Estrogen & recurrent UTI in postmenopausal women

Systematic Review of Interventions to Reduce Urinary Tract Infection in Nursing Home Residents

BACKGROUND

Urinary tract infections (UTIs) in nursing homes are common, costly, and morbid.

PURPOSE

Systematic literature review of strategies to reduce UTIs in nursing home residents.

DATA SOURCES

Ovid MEDLINE, Cochrane Library, CINAHL, Web of Science and Embase through June 22, 2015.

STUDY SELECTION

Interventional studies with a comparison group reporting at least 1 outcome for: catheter-associated UTI (CAUTI), UTIs not identified as catheter-associated, bacteriuria, or urinary catheter use.

DATA EXTRACTION

Two authors abstracted study design, participant and intervention details, outcomes, and quality measures.

DATA SYNTHESIS

Of 5794 records retrieved, 20 records describing 19 interventions were included: 8 randomized controlled trials, 10 pre-post nonrandomized interventions, and 1 nonrandomized intervention with concurrent controls. Quality (range, 8-25; median, 15) and outcome definitions varied greatly. Thirteen studies employed strategies to reduce catheter use or improve catheter care; 9 studies employed general infection prevention strategies (eg, improving hand hygiene, surveillance, contact precautions, reducing antibiotics). The 19 studies reported 12 UTI outcomes, 9 CAUTI outcomes, 4 bacteriuria outcomes, and 5 catheter use outcomes. Five studies showed CAUTI reduction (1 significantly); 9 studies showed UTI reduction (none significantly); 2 studies showed bacteriuria reduction (none significantly). Four studies showed reduced catheter use (1 significantly).

LIMITATIONS

Studies were often underpowered to assess statistical significance; none were pooled given variety of interventions and outcomes.

CONCLUSIONS

Several practices, often implemented in bundles, such as improving hand hygiene, reducing and improving catheter use, managing incontinence without catheters, and enhanced barrier precautions, appear to reduce UTI or CAUTI in nursing home residents. Journal of Hospital Medicine 2017;12:356-368.

Empiric antibiotic therapy in acute uncomplicated urinary tract infections and fluoroquinolone resistance: a prospective observational study

BACKGROUND

The aims of this study were to determine the antimicrobial susceptibility patterns of urinary isolates from community acquired acute uncomplicated urinary tract infections (uUTI) and to evaluate which antibiotics were empirically prescribed in the outpatient management of uUTI.

METHODS

Among the patients which were admitted to outpatient clinics of Ankara University Medical Faculty, Ibni-Sina Hospital during 2005-2006, a total of 429 women between the age of 18 and 65 years old who were clinically diagnosed with uUTI and to whom prescribed empirical antibiotics were enrolled in this prospective observational study. Patients' demographical data, urine culture results, resistance rates to antimicrobial agents and prescribed empiric antimicrobial therapy were analyzed.

RESULTS

Totally 390 (90.9%) patients among all study population were requested for urine culture by their physicians. 150 (38.5%) of these urine cultures were positive. The most common isolated uropathogen was Escherichia coli (E. coli) (71.3%). The variations of uropathogens according to age and menopause status were not significantly different.The resistance rates of E. coli isolates for ampicillin, ampicillin-sulbactam, amoxicillin-clavulonate, cefuroxime, ceftriaxone, fluoroquinolones (FQ), co-trimoxazole (TMP-SMX) and gentamicin were 55.1%, 32.7%, 32.7%, 23.4%, 15.9%, 25.2%, 41.1%, 6.1% respectively. FQ were the most common prescribed antibiotics (77.9%) (P < 0.001), followed by TMP-SMX (10.7%), fosfomycin (9.2%), nitrofurantoin (2.1%). Treatment durations were statistically longer than the recommended 3-day course (P < 0.001).

CONCLUSION

Empirical use of FQ in uUTI should be discouraged because of increased antimicrobial resistance rates.

Urinary Incontinence and Estrogen

Is hormone replacement therapy an effective treatment?

Urinary tract infections in general practice patients: diagnostic tests versus bacteriological culture

OBJECTIVES

Urinary tract infections (UTIs) are common bacterial infections encountered in general practice. For the optimal treatment the general practitioner (GP) should rely on the results of diagnostic tests and recent antimicrobial susceptibility of uropathogens.

PATIENTS AND METHODS

In total 1993 female patients (11-70 years) with complaints of an acute uncomplicated UTI were included. The performance characteristics of the diagnostic tests used were determined and compared with the antibiotic prescription rate. The antibiotic therapy (agent and duration), the uropathogens and the antibiotic susceptibility of Escherichia coli were determined for each age group.

RESULTS

The positive predictive value (PPV) (96%) and the specificity (94%) of the nitrite test were high for all samples. A negative nitrite with a positive leucocyte-esterase (LE) test showed a high PPV (79%) and sensitivity (82%). When both nitrite and LE tests were negative approximately 50% of the samples were culture positive. Of the patients, 94% of those with a positive nitrite test and 71% of those with a negative nitrite and positive LE test were prescribed antibiotics, mostly nitrofurantoin and trimethoprim. Nitrofurantoin prescriptions decreased and those of fluoroquinolones increased with increasing age. Nitrofurantoin was equally prescribed for 3-7 days in all patients. Trimethoprim was mostly prescribed for 3 days in patients aged 21-50 years and for 5 days in the other patients. E. coli, the uropathogen mostly isolated, decreased in frequency with increasing age. Proteus mirabilis was found more in the oldest patients and Staphylococcus saprophyticus in the younger patients. The antimicrobial susceptibility of E. coli was not age related. The lowest percentages were found for amoxicillin (67%) and trimethoprim (77%). Fluoroquinolone resistance was emerging in the older patients.

CONCLUSIONS

For female patients with symptoms of an acute uncomplicated UTI a positive nitrite test or a negative nitrite test with a positive LE test confirmed UTI whereas a negative nitrite together with a negative LE test did not rule out infection. For empirical treatment GPs should take into account the changing aetiology with increasing age. Prudent use of antibiotics in general and more specifically fluoroquinolones remains recommended. As trimethoprim resistance reached 20% it might be advisable to no longer use it as therapy of first choice for acute uncomplicated UTIs in The Netherlands.

Treatment of atrophic vaginitis with topical conjugated equine estrogens in postmenopausal Asian women

OBJECTIVE

We investigated the effects of 2 months of treatment with topical estrogens on atrophic vaginitis and gynecological health in Asian women.

STUDY DESIGN

Multicenter, open-label trial of 150 postmenopausal women age <70 years with atrophic vaginitis. Women applied conjugated equine estrogens (CEE) vaginal cream (0.625 mg/g) once daily on days 1-21 of two 28-day cycles. Changes in the vaginal maturation index (VMI) from baseline to days 21 (month 1) and 49 (month 2) were the primary outcome. Physiological changes were assessed by the Genital Health Clinical Examination (GHCE).

RESULTS

The VMI was significantly improved (p < 0.001) from baseline at each assessment period. The significant improvement in GHCE from baseline after 1 month (p < 0.001) was maintained at 2 months.

CONCLUSIONS

Vaginal treatment with CEE cream for 21 days of two consecutive 28-day cycles resulted in beneficial changes in the vaginal tissues and induced an overall genital health pattern more characteristic of the premenopausal state.

Effects of Local Estrogen Therapy on Recurrent Urinary Tract Infections in Young Females under Oral Contraceptives

BACKGROUND

Previous studies have demonstrated the efficacy of local application of estrogen in treating postmenopausal women with recurrent urinary tract infections (RUTI) and urinary incontinence. Younger women under oral contraceptives (OC) can suffer from similar symptoms. The aim of this pilot study was to evaluate the effectiveness of local estrogens on RUTI and the impact of local hormonal supplementation on bladder neck vascularization.

METHODS

30 women (mean age 22.7 years) with a longstanding history of RUTI were included. Pre-treatment investigation included complete clinical history, urinalysis, urine culture and cystoscopy. All subjects completed a questionnaire about onset and duration of disease and quality of life before and after treatment. Local (vaginal) estrogen therapy consisted of 1mg estriol (E3) 7 times a week for two weeks and twice a week for two additional weeks. Sonographic examination of bladder vascularization was performed before and after treatment using transperineal color Doppler ultrasound (6 MHz, Acuson Sequoia 512, Mountain View, CA, USA) with a filled bladder. After angle correction, peak systolic blood flow velocity (PSBFV) and end diastolic blood flow velocity (EDBFV) were measured in 2 bladder arteries; and the Resistive Index (RI) was calculated. Flow velocity in each vessel was measured at least four times and the mean value determined.

RESULTS

All patients completed the therapy course without severe side effects. Patients had a mean history of RUTI over 2.3 years; the mean period under OC was 3.2 years. In the follow-up period of 11 months after treatment, 24/30 patients reported no symptoms of cystitis and used no additional medication. Normal bladder epithelium in control cystoscopy after E3 therapy was seen in all patients with trigonal metaplasia and vulnerable, highly vascularized urothelium at the initial investigation. RI decreased from 0.945 to 0.705 after treatment (p<0.001), concomitantly the mean EDBFV increased highly significantly from 0.82 cm/sec to 4.45 cm/sec after estrogen treatment (p<0.001).

INTERPRETATION

In a majority of young patients under OC and a longstanding history of RUTI, a considerable infection-free period was achieved after local application of estrogen. Decreased RI and increased EDBFV indicate vasodilatation and less peripheral vascular resistance. Responsiveness to local E3 may correspond to improved cystoscopic findings as a consequence of increased bladder perfusion.