Non-surgical management of recurrent urinary tract infections in women

Antibiotic Duration and UTI Outcomes in Recurrent UTI Patients

IMPORTANCE

Little evidence is available to inform management of acute urinary tract infections (UTIs) in women with recurrent urinary tract infection (rUTI).

OBJECTIVE

This study aimed to compare the proportion of acute UTIs with persistence/relapse or recurrence based on duration of treatment antibiotics (acute UTI guideline-consistent versus extended).

STUDY DESIGN

A retrospective noninferiority study of women with rUTI was performed at an academic tertiary referral center from January 2016 to December 2020. Exposure was UTI treatment with acute UTI guideline-consistent versus extended antibiotics. Outcomes were persistent/relapsed UTI (subsequent culture with the same pathogen requiring additional antibiotics within 4 weeks), recurrent UTI (culture with different pathogen), or resolution. Sample size was calculated under the null hypothesis that the proportion of acute UTIs with persistence/relapse or recurrence after acute UTI guideline-consistent antibiotics would be within a 10% noninferiority margin of extended duration (α = 0.05, β = 0.20, 2-sided tests, P < 0.05 significant).

RESULTS

We included 219 patients with 553 acute UTIs. The mean ± SD number of UTIs per patient was 2.53 ± 1.88, the mean ± SD age was 68.60 ± 16.29 years, and the mean ± SD body mass index was 29.73 ± 7 (calculated as weight in kilograms divided by height in meters squared). There were no differences in prior surgical procedures postvoid residual volume, pelvic floor disorders, or preventive treatments between groups. Two-hundred sixty UTIs (260 of 553 [47%]) were treated with acute UTI guideline-consistent antibiotics. Overall, 86 of 553 UTIs (15.6%) persisted/relapsed, and 29 of 553 (5.2%) recurred. The difference in the proportions of UTIs with persistence/relapse or recurrence excluded the noninferiority margin (4.4%; 95% confidence interval, -0.04 to 6.80%). In total, 115 of 553 UTIs (20.8%) had persistence/relapse or recurrence.

CONCLUSION

In this cohort of patients with rUTI experiencing acute UTIs, acute UTI guideline-consistent duration of antibiotics was noninferior.

Incidence of Urinary Infections and Behavioral Risk Factors

This evaluation of the impact of behavioral risk factors on the incidence of urinary infections was based on a questionnaire in which 1103 respondents, predominantly women (883), participated. From the statistical processing of the data, it was observed that 598 of the respondents were of normal weight; the rest, more than half, were underweight or overweight (χ2 = 32.46, p < 0.001), with male respondents being predominantly overweight or obese (169 out of a total of 220). Most of the respondents were young (χ2 = 15.45, p < 0.001), under the age of 45 (840). According to the processed data, it was found that respondents in the age group of 26-35 years showed the greatest vulnerability to recurrent urinary infections, while the age group of 18-25 years recorded the highest number of responses related to the rare presence or even absence of episodes of urinary infections. A body weight-related vulnerability was also noted among the respondents; the majority of obese people declared that they face frequent episodes of urinary infections. Regarding diet quality, 210 respondents reported an adherence to an unhealthy diet, 620 to a moderately healthy diet, and 273 to a healthy diet. Of the respondents who adhered to a healthy diet, 223 were women (χ2 = 2.55, p = 0.279). There was a close connection between diet quality and the frequency of urinary infections: from the statistical processing of the data, it was observed that the highest percentage of respondents who rarely (57.14%) or never got urinary infections (29.30%) were among those who adhered to a healthy diet, and the highest percentage of those who declared that they often got urinary infections were among those with increased adherence to an unhealthy diet (χ2 = 13.46, p = 0.036). The results of this study highlight a strong impact of obesity, reduced consumption of fruit and vegetables, and sedentary lifestyle on the risk of recurring urinary infections.

Uropathogenic bacterial profile and antibiotic susceptibility pattern of isolates among gynecological cases admitted to Jimma Medical Center, South West Ethiopia

Urinary tract infection (UTI) is one of the most common bacterial infections in women; about 50% of women get during their life time. Moreover, it is a common health problem in patients with gynecological pathologies, which increases the chance of acquiring infection. The aim of this study was to determine the bacterial profile that causes UTI and their antibiotic susceptibility pattern among admitted gynecological cases. A cross-sectional study was conducted in south west Ethiopia region. A total of 386 patients admitted with gynecological cases were recruited by sequential sampling technique and structured questionnaire was used to collect socio-demographic and risk factor-related data. About 10 ml freshly voided midstream and catheterized urine specimens were collected using sterile containers. Identification of isolate was done using culture characteristics, gram staining, and a series of biochemical tests. The antibiotic susceptibility test was performed as per the Kirby-Bauer disc diffusion technique. The data obtained were entered into EpiData Version 3.1 and analyzed using SPSS Version 25. A P value of less than 0.05 was used as a level of significance. In this study, the overall prevalence of UTI was 25.4%. Escherichia coli was the most frequently isolated bacteria, which accounted for 38 (37.6%), followed by Klebsiella species 22 (21.8%), CONS 14 (13.9%), Staphylococcus aureus 10 (9.9%), Enterobacter species 6 (5.9%), Citrobacter species 5 (4.9%), Proteus mirabilis 4 (4%), and Pseudomonas aeroginosa 2(2%). Histories of UTI (AOR = 1.977, 95% CI 1.06, 3.68, P = 0.032) and catheterization (AOR = 2.38, 95% CI 1.28, 4.45, P = 0.006) were found to be statistically associated with significant bacteriuria. Gram-negative isolates showed a high level of resistance, 88.3% for ampicillin and 66.2% for tetracycline, and a relatively low level of resistance against ceftazidime, 22.1%, and meropenem, 3.9%. Gram-positive uropathogens showed a high level of resistance to penicillin, 91.6%, whereas all isolates were sensitive 100.0% to nitrofurantoin. Furthermore, 80 (79.2%) of the isolates had multidrug resistance, and 16 (26.7%) of both E. coli and Klebsiella spp. produced Extended spectrum β-lactamase (ESBL). In this study, a high prevalence of uropathogenic bacteria and multidrug resistance for commonly prescribed drugs were observed with a significant number of ESBL producers. Therefore, screening admitted gynecological patients, especially for those who have history of catheterization and UTI, by urine culture and antimicrobial susceptibility testing is important.

Uncertainty Management Strategies in Communication About Urinary Tract Infections

Urinary tract infections (UTIs) are the most common bacterial infection, and yet the etiology, treatment, and prevention of UTIs are often clouded by uncertainty. UTIs can cause severe pain and may lead to serious infection, but communication about UTIs can help individuals manage this condition and avoid recurring UTIs. Grounded in uncertainty management theory (UMT), this study explored how individuals with female anatomy manage uncertainty surrounding UTIs. Iterative analysis was employed using UMT to analyze 21 qualitative interviews. Participants used uncertainty management strategies of talking to health care providers, eliciting social support, and using the internet to gather information. Results indicated that talking to heath care providers was a dominant strategy intended to reduce uncertainty about the diagnosis and treatment of their symptoms. However, these interactions inadvertently increased uncertainty as well, as providers did not provide information about the causes and prevention of UTIs. Some participants also engaged in deception to reduce uncertainty about how their providers would respond to their pain and their illness. Finally, participants employed metaphors to interpret and neutralize uncertainty related to their experiences. Implications for these findings include guidelines and support for patient and provider communication, communication in social networks, as well as deeper nuances and development for UMT.

Recurrent Urinary Tract Infections: Diagnosis, Treatment, and Prevention

Urinary tract infections are common infections seen by obstetrician/gynecologists and primary care providers. Recurrent urinary tract infections are difficult to treat and decrease quality of life. This article addresses the diagnosis, treatment, and prevention of recurrent urinary tract infections, including pharmacologic and nonpharmacologic interventions. Most notably, increased interest in the urinary microbiome is leading to improved understanding of virulent and commensal bacteria in the genitourinary tract. Understanding the causative factors of recurrent urinary tract infections will lead to improved detection, treatment, and prevention.

Effect of sub-minimal inhibitory concentration ceftazidime on the pathogenicity of uropathogenic Escherichia coli

Uropathogenic Escherichia coli (UPEC) is the most prevalent causative agent of urinary tract infections (UTIs). The pathogenicity of UPEC relies on the expression of virulence factors which could be regulated by intercellular signal molecules. Our previous study found that sub-minimal inhibitory concentration ceftazidime (sub-MIC CAZ) could inhibit the biofilm formation of E. coli by luxS/AI-2 or indole. Therefore, we speculated that sub-MIC CAZ might affect the pathogenic capacity of UPEC. In this study, the results showed that sub-MIC CAZ could significantly inhibit the adhesion ability, biofilm formation and swimming and swarming motilities of UPEC isolated from recurrent UTI patient. Meanwhile, obvious decreased hemolytic activity and cytotoxicity were observed in CAZ-pretreated UPEC. Furthermore, qRT-PCR results confirmed the downregulating ability of CAZ on the expression of adhesion genes, motility genes, toxin gene and signal molecule synthesis genes, which are important for virulence and biofilm formation of UPEC. Pre-treatment of UPEC with sub-MIC CAZ resulted in the reduced adhesion to human bladder epithelial cell 5637 and the decreased numbers of intracellular bacterial communities in cells. Consistent with the results in vitro, the pretreatment of CAZ resulted in the reduction of UPEC load in the bladder and the less severity of UPEC-induced inflammation compared with control group. The present study results indicated that sub-MIC CAZ could decrease the pathogenicity of UPEC and might be served as an effective antimicrobial agent to combat recurrent UTI caused by UPEC.

Bacteriuria resistance patterns and the suitability of urinalysis as an initial diagnostic tool in a post-antibiotic era

AIMS

Urinalysis is used as a first-line investigation throughout healthcare to indicate bacteriuria and guide treatment of potential urinary tract infections. In light of rising bacterial multi-resistance, we aim to analyse its diagnostic accuracy, determine its usefulness in a present-day setting and evaluate current antibiotic resistance patterns across a Trust population.

METHODS

A retrospective case series of 712 paired urinalysis and urine culture results was obtained over a 1-month period. Sensitivity, specificity and diagnostic accuracy were calculated, and resistance profiles of commonly used Trust antibiotics assessed using statistical analysis.

RESULTS

A high false negative rate of nitrites on urinalysis, with sensitivity of 38.4%, was found. Leucocyte sensitivity was 87.6% and specificity 39.7%, with no improvement in diagnostic accuracy seen when combining both. Positive urine culture growth demonstrated a substantial resistance pattern to trimethoprim of 48%, compounded by a statistically significant correlation with gentamicin resistance (p < 0.0001).

CONCLUSION

Our study has highlighted a reduced accuracy of urinalysis compared with previous literature, questioning its usefulness in the real world. We have consolidated growing published trends doubting the efficacy of trimethoprim, revealing co-existing resistance patterns between commonly used antibiotics. This will have implications for future antibiotic-prescribing protocols and requires further research to ensure guidelines are progressive in consciously managing this growing concern in modern-day healthcare.

Medicaid Expansion and Hospitalization for Ambulatory Care-Sensitive Conditions Among Nonelderly Adults With Diabetes

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Among nonelderly adults with diabetes, we compared hospitalizations for ambulatory care–sensitive conditions from 2013 (pre-Medicaid expansion) and 2014 (post-Medicaid expansion) for 13 expansion and 4 nonexpansion states using State Inpatient Databases. Medicaid expansion was associated with decreases in proportions of hospitalizations for chronic conditions (difference between 2014 and 2013 −0.17 percentage points in expansion and 0.37 in nonexpansion states, P = .04), specifically diabetes short-term complications (difference between 2014 and 2013 −0.05 percentage points in expansion and 0.21 in nonexpansion states, P = .04). Increased access to care through Medicaid expansion may improve disease management in nonelderly adults with diabetes.

Pharmacotherapeutic advances for recurrent urinary tract infections in women

INTRODUCTION

Treatment of recurrent Urinary tract infections (UTIs) has become challenging because of the dramatic increase in the rates of recurrent infection andof multidrug-resistant (MDR) infections.

AREAS COVERED

The authors review recurrent UTIs(rUTI) management in women.

EXPERT OPINION

Continuous or post-coital prophylaxis with low-dose antimicrobials or intermittent self-treatment has all been demonstrated to be effective in managing rUTIs in women. Intravaginal estrogen therapy , shows potential toward preventing rUTI. Oral vaccine Uro-Vaxom seems to reduce the number of UTIs. There is evidence that other therapies (e.g. cranberry, Methenamine hippurate, oral D-mannose) may decrease the number of symptomatic UTIs. The treatment of CRE-UTIs is focused on a colistin backbone. Carbapenems are considered first-line agents for UTIs caused by ESBL, but their use is associated with increased MDR. The usage of non-carbapenem for the treatment of ESBL UTIs is necessary. Cefepime, Piperacillin-Tazobactam, Ceftolozane-Tazobactam, and Ceftazidime-Avibactam are justified options. Oral therapy with Pivmecillinam, Fosfomycin, and Nitrofurantoin can be used against uncomplicated UTIs due to ESBL infection.

Is a pelvic examination contributory in the initial evaluation of women with recurrent urinary tract infections?

INTRODUCTION AND HYPOTHESIS

Recurrent urinary tract infections (rUTIs) affect up to 44% of women; evidenced-based guidelines regarding the contributory role of a pelvic examination in these women are lacking. We hypothesize that routine pelvic examination has a limited role in evaluation and management of women with rUTI when appropriate symptoms-based screening is performed and normal post-void residual volume (PVR) is confirmed.

METHODS

We performed a retrospective chart review of women ages 18-85 years presenting to Wake Forest Pelvic Health Center with two culture-proven UTIs in 6 months or three UTIs in 12 months with a documented pelvic examination. Pregnant women were excluded. Data extraction included demographics, medical history, screening assessment of vaginal bulge symptoms, urine culture results, imaging, physical/pelvic examination findings, PVR, treatment recommendations and outcomes within 1 year of initial assessment. Descriptive statistics and Fisher's exact test were performed.

RESULTS

Of 160 charts screened, 91 met the inclusion criteria. Nineteen (21%) had symptoms of vaginal bulge, and 14 (17%) had PVR > 100 ml. Pelvic examination provided new/contributory information in eight (8.8%) of women. The negative predictive value of absence of bulge symptoms and normal PVR was 89%. Within 1 year, 41 (46%) reported symptom resolution with rUTI treatment with no difference between those with or without a contributory pelvic examination (p value = 0.64).

CONCLUSIONS

In women with rUTI who report absence of vaginal bulge symptoms and have a PVR < 100 ml, a pelvic examination provides contributory information in < 10% of women and did not change treatment outcomes.

Management of urinary tract infection in women: A practical approach for everyday practice

A common health-care problem worldwide, urinary tract infection (UTI), represents a disease of significant impact on every country's economy, being the most common cause of hospitalization among elderly people and the most common cause of antibiotic prescription in primary care. Diagnosing and managing upper and lower UTI have always been a challenge to physicians, given its high prevalence, risk of recurrence and improper treatment, and the fact of worldwide increase in antibiotic resistance, necessitating implementation of a proper antibiotic stewardship. Urinary infections are twice more likely to occur in females compared to males and its prevalence increases with increasing age. The following is a comprehensive review paper about UTI in females, discussing the various factors leading to a complicated infection. The various etiologies and microbiologies of UTI are also highlighted. In addition to various usual antibiotic regimens for treating UTI, a significant number of nonantimicrobial treatment modalities are highlighted and described in this manuscript, including the novel use of intravesical antibiotics and vaccines for suppression treatment. Finally, a pathway is suggested for the proper diagnosis and treatment that ensures antibiotic stewardship in order to decrease long-term complications.

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.

Use and Effectiveness of Antimicrobial Intravesical Treatment for Prophylaxis and Treatment of Recurrent Urinary Tract Infections (UTIs): a Systematic Review

Purpose of Review

Intravesical antibiotics (IVA) has been used for prophylaxis and treatment of recurrent urinary tract infections (rUTIs). However, there is a lack of comprehensive evidence and consensus on its use. We conducted a systematic review to collect all available data about the effectiveness of IVA in prevention and treatment of rUTIs and to give an overview on the outcomes to date.

Methods

A systematic review was carried out for all English language articles from inception to August 2017, according to the Cochrane and PRISMA standards using MEDLINE, Scopus, Biomed Central, EMBASE, CINAHL, and Web of Science with references cross-checked and individual urology journals hand-searched.

Results

After an initial identification of 658 studies, we screened 37 abstracts and 18 full-text papers of which 11 were included in our final review. This included 285 patients with a mean age of 52 years and a female:male ratio of 129:117. The IVA used was gentamicin, neomycin/polymyxin, neomycin or colistin and IVA was used for rUTIs as prophylaxis in 5 studies (n = 168) and treatment in 6 studies (n = 117). Overall, a good reduction in symptomatic UTI was seen in 78%, with a short-term success rate and discontinuation rates of 71% (120/168) and 8% (14/168) in the prophylaxis group and 88% (103/117) and 5% (6/117) in the treatment groups respectively. There was a change in the sensitivity of organisms in 30% (50/168) and 23% (27/117) in the treatment and prophylaxis groups respectively. Twenty patients discontinued their IVA instillations which were higher for the non-gentamicin group (11%) compared to the gentamicin group (5%). The side effects were minor and included allergy, suprapubic discomfort, autonomic dysreflexia, urinary tract infections and diarrhoea.

Summary

Intravesical antimicrobial instillation seems to be a relatively safe and effective method for the prophylaxis and treatment of recurrent UTIs, especially in the short term. It gives clinicians an alternative treatment modality in high-risk patients predisposed to UTIs where all other forms of systemic treatments have failed.

Urinary Tract Infection Antibiotic Resistance in the United States

Urinary tract infection (UTI) is one of the most common entities in medicine and affected patients present daily in a typical family medicine practice. The patients often present with the "classic symptoms" of dysuria and increased frequency, but sometimes they are asymptomatic or have a mixed picture. In most cases, an antibiotic is prescribed, and this practice is likely contributing to increasing worldwide antibiotic resistance. To help combat this problem, it is important that clinicians seek out their local bacterial resistance patterns and antibiograms, properly diagnose and treat UTI if indicated, and recognize their role in antibiotic stewardship.

High molecular weight hyaluronic acid: a two-pronged protectant against infection of the urogenital tract?

OBJECTIVES

Recurrent urinary tract infections are associated with uropathogenic Escherichia coli (UPEC) ascending and infecting the urinary tract. Antibiotics provide only symptomatic relief, not prevent recurrence. Clinical evidence suggests that intravesical glycosaminoglycan therapy, such as hyaluronic acid (HA), helps reduce UTI recurrence. This has been investigated here using in vitro systems modelling the urogenital tract tissues.

METHODS

RT4 bladder cells were preconditioned with high molecular weight HA (> 1500 kDa) at 2 mg mL-1 and challenged with UPEC to analyse barrier protection and bacterial adherence. Untreated and HA-preconditioned VK2 E6/E7 vaginal cells were challenged with E. coli flagellin (50 ng mL-1) to mimic bacterial challenge, and media analysed for lipocalin-2, human β-defensin 2 and interleukin-8 by ELISA. Experiments were repeated after siRNA knockdown of Toll-like receptors 2, 4 and 5, and CD44 to investigate signalling.

RESULTS

Microscopic analyses showed reduced bacterial adherence and urothelial disruption with HA, suggesting that HA functions as a barrier protecting the epithelium from bacterial infection. Cells treated with HA and flagellin simultaneously produced more of the host antimicrobial peptide LCN2 and pro-inflammatory IL-8 (P < 0.05) compared to the no HA/flagellin challenges. Increased gene expression of DEFB4 (P < 0.05), but not the hBD2 peptide, was observed in the HA/flagellin-challenged cells.

CONCLUSION

These data suggest that exogenous HA has potential to protect the urogenital epithelia from UPEC infection via a two-pronged approach that involves the physical enhancement of the epithelial barrier and augmentation of its innate immune response.