Womens' self-management skills for prevention and treatment of recurring urinary tract infection

Characteristics Associated With Recurrent Urinary Tract Infections: A Case-Control Study

IMPORTANCE

Recurrent urinary tract infections (rUTIs) affect 2-10% of adult women and are associated with a significant effect on quality of life, daily activities, and mental health.

OBJECTIVE

The aim of this study was to identify clinical characteristics associated with rUTIs among women seeking care for pelvic floor disorders at an academic tertiary urogynecology clinic.

STUDY DESIGN

A retrospective case-control study of women presenting to an academic tertiary urogynecology clinic was conducted. Cases were women with rUTIs, defined as ≥2 UTIs in 6 months or ≥3 within 1 year. Controls were women with no culture documented UTIs. Cases were matched 2:1 to controls by age and body mass index. Demographic and clinical characteristics were compared between cases and controls, and bivariate characteristics with P values ≤0.2 were assessed for an independent association with rUTIs by multivariable logistic regression.

RESULTS

A total of 285 cases with rUTIs were identified, and 150 matched controls had a mean (SD) age of 72 (11.8) years and a body mass index of 29.6 (6.7; calculated as weight in kilograms divided by height in meters squared). Multivariable analysis revealed that prolapse beyond the introitus (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.13-0.60), parity (OR, 1.33; 95% CI, 1.08-1.64), Charlson Comorbidity Index (OR, 1.66; 95% CI, 1.37-2.03), and postvoid residual volume ≥100 mL (OR, 4.05; 95% CI, 2.01, 8.18) were associated with rUTIs.

CONCLUSIONS

In this ambulatory urogynecologic population, prolapse through the introitus was negatively associated with rUTIs, whereas parity, increased medical comorbidities, and elevated postvoid residual volume were positively associated with rUTI. Future research should seek an increased understanding of these factors associated with rUTI to implement effective preventive strategies.

Unravelling patient pathways in the context of antibacterial resistance in East Africa

BACKGROUND

A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high.

METHODS

The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs.

RESULTS

Although most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability.

CONCLUSION

There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).

An Analysis of Google Trends During COVID-19: Determining Public Urological Cancer Concerns

Background The COVID-19 pandemic put a massive strain on the healthcare system as patients avoided the hospital, elective cases were postponed, and general medical anxiety was increased. We aimed to capture public interest in urological cancers during this massive shock to the medical field. Methodology A total of 12 keywords related to the three most prevalent urological cancers (prostate, bladder, and kidney) were searched using Google Trends from 2018 to 2022. The search volume index of these 12 keywords was extracted to assess public interest before and after the pandemic. Results There was a reduction in search volume for "prostate, bladder, and kidney cancer" and "kidney cancer treatment" after the postponement of elective surgeries. However, there was an increase in search volume for "prostate, bladder, and kidney cancer survival rates" and "prostate cancer symptoms" after this period. There was no change in search volume for bladder cancer symptoms, bladder cancer treatment, or kidney cancer symptoms. Conclusions Public interest in urological cancers decreased after COVID, while interest in survival rates across all three cancers increased. Future research is needed to investigate the effects of changing priorities and delays in medical care on patients' experiences with urological cancers.

Shared decision making for women with uncomplicated Cystitis in Primary Care in the Netherlands: a qualitative interview study

BACKGROUND

Urinary tract infections (UTIs) are common, especially among women. Antibiotics are commonly used to treat UTIs, but might not always be necessary, for example in the case of uncomplicated UTIs such as cystitis. Shared decision making (SDM) could reduce the risk of unnecessary antibiotic prescriptions for uncomplicated cystitis. We investigated the current management and the use of SDM for uncomplicated cystitis in primary care.

METHODS

We performed a qualitative semi-structured interview study among 23 women with a history of cystitis, 12 general practitioner (GP) assistants, and 12 GPs in the Netherlands from July to October 2020. All interviews were individually performed by telephone. The data were analyzed through the use of using open and axial coding.

RESULTS

The GP assistants managed the initial diagnostics and treatment of uncomplicated cystitis in all general practices. Usually, antibiotics were considered the standard treatment of cystitis. In most general practices, SDM was not used in the treatment of uncomplicated cystitis, mainly because of a lack of time. Women reported that they valued being involved in the treatment decision-making process, but they were not always involved. Further, both GP assistants and GPs indicated that SDM would improve the care pathway of uncomplicated UTIs.

CONCLUSION

In our study, SDM was infrequently used to help women with uncomplicated cystitis. To reduce the use of antibiotics for uncomplicated UTIs, a tailored intervention is needed to implement SDM for the treatment of uncomplicated cystitis in primary care.

Impact of COVID-19 on Online Interest in Urologic Conditions: An Analysis of Google Trends

Background

With COVID-19 leading to several isolation measures for preventative care, health care utilization, especially within urology, decreased substantially. The impact of COVID-19 on the population’s interests in urologic conditions remains to be established. By using the platform of Google Trends, which allows search behaviors and interest in healthcare topics to be quantified over time, we investigated the impact of COVID-19 on online search behaviors relating to common urologic conditions in the US.

Methods

The platform of Google Trends was utilized to analyze online interest in twelve common urologic conditions in the US from October 1, 2018 to August 1, 2021 (divided into “pre-COVID” and “COVID” periods at March 1, 2020). Search volume index (SVI), a measure of relative search volume on Google, data sets for the US, top queried and populated states, rising queries, and top queries were retrieved and analyzed for all conditions. Pre-COVID and COVID median SVIs were compared using the Mann Whitney U test, and correlations were analyzed using Spearman’s rank-order correlation test.

Results

For all twelve urologic conditions, rising and top queries were often related to symptoms, treatments, and COVID-19. COVID showed higher SVIs for erectile dysfunction (p=0.04) and lower SVIs for bladder cancer (p<0.01), hematuria (p<0.01), kidney cancer (p<0.01), kidney stones (p=0.03), and prostate cancer (p<0.01). Correlations to COVID-19 searches were seen for bladder cancer (R_S=-0.36, p<0.01), erectile dysfunction (R_S=0.20, p=0.04), hematuria (R_S=-0.31, p<0.01), overactive bladder (R_S=-0.23, p=0.04), and prostate cancer (R_S=-0.33, p<0.01). No correlations were found for benign prostatic hyperplasia, interstitial cystitis, low testosterone, urinary incontinence, and urinary tract infections.

Conclusions

Online interest in many urologic conditions, especially cancers, decreased during COVID. Given the internet’s increasing role in healthcare, a reduced interest could translate to delayed diagnosis and treatment of these conditions. Only erectile dysfunction showed increasing interest, potentially due to research or misinformation linking it to COVID-19.

Guideline Adherence of Asymptomatic Bacteriuria Could Be Improved among General Practitioners in The Netherlands: A Survey Study

Asymptomatic bacteriuria (ASB) is a common finding in certain populations. This study assessed general practitioners’ (GPs’) knowledge about ASB and their current clinical practice regarding urine testing. Methods: An online survey was used for GPs in the Netherlands from October to December 2020. Results: In total, 99 surveys were included in the analyses. All GPs strongly agreed with the statements about their knowledge and self-confidence regarding urine diagnostics and treatment of ASB. The median knowledge score was 4 out of 6 (IQR 2 to 6). Most GPs (64 of 92; 70%) followed the guideline for the choice of urine diagnostics and reported appropriate indications for urine testing. However, 71/94 (75.5%) GPs would treat patients for ASB if they have diabetes mellitus. Further, 34 (37%) of 92 participants would inappropriately repeat a urine test after a patient was treated for a urinary tract infection (UTI). One-third of the GPs responded that ASB was insufficiently addressed within the guidelines for UTI. Conclusion: These results indicate that knowledge about ASB could be improved in primary care in the Netherlands, mainly in diabetic patients that have ASB, as well as for follow-up tests after treatment for UTI.

Diagnosis of acute cystitis in primary care: symptom-based versus urinalysis-based diagnosis

Aim:

This study aimed to provide insight into the congruity of acute cystitis (AC) diagnosis in women, measured both by the Acute Cystitis Symptom Score (ACSS) questionnaire and urine test(s).

Background:

The ACSS questionnaire was developed as a self-administering tool for assessing urinary symptoms, quality of life (QoL) and treatment outcomes in healthy, nonpregnant female patients.

Methods:

This prospective observational cohort study compared AC diagnosis based on the questionnaire with a GP diagnosis based on dipstick/dipslide test(s). ACSS questionnaire form A (typical and differential symptoms, QoL and relevant conditions) was filled in by the patient group, women suspected for AC visiting a GP practice with a urine sample, and the reference group, women visiting a community pharmacy for any medication. Analyses were performed assuming that the GP diagnosis based on urine test(s) was correct. Divergent result(s) of urine test(s) and ACSS questionnaire were analysed for scores of all individual questionnaire domains. Statistical analyses included descriptive statistics and the positive predictive value (PPV) and the negative predictive value (NPV) of the ACSS questionnaire and the urine test(s).

Findings:

In the patient group, 59 women were included, 38 of whom a GP positively diagnosed for AC. The reference group included 70 women. The PPV of the ACSS questionnaire was 77.3%, and the NPV was 73.3%. Analysis of patient data for divergent results showed that differential symptoms, QoL and relevant conditions explained false-positive and false-negative results. Revised results (most probable diagnosis) based on this analysis showed a PPV and NPV of 88.6% and 73.3% for the ACSS questionnaire and 100% and 76.2% for the urine test(s). For use in primary care, a reduction in false-positive and false-negative results can be achieved by including scores for differential symptoms, QoL and relevant conditions, alongside a total typical symptoms score of 6 or higher.

Womens' self-management skills for prevention and treatment of recurring urinary tract infection

BACKGROUND

The guideline on urinary tract infections (UTI) of the Dutch College of General Practitioners provides recommendations on patient-initiated treatment and prevention of recurring UTI.

AIM

To study familiarity with self-management skills for prevention of recurring UTI amongst adult women.

DESIGN AND SETTINGS

An online questionnaire was developed, based on the UTI guideline and interviews with women having recurring UTI. Pharmacists in a postgraduate education programme (N = 76) aimed to invite 10 adult women with a recurring UTI prescription to complete the questionnaire. Women were asked for informed consent to link medication record data to questionnaire data.

METHOD

We calculated proportions of the scores for self-management skills and analysed differences between age groups with chi-square test.

RESULTS

Complete questionnaires were available for 719 women (mean age 55.1 ± 18.5 years). The proportions of women 18-50 years and women 51 years or older were 36.4% and 63.6%, respectively. Education levels of women 18-50 years were significantly higher than those of women 51 years and older. Before consulting a general practitioner (GP) for symptoms, 32.1% of all women increased fluid intake; additionally, 15.0% used analgesics and increased fluid intake. Of all women, 33.9% searched internet for information on self-management and 18% occasionally received a prescription for patient-initiated treatment, half of these prescriptions for use during vacation. Cranberry was used by 47%, d-mannose by 5% and vitamin C by 29% of all women. Awareness of different preventive behavioural measures (eg, fluid intake, washing without soap and emptying bladder after sexual intercourse) varied between 20% and 90%.

CONCLUSION

Almost half of all women applied self-management (increased fluid intake, analgesics) before consulting a GP for recurring UTI. Awareness of preventive behavioural measures for recurring UTI varied considerably. Thus, education of women about the use of analgesics and behavioural measures deserves attention.

Pycnogenol® Supplementation Prevents Recurrent Urinary Tract Infections/Inflammation and Interstitial Cystitis

This open pilot registry study aimed to evaluate and compare the prophylactic effects of Pycnogenol® or cranberry extract in subjects with previous, recurrent urinary tract infections (UTI) or interstitial cystitis (IC). Methods. Inclusion criteria were recurrent UTI or IC. One subject group was supplemented with 150 mg/day Pycnogenol®, another with 400 mg/day cranberry extract, and a group served as a control in a 2-month open follow-up. Results. 64 subjects with recurrent UTI/IC completed the study. The 3 groups of subjects were comparable at baseline. All subjects had significant symptoms (minor pain, stranguria, repeated need for urination, and lower, anterior abdominal pain) at inclusion. In the course of the study, the subjects reported no tolerability problems or side effects. The incidence of UTI symptoms, in comparison with the period before inclusion in the standard management (SM) group, decreased significantly; there was a more pronounced decrease in the rate of recurrent infections in the Pycnogenol® group (p < 0.05). The improvement in patients supplemented with Pycnogenol® was significantly superior to the effects of cranberry. At the end of the study, all subjects in the Pycnogenol® group were infection-free (p < 0.05vs. cranberry). Significantly, more subjects were completely symptom-free after 2 months of management with Pycnogenol® (20/22) than with SM (18/22) and cranberry (16/20). Conclusions. This pilot registry suggests that 60 days of Pycnogenol® supplementation possibly decrease the occurrence of UTIs and IC without side effects and with an efficacy superior to cranberry.