- and Post-menopausal Women in Egypt

Urinary tract infection (UTI) is regarded one of the most frequent bacterial infections in women. Accordingly, the aim of the current study was to determine the prevalence of extended-spectrum beta-lactamase (ESBL), as well as the degree of antimicrobial resistance among premenopausal (n = 44) and postmenopausal (n = 49) women suffering from uncomplicated UTI. Urinary samples (n = 93) collected from women with UTI were tested for their antimicrobial sensitivity and assessed for ESBL production by both phenotypic and genotypic methods. Phenotypically, the presence of ESBL was observed in 64 isolates, while polymerase chain reaction detected ESBL-encoding genes in 57 isolates. The CTX-M gene was the most predominant (51.6%), followed by TEM (46.2%), and the SHV gene (17.2%). Surprisingly, all ESBL-producing Escherichia coli isolates were multidrug-resistant (MDR). To the best of our knowledge, this is the first study conducted in Egypt showing significant correlation between ESBL production, multidrug resistance and menopausal state in women. The results demonstrate alarming signal for the dissemination of ESBL genes among uropathogenic E. coli that are MDR in Egypt.

Role of D-Mannose in the Prevention of Recurrent Uncomplicated Cystitis: State of the Art and Future Perspectives

BACKGROUND

Urinary tract infections (UTI) are highly frequent in women, with a significant impact on healthcare resources. Although antibiotics still represent the standard treatment to manage recurrent UTI (rUTI), D-mannose, an inert monosaccharide that is metabolized and excreted in urine and acts by inhibiting bacterial adhesion to the urothelium, represents a promising nonantibiotic prevention strategy. The aim of this narrative review is to critically analyze clinical studies reporting data concerning the efficacy and safety of D-mannose in the management of rUTIs.

METHODS

A non-systematic literature search, using the Pubmed, EMBASE, Scopus, Web of science, Cochrane Central Register of Controlled Trials, and Cochrane Central Database of Systematic Reviews databases, was performed for relevant articles published between January 2010 and January 2021. The following Medical Subjects Heading were used: "female/woman", "urinary tract infection", and "D-mannose". Only clinical studies, systematic reviews, and meta-analyses reporting efficacy or safety data on D-mannose versus placebo or other competitors were selected for the present review. Evidence was limited to human data. The selected studies were organized in two categories according to the presence or not of a competitor to D-mannose.

RESULTS

After exclusion of non-pertinent studies/articles, 13 studies were analyzed. In detail, six were randomized controlled trials (RCTs), one a randomized cross-over trial, five prospective cohort studies, and one a retrospective analysis. Seven studies compared D-mannose to placebo or others drugs/dietary supplements. Six studies evaluated the efficacy of D-mannose comparing follow-up data with the baseline. D-mannose is well tolerated, with few reported adverse events (diarrhea was reported in about 8% of patients receiving 2 g of D-mannose for at least 6 months). Most of the studies also showed D-mannose can play a role in the prevention or rUTI or urodynamics-associated UTI and can overlap antibiotic treatments in some cases. The possibility to combine D-mannose with polyphenols or Lactobacillus seems another important option for UTI prophylaxis. However, the quality of the collected studies was very low, generating, consequently, a weak grade of recommendations as suggested by international guidelines. Data on D-mannose dose, frequency, and duration of treatment are still lacking.

CONCLUSION

D-mannose alone or in combination with several dietary supplements or Lactobacillus has a potential role in the non antimicrobial prophylaxis or recurrent UTI in women. Despite its frequent prescription in real-life practice, we believe that further well-designed studies are urgently needed to definitively support the role of D-mannose in the management of recurrent UTIs in women.

Deep insights into urinary tract infections and effective natural remedies

Background

Urinary tract infection (UTI) is a common occurrence in females, during pregnancy, and in peri- and postmenopausal women. UTIs are associated with significant morbidity and mortality, and they affect the quality of life of the affected patients. Antibiotic therapy is an effective approach and reduces the duration of symptoms. Development of resistance, adverse effects of antibiotics, and other associated problems lead to establishing the research framework to find out the alternative approaches in controlling UTIs. Natural approaches have been extensively used for the management of various diseases to improve symptoms and also improve general health.

Main body

Different databases were employed to identify studies reporting on natural options including herbal medicines, vitamins, trace elementals, sugars, and probiotics without time limitations.

Conclusion

Herbal medicines can be effective at the first sign of the infection and also for short-term prophylaxis. Using vitamins, trace elementals, and/or sugars is an effective approach in preventing UTIs, and a combination of them with other antibacterial agents shows positive results. Probiotics have great potential for the threat of antibiotic over-usage and the prevalence of antibiotic-resistant microorganisms. This study may be of use in developing the efficient formulation of treatment of UTI.

In Vitro and In Vivo Biological Activity of Berberine Chloride against Uropathogenic E. coli Strains Using Galleria mellonella as a Host Model

Berberine is an alkaloid of the protoberberine type used in traditional oriental medicine. Its biological activities include documented antibacterial properties against a wide variety of microorganisms; nonetheless, its use against Escherichia coli strains isolated from urinary infections has not yet been widely investigated in vivo. The emergence of antimicrobial resistance requires new therapeutic approaches to ensure the continued effectiveness of antibiotics for the treatment and prevention of urinary infections. Moreover, uropathogenic Escherichia coli (UPEC) has developed several virulence factors and resistance to routine antibiotic therapy. To this end, several in vitro and in vivo tests were conducted to assess the activity of berberine on uropathogenic E. coli strains. Galleria mellonella as an infection model was employed to confirm the in vivo translatability of in vitro data on berberine activity and its influence on adhesion and invasion proprieties of E. coli on human bladder cells. In vitro pre-treatment with berberine was able to decrease the adhesive and invasive UPEC ability. In vivo treatment increased the larvae survival infected with UPEC strains and reduced the number of circulating pathogens in larvae hemolymph. These preliminary findings demonstrated the efficacy and reliability of G. mellonella as in vivo model for pre-clinical studies of natural substances.

Medicinal plants consumption against urinary tract infections: a narrative review of the current evidence

INTRODUCTION

Urinary tract infections (UTIs) are usual diseases caused by different strains of microorganisms. Many antibiotics have been applied for the treatment of these infections. However, the development of multidrug-resistant strains is a major problem in these treatments. As alternative complementary agents, several medicinal plants are often used to prevent and/or treat these diseases.

AREAS COVERED

This review summarized the current evidence about the efficacy of medicinal plants' consumption to prevent and/or co-treat UTIs. The most precise scientific databases, e.g. Medline, Scopus, and Web of Science were comprehensively searched, using relative keywords to identify the relative in vivo and ex vivo animal and human studies.

EXPERT OPINION

Current studies supported evidence for potential benefit overall concerning medicinal plants' consumption against UTIs by preventing bacterial adherence and inhibiting inflammation cascades through responding immunologically to bacteria invasion. However, most of the current evidence have been focused on in vivo and ex vivo animal studies, while human studies are currently limited and did not focus on a specific medicinal plant. Thus, well-designed clinical trials for long study periods focused on individual medicinal plants are intensely recommended to delineate their effectiveness on the prevention and/or co-treatment of UTIs.

D-mannose vs other agents for recurrent urinary tract infection prevention in adult women: a systematic review and meta-analysis

OBJECTIVE

We performed a systematic review and meta-analysis to determine whether D-mannose reduces urinary tract infection recurrence (ie, cumulative incidence) in adult women with recurrent urinary tract infection compared with other prevention agents. Secondary outcomes included side effects and compliance with D-mannose use.

DATA SOURCES

Ovid Medline 1946-, Embase 1947-, Scopus 1823-, Cochrane Library, Web of Science 1900-, and ClinicalTrials.gov were searched through 4/15/2020.

STUDY ELIGIBILITY CRITERIA

Systematic review inclusion: randomized controlled trials, prospective cohorts, and retrospective cohorts written in English of women ≥18 years old with recurrent urinary tract infection in which D-mannose was utilized as an outpatient prevention regimen. Systematic review exclusion: lab or animal-based research, study protocols only, and conference abstracts. Meta-analysis inclusion: stated D-mannose dose, follow-up time ≥6 months, a comparison arm to D-mannose, and data available from women ≥18 years of age.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two independent reviewers made abstract, full text, and data extraction decisions. Study methodologic quality was assessed using the Cochrane Risk of Bias tool. Relative risks, confidence intervals, and heterogeneity were computed.

RESULTS

Searches identified 776 unique citations. Eight publications met eligibility: 2 using D-mannose only; 6 using D-mannose combined with another treatment. Seven studies were prospective: 2 randomized controlled trials, 1 randomized cross-over trial, and 4 prospective cohort studies. One retrospective cohort study was included. Three studies met meta-analysis eligibility (1 randomized controlled trial, 1 randomized cross-over trial, and 1 prospective cohort). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to placebo was 0.23 (95% confidence interval, 0.14-0.37; heterogeneity=0%; D-mannose n=125, placebo n=123). Pooled relative risk of urinary tract infection recurrence comparing D-mannose to preventative antibiotics was 0.39 (95% confidence interval, 0.12-1.25; heterogeneity=88%; D-mannose n=163, antibiotics n=163). Adverse side effects were reported in 2 studies assessing D-mannose only (1 study (n=10) reported none; the other reported a low incidence (8/103 participants) of diarrhea). Two studies reported compliance, which was high.

CONCLUSION

D-mannose appears protective for recurrent urinary tract infection (vs placebo) with possibly similar effectiveness as antibiotics. Overall, D-mannose appears well tolerated with minimal side effects-only a small percentage experiencing diarrhea. Meta-analysis interpretation must consider the small number of studies with varied study design and quality and the overall small sample size.

FimH and Anti-Adhesive Therapeutics: A Disarming Strategy Against Uropathogens

Chaperone-usher fimbrial adhesins are powerful weapons against the uropathogens that allow the establishment of urinary tract infections (UTIs). As the antibiotic therapeutic strategy has become less effective in the treatment of uropathogen-related UTIs, the anti-adhesive molecules active against fimbrial adhesins, key determinants of urovirulence, are attractive alternatives. The best-characterized bacterial adhesin is FimH, produced by uropathogenic Escherichia coli (UPEC). Hence, a number of high-affinity mono- and polyvalent mannose-based FimH antagonists, characterized by different bioavailabilities, have been reported. Given that antagonist affinities are firmly associated with the functional heterogeneities of different FimH variants, several FimH inhibitors have been developed using ligand-drug discovery strategies to generate high-affinity molecules for successful anti-adhesion therapy. As clinical trials have shown d-mannose's efficacy in UTIs prevention, it is supposed that mannosides could be a first-in-class strategy not only for UTIs, but also to combat other Gram-negative bacterial infections. Therefore, the current review discusses valuable and effective FimH anti-adhesive molecules active against UTIs, from design and synthesis to in vitro and in vivo evaluations.

Antimicrobial Resistance Profiling of Coagulase-Negative Staphylococci in a Referral Center in South Italy: A Surveillance Study

Background:

CoNS are part of the normal flora of the skin, upper respiratory tract and human intestine. CoNS are able to colonize host tissues or inert materials such as prosthetics, heart valves, pacemakers, and urinary and venous catheters. They can also internalize in host cells, thus eluding immune defenses and attack by antibiotics.

Objective:

In this study, we collected the epidemiological data and determined the antibiotic susceptibility of 828 CoNS, collected in Garibaldi Hospital (Catania, Italy) between January 2016 and October 2018.

Methods:

Strains were evaluated by determining the Minimum Inhibitory Concentration (MIC) using the broth microdilution method, according to the guidelines of the Clinical and Laboratory Standards Institute. The antibiotic sensitivity pattern of CoNS against eighteen antibiotics was determined.

Results:

For all the 828 clinical isolates, varying resistance rates were observed: ampicillin (87%), penicillin (86%), amoxicillin-clavulanate (71%), oxacillin (70%), erythromycin (69%), azithromycin (68%), levofloxacin (55%), ciprofloxacin (54%), gentamycin (47%), moxifloxacin (42%), trimethoprim-sulfamethoxazole (30%), clindamycin (28%), tetracycline (24%), rifampicin (20%), quinupristin-dalfopristin (synercid) (4%). No strains investigated demonstrated resistance to teicoplanin, vancomycin and linezolid.

Conclusion:

Our results highlight the importance of monitoring the evolution of CoNS resistance in order to implement control measures and reduce the risk of spread in the population.

Targeting Metabolic Consequences of Insulin Resistance in Polycystic Ovary Syndrome by D-chiro-inositol and Emerging Nutraceuticals: A Focused Review

Polycystic ovary syndrome (PCOS) is a complex disorder associated with ovarian dysfunction, infertility, menstrual irregularity, and hormonal impairments. Over the last decade, several studies have shown that some PCOS women have insulin resistance (InsR) and hyperinsulinemia, apart from being overweight or obese. Therefore, a crucial clinical aspect is that PCOS patients might develop glucose intolerance and type 2 diabetes. Insulin-sensitizing drugs have been used as first-line treatment to improve hyperinsulinemia in women with PCOS. Although reducing PCOS symptoms and signs, several used insulin-sensitizer drugs may induce side effects, which reduces compliance. D-chiro-inositol (DCI), which is a naturally occurring stereoisomer of inositol, has been classified as an insulin-sensitizer and seems to mitigate multiple InsR-related metabolic alterations in PCOS with a safe profile. However, according to a multi-targeted design, the supplementation with DCI can be synergistically integrated by combining other potential insulin-sensitizing drugs and/or nutraceuticals. The literature provides the initial support for using several unexplored nutraceutical interventions that may target relevant metabolic abnormalities associated with InsR in PCOS. With a need to promote interest in clinical research, this review aims to discuss the efficacy of DCI and the role of emerging nutraceuticals for managing InsR in PCOS.

Preliminary in Vitro Studies on Corynebacterium urealyticum Pathogenetic Mechanisms, a Possible Candidate for Chronic Idiopathic Prostatitis?

Corynebacterium urealyticum is a well-known opportunistic uropathogen that can occur with cystitis, pyelonephritis, and urinary sepsis. Although a wide variety of coryneform bacteria have been found from the male genital tract of prostatitis patients, only one clinical case of prostatitis caused by C. urealyticum has been reported. The aim of this study was to evaluate the in vitro tropism of C. urealyticum towards LNCaP (lymph node carcinoma of the prostate) human cells line and the influence of acetohydroxamic acid as an irreversible urease inhibitor on different aspects of its pathogenicity by means of several in vitro tests, such as the determination and analysis of growth curves, MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay, the production of biofilms, and adhesion to LNCaP and HeLa cell lines. Results have brought new pieces of evidence on the in vitro tropism of C. urealyticum for the human prostate cell line LNCaP and the therapeutic use of the irreversible urease inhibitors such as acetohydroxamic acid (AHA), not only as enzyme blockers to facilitate the removal of encrustations but also as modulators of some pathogenic mechanisms. These interesting preliminary data allow us to assert that there is a real possibility that C. urealyticum is a new candidate for chronic idiopathic prostatitis.

Natural Flavones from Morus alba against Methicillin-Resistant Staphylococcus aureus via Targeting the Proton Motive Force and Membrane Permeability

The emergence and rapid spread of methicillin-resistant Staphylococcus aureus (MRSA) critically requires alternative therapeutic options. New antibacterial drugs and strategies are urgently needed to combat MRSA-associated infections. Here, we investigated the antibacterial activity of flavones from Morus alba and the potential mode of action against MRSA. Kuwanon G, kuwanon H, mulberrin, and morusin displayed high efficiency in killing diverse MRSA isolates. On the basis of structure-activity analysis, the cyclohexene-phenyl ketones and isopentenyl groups were critical to increase the membrane permeability and to dissipate the proton motive force. Meanwhile, mechanistic studies further showed that kuwanon G displayed rapid bactericidal activity in vitrowith difficulty in developing drug resistance. Kuwanon G targeted phosphatidylglycerol and cardiolipin in the cytoplasmic membrane through the formation of hydrogen bonds and electrostatic interactions. Additionally, kuwanon G promoted wound healing in a mouse model of MRSA skin infection. In summary, these results indicate that flavones are promising lead compounds to treat MRSA-associated infections through disrupting the proton motive force and membrane permeability.

Antibacterial and anti-biofilm activities of walnut pellicle extract (Juglans regia L.) against coagulase-negative staphylococci

Juglans regia L. (common walnut) is a deciduous tree belonging to Juglandaceae family. Since ancient time, walnut was widely used in traditional medicine for its antioxidant, antidiabetic, antimicrobial, anti-inflammatory, anti-atherogenic and liver-protective effects. In this work, the antibacterial and anti-biofilm activities of walnuts pellicle extract against coagulase-negative staphylococci were evaluated. Qualitative chemical analysis was performed by the thin layer chromatography. UPLC-Ms/Ms was used to identify the chemical composition of J. regia extract. The total flavonoid and phenolic contents were determined by the Aluminium chloride and Folin-Ciocalteu methods, respectively. The extract showed antibacterial activity with MIC ranging from 3.60 to 461.75 µg/ml and MBC ranging from 461.75 to >461.75 µg/ml. Furthermore, it significantly reduced biofilm biomass and cell viability in a dose-dependent manner. Biological activities of J. regia extract may be due to its high flavonoid and phenolic contents. The obtained results are promising and they deserve further scientific investigations.

Arbutin promotes MC3T3‑E1 mouse osteoblast precursor cell proliferation and differentiation via the Wnt/β‑catenin signaling pathway

Arbutin is a natural compound extracted from various plants, including bearberry leaves, that exerts multiple effects including skin whitening, anti‑inflammatory and oxidative stress‑protective properties. However, the effects of arbutin on osteoblasts remain unknown. The aim of the present study was to investigate the function and the mechanisms of arbutin on the proliferation and differentiation of MC3T3‑E1 mouse osteoblast precursor cells in vitro. The proliferation of MC3T3‑E1 cells treated with arbutin was assessed using a Cell Counting Kit‑8 assay and a 5‑ethynyl‑2'‑deoxyuridine labeling assay. Additionally, cell cycle and apoptosis were examined using flow cytometry analysis. The effects of arbutin on osteoblast differentiation were investigated using alkaline phosphatase (ALP) staining and by examining the mRNA expression levels of collagen type I α1 chain (COL1A1), bone γ‑carboxyglutamate protein (BGLAP) and Sp7 transcription factor (SP7). To further investigate the molecular mechanism underlying arbutin function in promoting osteogenesis, the mRNA and protein expression levels of runt‑related transcription factor 2 (RUNX2) and β‑catenin were analyzed by reverse transcription‑quantitative polymerase chain reaction and western blotting. Arbutin significantly promoted MC3T3‑E1 cell proliferation and increased the ratio of cells in S‑phase. Treatment with arbutin increased ALP activity and the mRNA expression levels of COL1A1, BGLAP and SP7 in MC3T3‑E1 cells. Furthermore, the protein and the mRNA expression levels of RUNX2 and β‑catenin increased significantly following treatment with arbutin. Collectively, the present findings suggested that arbutin was able to promote proliferation and differentiation of MC3T3‑E1 cells via the Wnt/β‑catenin signaling pathway.

Forskolin exerts anticancer roles in non-Hodgkin's lymphomas via regulating Axin/β-catenin signaling pathway

Background

Non-Hodgkin’s lymphomas (NHLs) account for 85% of lymphomas, which are characterized by high-degree malignancy, rapid progress, and even invasion into central nervous system in pediatric patients. Although the cure rate of pediatric NHL has improved, some patients have still underwent recurrence or death. This study focuses on the effects and mechanism of forskolin on the progression of NHL, aiming to find efficient therapy methods for pediatric NHL.

Methods

MTT, flow cytometry and mice tumor bearing experiments were used to evaluate the effects of forskolin on NHL cell proliferation, apoptosis and tumorigenesis. Western blotting and RT-PCR assays were used to detect protein and mRNA expression. Immunohistochemistry technology was recruited to analyze Ki-67 expression in tumor tissues.

Results

Forskolin significantly increased the expression of cleaved caspase-3/9 in both NHL Toledo and NK-92 cell lines, and inhibited cell growth. Besides, forskolin obviously reduced the expression of β-catenin protein, promoted its ubiquitination, enhanced its transportation from nuclear to cytoplasm, as well as decreased the expression of its downstream oncogenes c-myc and cyclin D1 through upregulating Axin expression and stability and inhibiting Axin ubiquitination. Moreover, forskolin enhanced the effects of SP600125, an inhibitor of c-Jun N-terminal kinase signaling on cell apoptosis promotion and tumorigenesis inhibition via Axin-induced β-catenin signaling repression.

Conclusion

The current study clarifies that forskolin can inhibit the progression of NHL through Axin-mediated inhibition of β-catenin signaling. Moreover, forskolin improves the effects of SP600125 on cell apoptosis enhancement and tumorigenesis inhibition of NHL cells. These findings provide theoretical foundation of serving forskolin as a new effective therapeutic drug for pediatric NHL.

In vitro evaluation of biological activities of Orobanche crenata Forssk. leaves extract

Orobanche crenata Forssk. (Orobanchaceae) is a holoparasitic plant noxious to legumes. Orobanchaceae are well known in traditional medicine for their hypotensive, antihyperglycemic, antispasmodic, analgesic and antimicrobial effects. In this work, the biological activities of the acetonic leaves extract were evaluated. Qualitative chemical analysis was determined through thin layer chromatography. Total phenols and flavonoids content was obtained by the Folin-Ciocalteu and the Aluminium chloride colorimetric methods, respectively. The antimicrobial activity was performed by the broth microdilution method. The extract showed antibacterial activity, particularly against Gram-positive strains, with MIC ranging from 376.00 to 3011.00 µg/ml. Besides, it exhibited antifungal effects on Candida spp. with MIC ranging from 94.10 to 3011.00 µg/ml. In addition, O. crenata inhibited superoxide anion formation and showed a DPPH quenching capacity, particularly at 80 µg/ml. Interestingly, our results are promising thus indicating the importance of O. crenata as a significant source of biologically active natural compounds.

Development of an advanced integrative process to create valuable biosugars including manno-oligosaccharides and mannose from spent coffee grounds

Spent coffee grounds (SCG) or coffee residue wastes (CRW) provide excellent raw material for mannose and bioethanol production. In this study, SCG were used to produce valuable biosugars, including oligosaccharides (OSs), manno-oligosaccharides (MOSs), mannose, and bioethanol. SCG were subjected to delignification and defatting, producing SCG-derived polysaccharides. Two-stage enzymatic hydrolysis (short- and long-term) was performed to produce short-chain manno-oligosaccharides (MOSs) and monosaccharides (MSs), respectively. From 100 g dry weight (DW) amounts of SCG, approximately 77 g delignified SCG and 61 g SCG-derived polysaccharides, amounts of 15.9 g of first biosugars (mostly MOSs), 25.6 g of second biosugars (mostly MSs), and 3.1 g of bioethanol, were recovered. This technique may aid in the production of high-value mannose and OSs from SCG and other lignocellulosic biomasses that contain specific polysaccharides.

Review of Catheter-Associated Urinary Tract Infections and In Vitro Urinary Tract Models

Catheter-associated urinary tract infections (CAUTIs) are one of the most common nosocomial infections and can lead to numerous medical complications from the mild catheter encrustation and bladder stones to the severe septicaemia, endotoxic shock, and pyelonephritis. Catheters are one of the most commonly used medical devices in the world and can be characterised as either indwelling (ID) or intermittent catheters (IC). The primary challenges in the use of IDs are biofilm formation and encrustation. ICs are increasingly seen as a solution to the complications caused by IDs as ICs pose no risk of biofilm formation due to their short time in the body and a lower risk of bladder stone formation. Research on IDs has focused on the use of antimicrobial and antibiofilm compounds, while research on ICs has focused on preventing bacteria entering the urinary tract or coming into contact with the catheter. There is an urgent need for in vitro urinary tract models to facilitate faster research and development for CAUTI prevention. There are currently three urinary tract models that test IDs; however, there is only a single very limited model for testing ICs. There is currently no standardised urinary tract model to test the efficacies of ICs.

Acute uncomplicated cystitis: is antibiotic unavoidable?

Background

Acute uncomplicated cystitis in women is one of the most frequently diagnosed bacterial infections.

Methods

In a pilot, open, noncomparative prospective study, 29 nonpregnant, sexually active women with acute uncomplicated cystitis were enrolled. The mean age was 28.9 ± 4.3, range 22-36 years. All patients received unique therapy: the nonsteroidal anti-inflammatory drug (NSAID) ketoprofen, 100 mg once a day for 5 days, and Canephron, 2 dragees three times a day for 1 month.

Results

In 2 days, four patients (13.8%) had no tendency to improvement; they were considered as nonresponders and antibiotics were prescribed for them. The remaining 25 patients (86.2%) showed significant improvement and were considered as responders; they continued the therapy with ketoprofen and Canephron. In 7 days, 21 patients (72.4%) had no dysuria and leucocyturia; they were considered as fast responders to phytotherapy. In four patients (13.8%), after 7 days of therapy insignificant dysuria and leucocyturia were found; they were considered as slow responders to phytotherapy. All 25 patients continued the intake of Canephron for 1 month to prevent a relapse. When treatment finished, all patients were well. In 6 months, no relapses were diagnosed.

Conclusion

The majority (86.2%) of young, nonpregnant women with acute uncomplicated cystitis were cured by 30 days of phytotherapy combined initially (5 days) with the NSAID ketoprofen; an antibiotic was indicated in only 13.8% of patients. Patients with acute uncomplicated cystitis may be divided into three subgroup: nonresponders to phytotherapy; slow responders to phytotherapy; fast responders to phytotherapy. Antibiotic therapy is indicated in nonresponders, but slow and fast responders may be treated without an antibiotic, by phytotherapy with an initial short course of an NSAID only.

Forskolin Sensitizes Human Acute Myeloid Leukemia Cells to H3K27me2/3 Demethylases GSKJ4 Inhibitor via Protein Kinase A

Acute myeloid leukemia (AML) is an aggressive hematological malignancy occurring very often in older adults, with poor prognosis depending on both rapid disease progression and drug resistance occurrence. Therefore, new therapeutic approaches are demanded. Epigenetic marks play a relevant role in AML. GSKJ4 is a novel inhibitor of the histone demethylases JMJD3 and UTX. To note GSKJ4 has been recently shown to act as a potent small molecule inhibitor of the proliferation in many cancer cell types. On the other hand, forskolin, a natural cAMP raising compound, used for a long time in traditional medicine and considered safe also in recent studies, is emerging as a very interesting molecule for possible use in cancer therapy. Here, we investigate the effects of forskolin on the sensitivity of human leukemia U937 cells to GSKJ4 through flow cytometry-based assays (cell-cycle progression and cell death), cell number counting, and immunoblotting experiments. We provide evidence that forskolin markedly potentiates GSKJ4-induced antiproliferative effects by apoptotic cell death induction, accompanied by a dramatic BCL2 protein down-regulation as well as caspase 3 activation and PARP protein cleavage. Comparable effects are observed with the phosphodiesterase inhibitor IBMX and 8-Br-cAMP analogous, but not by using 8-pCPT-2'-O-Me-cAMP Epac activator. Moreover, the forskolin-induced enhancement of sensitivity to GSKJ4 is counteracted by pre-treatment with Protein Kinase A (PKA) inhibitors. Altogether, our data strongly suggest that forskolin sensitizes U937 cells to GSKJ4 inhibitor via a cAMP/PKA-mediated mechanism. Our findings provide initial evidence of anticancer activity induced by forskolin/GSKJ4 combination in leukemia cells and underline the potential for use of forskolin and GSKJ4 in the development of innovative and effective therapeutic approaches for AML treatment.

Cardioprotection by Cocoa Polyphenols and ω-3 Fatty Acids: A Disease-Prevention Perspective on Aging-Associated Cardiovascular Risk

Cardiovascular disease (CVD) remains the leading cause of death today. Many of the biochemical alterations associated with the pathophysiology of CVD can be modified by adequate intakes of bioactive nutrients through a correct diet or supplementation. Recently, there has been growing public and clinical interest in cocoa polyphenols (CPs) and omega-3 (ω-3) fatty acids. A plethora of nutritional intervention trials and experimental studies demonstrates that consumption of these bioactive food compounds is beneficial to promote cardiovascular health. The purpose of this review is to summarize the major cardioprotective effects of CPs and ω-3 fatty acids, providing a scientific rationale for incorporating the combination of these molecules as a nutritional intervention in the prevention of CVD. Although several studies have shown the individual cardioprotective nature of these compounds, a combination treatment with CPs and ω-3 fatty acids may be a promising approach to enhance the preventive value of these molecules and reduce cardiovascular risk factors associated with aging. Therefore, this article also reviews some of the key studies on the interaction between CPs and the metabolism of ω-3 fatty acids.