The Benefits and Harms of Antibiotic Prophylaxis for Urinary Tract Infection in Older Adults

d-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women: A Randomized Clinical Trial

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.

Recurrent UTI in Women-Risk Factors and Management

Urinary tract infections (UTIs) are common in women; more than 50% of women will be diagnosed with a UTI in her lifetime. Many of these women will go on to develop recurrent UTI. Nevertheless, evidence-based prevention of recurrent UTI is under-utilized. Here, the authors provide detailed practical advice on UTI prevention with a thorough review of the evidence. Non-antibiotic prevention measures discussed include increased fluid intake, vaginal estrogen therapy, methenamine, and cranberry. Antibiotic prophyalxis for carefully selected patients is also discussed.

MV140 Mucosal Vaccine Induces Targeted Immune Response for Enhanced Clearance of Uropathogenic E. coli in Experimental Urinary Tract Infection

MV140 is an inactivated whole-cell bacterial mucosal vaccine with proven clinical efficacy against recurrent urinary tract infections (UTIs). These infections are primarily caused by uropathogenic E. coli (UPEC) strains, which are unique in their virulence factors and remarkably diverse. MV140 contains a non-UPEC strain, suggesting that it may induce an immune response against different UPEC-induced UTIs in patients. To verify this, we experimentally evaluated the cellular and humoral responses to UTI89, a prototypical UPEC strain, in mice vaccinated with MV140, as well as the degree of protection achieved in a UPEC UTI89 model of acute cystitis. The results show that both cellular (Th1/Th17) and antibody (IgG/IgA) responses to UTI89 were induced in MV140-immunized mice. MV140 vaccination resulted in an early increased clearance of UTI89 viable bacteria in the bladder and urine following transurethral infection. This was accompanied by a highly significant increase in CD4+ T cells in the bladder and an increase in urinary neutrophils. Collectively, our results support that MV140 induces cross-reactive humoral and cellular immune responses and cross-protection against UPEC strains.

Characteristics of Patients With Initial Clostridioides difficile Infection (CDI) That Are Associated With Increased Risk of Multiple CDI Recurrences

Background

Because interventions are available to prevent further recurrence in patients with recurrent Clostridioides difficile infection (rCDI), we identified predictors of multiple rCDI (mrCDI) in adults at the time of presentation with initial CDI (iCDI).

Methods

iCDI was defined as a positive C difficile test in any clinical setting during January 2018-August 2019 in a person aged ≥18 years with no known prior positive test. rCDI was defined as a positive test ≥14 days from the previous positive test within 180 days after iCDI; mrCDI was defined as ≥2 rCDI. We performed multivariable logistic regression analysis.

Results

Of 18 829 patients with iCDI, 882 (4.7%) had mrCDI; 437 with mrCDI and 7484 without mrCDI had full chart reviews. A higher proportion of patients with mrCDI than without mrCDI were aged ≥65 years (57.2% vs 40.7%; P < .0001) and had healthcare (59.1% vs 46.9%; P < .0001) and antibiotic (77.3% vs 67.3%; P < .0001) exposures in the 12 weeks preceding iCDI. In multivariable analysis, age ≥65 years (adjusted odds ratio [aOR], 1.91; 95% confidence interval [CI], 1.55-2.35), chronic hemodialysis (aOR, 2.28; 95% CI, 1.48-3.51), hospitalization (aOR, 1.64; 95% CI, 1.33-2.01), and nitrofurantoin use (aOR, 1.95; 95% CI, 1.18-3.23) in the 12 weeks preceding iCDI were associated with mrCDI.

Conclusions

Patients with iCDI who are older, on hemodialysis, or had recent hospitalization or nitrofurantoin use had increased risk of mrCDI and may benefit from early use of adjunctive therapy to prevent mrCDI. If confirmed, these findings could aid in clinical decision making and interventional study designs.

Methenamine for urinary tract infection prophylaxis: A systematic review

Urinary tract infections (UTIs) commonly affect many patient populations. Recurrent UTIs (rUTIs) can be particularly problematic and lead to potential hospitalizations, multiple antibiotic courses, and have a potential negative impact on quality of life. To prevent UTIs, antibiotics are frequently used for prophylaxis; however, antibiotic prophylaxis has notable untoward consequences including but not limited to potential adverse effects and development of antibiotic resistance. Methenamine, an antiseptic agent initially available in 1967, has re-emerged as a potential option for UTI prophylaxis in various populations, including older adults and renal transplant recipients. The objective of this systematic review was to evaluate the clinical effectiveness and safety of methenamine for UTI prophylaxis. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance was performed. A PubMed, Embase, and Cochrane library search was conducted to identify relevant English-language studies evaluating methenamine for UTI prophylaxis including randomized controlled trials, case-control studies, and meta-analyses through June 2023. Articles were excluded if the studies did not primarily describe or evaluate methenamine for UTI prophylaxis, were commentaries/viewpoints articles, point prevalence studies, review articles, studies that evaluated methenamine used with another agent, and any duplicate publications from searched databases. A total of 11 articles were identified for inclusion. This systematic review suggests methenamine generally appears to be an effective and well-tolerated antibiotic-sparing option for UTI prophylaxis. Furthermore, the pharmacology, dosage and formulation, warnings, precautions, and safety considerations of methenamine that provide potential clinical considerations regarding its use for UTI prophylaxis are described. Further studies are needed to evaluate the clinical utility of methenamine for UTI prophylaxis.

Diagnostic accuracy of urine biomarkers for urinary tract infection in older women: a case-control study

OBJECTIVES

Urinary tract infection (UTI) is common among older women. However, diagnosis is challenging because of frequent chronic lower urinary tract symptoms, cognitive impairment, and a high prevalence of asymptomatic bacteriuria (ASB). Current urine diagnostics lack specificity, leading to unnecessary treatment and antimicrobial resistance. This study aimed to evaluate the diagnostic accuracy of 12 urine biomarkers for diagnosing UTI in older women.

METHODS

In this case-control study, cases were women ≥65 years with ≥2 new-onset lower urinary tract symptoms, pyuria, and one uropathogen ≥104 CFU/mL. Controls were asymptomatic and classified as ASB (one uropathogen ≥105 CFU/mL), negative culture, or mixed flora. Urine biomarker concentrations were measured through liquid chromatography-mass spectrometry and ELISA. Diagnostic accuracy parameters of individual biomarkers and a biomarker model were derived from receiver operating characteristic curves.

RESULTS

We included 162 community-dwelling and institutionalized older women. Five urine inflammatory biomarkers demonstrated high discriminative ability (area under the curve ≥0.80): interleukin 6, azurocidin, neutrophil gelatinase-associated lipocalin, tissue inhibitor of metalloproteinases 2, and C-X-C motif chemokine 9. Azurocidin exhibited the highest diagnostic accuracy (sensitivity 86% [95% CI 75%-93%] and specificity 89% [95% CI 82%-94%] at 16.7 ng/mmol creatinine). A combined biomarker and pyuria model showed improved diagnostic accuracy in patients with UTI and ASB, compared with pyuria alone.

DISCUSSION

We identified several urine biomarkers that accurately differentiated older women with UTI from asymptomatic women, including ASB. These findings represent a potential advancement towards improved diagnostics for UTI in older women and warrant validation in a diverse population.

Repurposing antibiotic resistance surveillance data to support treatment of recurrent infections in a remote setting

In northern Australia, a region with limited access to healthcare and a substantial population living remotely, antibiotic resistance adds to the complexity of treating infections. Focussing on Escherichia coli urinary tract infections (UTIs) and Staphylococcus aureus skin & soft tissue infections (SSTIs) captured by a northern Australian antibiotic resistance surveillance system, we used logistic regression to investigate predictors of a subsequent resistant isolate during the same infection episode. We also investigated predictors of recurrent infection. Our analysis included 98,651 E. coli isolates and 121,755 S. aureus isolates from 70,851 patients between January 2007 and June 2020. Following an initially susceptible E. coli UTI, subsequent recovery of a cefazolin (8%) or ampicillin (13%) -resistant isolate during the same infection episode was more common than a ceftriaxone-resistant isolate (2%). For an initially susceptible S. aureus SSTI, subsequent recovery of a methicillin-resistant isolate (8%) was more common than a trimethoprim-sulfamethoxazole-resistant isolate (2%). For UTIs and SSTIs, prior infection with a resistant pathogen was a strong predictor of both recurrent infection and resistance in future infection episodes. This multi-centre study demonstrates an association between antibiotic resistance and an increased likelihood of recurrent infection. Particularly in remote areas, a patient's past antibiograms should guide current treatment choices since recurrent infection will most likely be at least as resistant as previous infection episodes. Using population-level surveillance data in this way can also help clinicians decide if they should switch antibiotics for patients with ongoing symptoms, while waiting for diagnostic results.

Antimicrobial treatment imprecision: an outcome-based model to close the data-to-action loop

Health-care systems, food supply chains, and society in general are threatened by the inexorable rise of antimicrobial resistance. This threat is driven by many factors, one of which is inappropriate antimicrobial treatment. The ability of policy makers and leaders in health care, public health, regulatory agencies, and research and development to deliver frameworks for appropriate, sustainable antimicrobial treatment is hampered by a scarcity of tangible outcome-based measures of the damage it causes. In this Personal View, a mathematically grounded, outcome-based measure of antimicrobial treatment appropriateness, called imprecision, is proposed. We outline a framework for policy makers and health-care leaders to use this metric to deliver more effective antimicrobial stewardship interventions to future patient pathways. This will be achieved using learning antimicrobial systems built on public and practitioner engagement; solid implementation science; advances in artificial intelligence; and changes to regulation, research, and development. The outcomes of this framework would be more ecologically and organisationally sustainable patterns of antimicrobial development, regulation, and prescribing. We discuss practical, ethical, and regulatory considerations involved in the delivery of novel antimicrobial drug development, and policy and patient pathways built on artificial intelligence-augmented measures of antimicrobial treatment imprecision.

Urinary tract infections: a review of the current diagnostics landscape

Urinary tract infections are the most common bacterial infections worldwide. Infections can range from mild, recurrent (rUTI) to complicated (cUTIs), and are predominantly caused by uropathogenic Escherichia coli (UPEC). Antibiotic therapy is important to tackle infection; however, with the continued emergence of antibiotic resistance there is an urgent need to monitor the use of effective antibiotics through better stewardship measures. Currently, clinical diagnosis of UTIs relies on empiric methods supported by laboratory testing including cellular analysis (of both human and bacterial cells), dipstick analysis and phenotypic culture. Therefore, development of novel, sensitive and specific diagnostics is an important means to rationalise antibiotic therapy in patients. This review discusses the current diagnostic landscape and highlights promising novel diagnostic technologies in development that could aid in treatment and management of antibiotic-resistant UTIs.

Antibiotic Selection and Duration for Catheter-Associated Urinary Tract Infection in Non-Hospitalized Older Adults: A Population-Based Cohort Study

Background

We sought to evaluate the impact of antibiotic selection and duration of therapy on treatment failure in older adults with catheter-associated urinary tract infection (CA-UTI).

Methods

We conducted a population-based cohort study comparing antibiotic treatment options and duration of therapy for non-hospitalized adults aged 66 and older with presumed CA-UTI (defined as an antibiotic prescription and an organism identified in urine culture in a patient with urinary catheterization documented within the prior 90 d). The primary outcome was treatment failure, a composite of repeat urinary antibiotic prescribing, positive blood culture with the same organism, all-cause hospitalization or mortality, within 60 days. We determined the risk of treatment failure accounting for age, sex, comorbidities, and healthcare exposure using log-binomial regression.

Results

Of 4,436 CA-UTI patients, 2,709 (61.1%) experienced treatment failure. Compared to a reference of TMP-SMX (61.9% failure), of those treated with fluoroquinolones, 56.3% experienced failure (RR 0.91, 95% CI: 0.85-0.98) and 60.9% of patients treated with nitrofurantoin experienced failure (RR 1.02, 95% CI: 0.94-1.10). Compared to 5-7 days of therapy (treatment failure: 59.4%), 1-4 days was associated with 69.5% failure (RR 1.15, 95% CI: 1.05-1.27), and 8-14 days was associated with a 62.0% failure (RR 1.05, 95% CI: 0.99-1.11).

Conclusions

Although most treatment options for CA-UTI have a similar risk of treatment failure, fluoroquinolones, and treatment durations ≥ 5 days in duration appear to be associated with modestly improved clinical outcomes. From a duration of therapy perspective, this study provides reassurance that relatively short courses of 5-7 days may be reasonable for CA-UTI.

Recurrent Urinary Tract Infection in Adult Patients, Risk Factors, and Efficacy of Low Dose Prophylactic Antibiotics Therapy

BACKGROUND

Recurrent urinary tract infection (UTI) occurs in sizable percentages of patients after a single episode and is a frequent cause of primary healthcare visits and hospital admissions, accounting for up to one quarter of emergency department visits. We aim to describe the pattern of continuous antibiotic prophylaxis prescription for recurrent urinary tract infections, in what group of adult patients they are prescribed and their efficacy.

METHODS

A retrospective chart review of all adult patients diagnosed with single and recurrent symptomatic urinary tract infection in the period of January 2016 to December 2018.

RESULTS

A total of 250 patients with a single UTI episode and 227 patients with recurrent UTI episodes were included. Risk factors for recurrent UTI included diabetes mellitus, chronic renal disease, and use of immunosuppressive drugs, renal transplant, any form of urinary tract catheterization, immobilization and neurogenic bladder. E. coli infections were the most prevalent organism in patients with UTI episodes. Prophylactic antibiotics were given to 55% of patients with UTIs, Nitrofurantoin, Bactrim or amoxicillin clavulanic acid. Post renal transplant is the most frequent reason to prophylaxis antibiotics (44%). Bactrim was more prescribed in younger patients (P < 0.001), in post-renal transplantation (P < 0.001) and after urological procedures (P < 0.001), while Nitrofurantoin was more prescribed in immobilized patients (P = 0.002) and in patients with neurogenic bladder (P < 0.001). Patients who received continuous prophylactic antibiotics experienced significantly less episodes of urinary tract infections (P < 0.001), emergency room visits and hospital admissions due to urinary tract infections (P < 0.001).

CONCLUSION

Despite being effective in reducing recurrent urinary tract infection rate, emergency room visits and hospital admissions due to UTI, continuous antibiotic prophylaxis was only used in 55% of patients with recurrent infections. Trimethoprim/sulfamethoxazole was the most frequently used prophylactic antibiotic. Urology and gynecological referral were infrequently requested as part of the evaluation process for patients with recurrent UTI. There was a lack of use of other interventions such as topical estrogen in postmenopausal women and documentation of education on non-pharmacological methods to decrease urinary tract infections.

Microbiota Ecosystem in Recurrent Cystitis and the Immunological Microenvironment of Urothelium

Urinary tract infections (UTIs) represent one of the most frequent low genital tract diseases in the female population. When UTIs occur with a frequency of at least three times per year or two times in the last six month, we speak of recurrent UTI (rUTI) and up to 70% of women will have rUTI within 1 year. It was previously thought that antibiotic resistance was principally responsible for the recurrence of UTIs, but nowadays new diagnostic technologies have shown the role of microbiota in the pathophysiology of these diseases. Much research has been conducted on the role of gut microbiome in the development of rUTI, while little is known yet about vaginal and urinary microbiome and the possible immunological and microscopical mechanisms through which they trigger symptoms. New discoveries and clinical perspectives are arising, and they all agree that a personalized, multi-modal approach, treating vaginal and urinary dysbiosis, may reduce rUTIs more successfully.

Urinary Tract Infection Frequency and Prescription Prophylaxis in Females and Males with Recurrent Urinary Tract Infection

Females and males with recurrent urinary tract infections may receive prescription prophylaxis to reduce the infection frequency. Little is known about how prescription prophylaxis differs between patients meeting and exceeding the minimum threshold for recurrent urinary tract infections. The objectives of this study were to estimate the association between infection frequency and receipt of prescription prophylaxis and describe the type of prescription prophylaxis initiated. This observational study used de-identified fully-insured commercial insurance data from the Midwest from 2003-2016 to identify females and males under age 64 with recurrent urinary tract infections. The patients were categorized as having three or more urinary tract infections in twelve months or only two infections in six months. Multiple logistic regression models were used to determine the association between the infection frequency and receipt of prophylaxis. The frequency of the type of prophylaxis initiated was measured. The odds of receiving prophylaxis were greater in the females and males with three or more infections compared to the patients with only two infections. Estrogen prophylaxis was initiated at a higher rate in females aged 45-63 with two infections than the females with three or more infections. Prescription prophylaxis in females and males with recurrent urinary tract infections differs between those meeting and exceeding the minimum frequency threshold.

Post-procedural Antibiotic Use and Associated Outcomes After Common Urologic Procedures Across a National Healthcare System

OBJECTIVE

To quantify the benefits and harms of post-procedural antibiotic use after common urologic procedures.

MATERIALS AND METHODS

This retrospective cohort study included patients who underwent an endoscopic urologic procedure (transurethral resection of bladder tumor, transurethral resection of prostate, or ureteroscopy) within the Veterans Health Administration between January 1, 2017 and June 30, 2021. A post-procedural antibiotic was any qualifying antibiotic prescribed for administration on the day after the procedure. Guidelines generally do not recommend post-procedural antibiotics for surgical prophylaxis. Outcomes included unplanned return visits and Clostridioides difficile infection within 30 days. Log-binomial models with risk-adjustment were used to measure the association between post-procedural antibiotic use and outcomes. Hospital-level observed-to-expected (O:E) ratios were constructed to compare post-procedural antibiotic use.

RESULTS

There were 74,629 qualifying procedures across 105 hospitals; 27,422 (36.7%) received post-procedural antibiotics (median 3 days, IQR 3-6). An unplanned return visit occurred in 20.2% of patients who received post-procedural antibiotics vs 17.2% who did not (adjusted RR 1.032, 95% CI 0.999-1.066). C. difficile infection was diagnosed in 0.27% vs 0.10% in those who received and did not receive post-procedural antibiotics (adjusted RR 1.67, 95% CI 1.13-2.45). The O:E ratio for post-procedural antibiotic use ranged from 0.46 among hospitals in the lowest-use quartile to 1.93 in the highest-use quartile.

CONCLUSION

Post-procedural antibiotics were frequently prescribed after urologic procedures with large inter-facility variability even after adjusting for case-mix differences. Post-procedural antibiotic use was associated with increased risk for C. difficile infection but not fewer unplanned return visits. Efforts to reduce guideline-discordant use of post-procedural antibiotics are needed.

Electro-fulguration for extensive inflammatory bladder lesions in post-menopausal women with antibiotic-recalcitrant recurrent urinary tract infections

INTRODUCTION AND HYPOTHESIS

To evaluate how women with uncomplicated antibiotic-recalcitrant recurrent urinary tract infections (RUTIs) and extensive inflammatory bladder lesions on office cystoscopy responded to electro-fulguration (EF) to eliminate these chronic bladder sites.

METHODS

After IRB approval, a retrospective study of non-neurogenic women with RUTIs, inflammatory lesions on cystoscopy, and who underwent EF was performed. Lesions were classified through a simplified staging system based on the extent of bladder wall involvement. Only those with extensive bladder wall involvement (stages 3 and 4) at the time of EF were analyzed in this report. Six months after EF, an office cystoscopy was performed, with endoscopic success defined as no lesions seen. The primary clinical outcome was number of symptomatic UTIs after EF, defined as cure (0/year), improvement (1-2/year), and failure (≥3/year).

RESULTS

From 2007 to 2019, a total of 57 women met the study criteria, 30 stage 3 and 27 stage 4. Nineteen (63%) were endoscopically successful in stage 3 and 11 (41%) in stage 4. Mean follow-up was 2.9 years (stage 3) and 3.1 years (stage 4). All had at least a 6-month UTI follow-up after the 6 months of office cystoscopy, with 15 patients cured, 37 improved, and 5 failed (all stage 4).

CONCLUSIONS

Although EF only resulted in 63% complete endoscopic resolution, the majority experienced a decrease in the frequency of UTIs, suggesting that EF can be durably effective even in women with very extensive cystitis lesions.

Antibiotics versus no treatment for asymptomatic bacteriuria in residents of aged care facilities: a systematic review and meta-analysis

BACKGROUND

Asymptomatic bacteriuria (ASB) is common among residents of residential aged care facilities (RACFs). However, differentiating between an established urinary tract infection and ASB in older adults is difficult. As a result, the overuse of dipstick urinalysis, as well as the subsequent initiation of antibiotics, is common in RACFs.

AIM

To find, appraise, and synthesise studies that reported the effectiveness, harms, and adverse events associated with antibiotic treatment for older patients with ASB residing in RACFs.

DESIGN AND SETTING

A systematic review using standard Cochrane methods of RACF residents with ASB using antibiotics against placebo, or no treatment.

METHOD

Three electronic databases (PubMed, EMBASE, and CENTRAL), clinical trial registries, and forward-backward reference checks of included studies were searched.

RESULTS

Nine randomised controlled trials, comprising 1391 participants were included; two of which used a placebo comparator, and the remaining seven used no therapy control groups. There was a relatively small number of studies assessed per outcome and an overall moderate risk of bias. Outcomes related to mortality, development of ASB, and complications were comparable between the two groups. Antibiotic therapy was associated with a higher number of adverse effects (four studies; 303 participants; risk ratio [RR] 5.62, 95% confidence interval [CI] = 1.07 to 29.55, P = 0.04) and bacteriological cure (nine studies; 888 participants; RR 1.89, 95% CI = 1.08 to 3.32, P = 0.03).

CONCLUSION

Overall, although antibiotic treatment was associated with bacteriological cure, it was also associated with significantly more adverse effects. The harms and lack of clinical benefit of antibiotic use for older patients in RACFs may outweigh the benefits.

A New Strategy to Prevent "Deja vUTI"

Deja vu is the sensation of having a recurrent experience. Within a year after an initial urinary tract infection (UTI), up to 30% of women will experience a recurrence of UTI symptoms.1 A smaller group of women (1%) may experience frequent recurrence with six or more episodes in a year. Recurrent UTI, or "deja vUTI," is a challenging problem that still lacks a cohesive pathophysiological mechanism, and it is currently addressed with a wide range of clinical practices often based on experience rather than on high-quality evidence.

Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: multicentre, open label, randomised, non-inferiority trial

OBJECTIVE

To test and compare the efficacy of methenamine hippurate for prevention of recurrent urinary tract infections with the current standard prophylaxis of daily low dose antibiotics.

DESIGN

Multicentre, open label, randomised, non-inferiority trial.

SETTING

Eight centres in the UK, recruiting from June 2016 to June 2018.

PARTICIPANTS

Women aged ≥18 years with recurrent urinary tract infections, requiring prophylactic treatment.

INTERVENTIONS

Random assignment (1:1, using permuted blocks of variable length via a web based system) to receive antibiotic prophylaxis or methenamine hippurate for 12 months. Treatment allocation was not masked and crossover between arms was allowed.

MAIN OUTCOME MEASURE

Absolute difference in incidence of symptomatic, antibiotic treated, urinary tract infections during treatment. A patient and public involvement group predefined the non-inferiority margin as one episode of urinary tract infection per person year. Analyses performed in a modified intention-to-treat population comprised all participants observed for at least six months.

RESULTS

Participants were randomly assigned to antibiotic prophylaxis (n=120) or methenamine hippurate (n=120). The modified intention-to-treat analysis comprised 205 (85%) participants (antibiotics, n=102 (85%); methenamine hippurate, n=103 (86%)). Incidence of antibiotic treated urinary tract infections during the 12 month treatment period was 0.89 episodes per person year (95% confidence interval 0.65 to 1.12) in the antibiotics group and 1.38 (1.05 to 1.72) in the methenamine hippurate group, with an absolute difference of 0.49 (90% confidence interval 0.15 to 0.84) confirming non-inferiority. Adverse reactions were reported by 34/142 (24%) in the antibiotic group and 35/127 (28%) in the methenamine group and most reactions were mild.

CONCLUSION

Non-antibiotic prophylactic treatment with methenamine hippurate might be appropriate for women with a history of recurrent episodes of urinary tract infections, informed by patient preferences and antibiotic stewardship initiatives, given the demonstration of non-inferiority to daily antibiotic prophylaxis seen in this trial.

TRIAL REGISTRATION

ISRCTN70219762.

Increasing the usefulness of acupuncture guideline recommendations

Yu-Qing Zhang and colleagues examine the progress and pitfalls in guideline recommendations for acupuncture and provide suggestions for improvement

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.

Effect of Urogenital Infection Educational Program on Women Knowledge and Practices

Background:

Urogenital infection is generally regarded as a silent epidemic. It is one of the major public health problems among women that causes a considerable proportion of gynecological morbidity and maternal mortality in developing countries.

Aim:

The aim of this study is to evaluate the effect of an educational program on women’s knowledge and practices about urogenital infection.

Methods:

A quasi-experimental research design was utilized in this study and was implemented at El Hadaka Maternity and Children’s Hospital (MCH) in Fayoum, Egypt. A purposive sample consisting of 50 women with ages ranging from 30 to 45 years old was considered for this study.

Two tools were used to conduct this study: a structured interview questionnaire consisting of the respondents’ demographic characteristics, knowledge, and practices regarding urogenital infection and a scale that aimed to assess their lifestyle.

Results:

The results revealed that 96% of the women have unsatisfactory knowledge about urogenital infection during the pre-intervention stage, 94% of them have satisfactory knowledge post-intervention, and 90% of them have satisfactory knowledge at follow-up, with a highly statistically significant difference at p-value < 0.01. The results also showed that 82% of the respondents have unsatisfactory practices at pre-intervention, 96% have satisfactory practices at post-intervention, and 98% of them have satisfactory practices at follow-up, with a highly statistically significant difference at p-value < 0.01.

Conclusion:

There was a significant improvement in women's knowledge and practices related to urogenital infection post-intervention and at follow-up with a p-value < 0.01. Likewise, a high positive correlation between total lifestyle, level of knowledge, and practices was noted during the pretest with a p-value < 0.01.

There is a need to provide different educational programs regarding knowledge and self-care practices for women with urogenital infection in different women's care settings.

Effect of Urogenital Infection Educational Program on Women Knowledge and Practices

Background:

Urogenital infection is generally regarded as a silent epidemic. It is one of the major public health problems among women that causes a considerable proportion of gynecological morbidity and maternal mortality in developing countries.

Aim:

The aim of this study is to evaluate the effect of an educational program on women’s knowledge and practices about urogenital infection.

Methods:

A quasi-experimental research design was utilized in this study and was implemented at El Hadaka Maternity and Children’s Hospital (MCH) in Fayoum, Egypt. A purposive sample consisting of 50 women with ages ranging from 30 to 45 years old was considered for this study.

Two tools were used to conduct this study: a structured interview questionnaire consisting of the respondents’ demographic characteristics, knowledge, and practices regarding urogenital infection and a scale that aimed to assess their lifestyle.

Results:

The results revealed that 96% of the women have unsatisfactory knowledge about urogenital infection during the pre-intervention stage, 94% of them have satisfactory knowledge post-intervention, and 90% of them have satisfactory knowledge at follow-up, with a highly statistically significant difference at p-value < 0.01. The results also showed that 82% of the respondents have unsatisfactory practices at pre-intervention, 96% have satisfactory practices at post-intervention, and 98% of them have satisfactory practices at follow-up, with a highly statistically significant difference at p-value < 0.01.

Conclusion:

There was a significant improvement in women's knowledge and practices related to urogenital infection post-intervention and at follow-up with a p-value < 0.01. Likewise, a high positive correlation between total lifestyle, level of knowledge, and practices was noted during the pretest with a p-value < 0.01.

There is a need to provide different educational programs regarding knowledge and self-care practices for women with urogenital infection in different women's care settings.

A global perspective on improving patient care in uncomplicated urinary tract infection: Expert consensus and practical guidance

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are a common problem in women. Management is mainly based on empirical prescribing, but there are concerns about overtreatment and antimicrobial resistance (AMR), especially in patients with recurrent uUTIs.

METHODS

A multidisciplinary panel of experts met to discuss diagnosis, treatment, prevention, guidelines, AMR, clinical trial design, and the impact of COVID-19 on clinical practice.

RESULTS

Symptoms remain the cornerstone of uUTI diagnosis, and urine culture is necessary only when empirical treatment fails, or rapid recurrence of symptoms or AMR is suspected. Specific antimicrobials are first-line therapy (typically nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, and pivmecillinam; dependent on availability and local resistance data). Fluoroquinolones are not first-line options for uUTIs due primarily to safety concerns, but also rising resistance rates. High-quality data to support most non-antimicrobial approaches are lacking. Local AMR data specific to community-acquired uUTIs are needed, but representative information is difficult to obtain; instead, identification of risk factors for AMR can provide a basis to guide empirical antimicrobial prescribing. The COVID-19 pandemic has impacted management of uUTIs in some countries and may have long-lasting implications for future models of care.

CONCLUSIONS

The management of uUTIs in women can be improved without increasing complexity, including simplified diagnosis, and empirical antimicrobial prescribing based on patient characteristics, including review of recent antimicrobial use and past pathogen resistance profiles, drug availability, and guidelines. Current data for non-antimicrobial approaches are limited. The influence of COVID-19 on telehealth could provide an opportunity to enhance patient care in the long term.

Indications for medical antibiotic prophylaxis and potential targets for antimicrobial stewardship intervention: a narrative review

BACKGROUND

Most of the antimicrobial stewardship (AMS) literature has focused on antimicrobial consumption for the treatment of infections, for the prophylaxis of surgical site infection and for the prevention of endocarditis. The role of AMS for medical antibiotic prophylaxis (AP) has not been adequately addressed.

AIMS

To identify targets for AMS interventions for medical AP in adult patients.

SOURCES

Targeted searches were conducted in PubMed.

CONTENT

The various indications for medical AP and relevant evidence from practice guidelines are outlined. The following were identified as potential targets for AMS interventions: (a) addressing under-utilization of antibiotic-sparing strategies (e.g. for recurrent urinary tract infections, recurrent soft-tissue infections, recurrent exacerbations associated with bronchiectasis or chronic obstructive pulmonary disease), (b) reducing unnecessary AP beyond recommended indications (e.g. for acute pancreatitis, bite wounds, or urinary catheter manipulations), (c) reducing the use of AP with a broader spectrum than necessary, (d) reducing the use of AP for longer than the recommended duration (e.g. AP for prevention of osteomyelitis in open fractures or AP in high-risk neutropenia), (e) evaluating the role of antibiotic cycling to prevent the emergence of resistance during prolonged AP (e.g. in recurrent urinary tract infections or prophylaxis for spontaneous bacterial peritonitis), and (f) addressing research gaps regarding appropriate indications or antibiotic regimens for medical prophylaxis.

IMPLICATIONS

This review summarizes current trends in AP and proposes targets for AMS interventions.