Gentamicin bladder instillations decrease symptomatic urinary tract infections in neurogenic bladder patients on intermittent catheterization

Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida

OBJECTIVE

To identify factors associated with overtreatment of presumed urinary tract infection (UTI) among children with spina bifida using such criteria.

STUDY DESIGN

A retrospective review of children with spina bifida (age <21 years) evaluated in the Emergency Department (ED) at a single institution was performed. Patients with a urinalysis (UA) performed who were reliant on assisted bladder emptying were included. The primary outcome was overtreatment, defined as receiving antibiotics for presumed UTI but ultimately not meeting spina bifida UTI criteria (≥2 urologic symptoms plus pyuria and urine culture growing >100k CFU/mL). The primary exposure was whether the components of the criteria available at the time of the ED visit (≥2 urologic symptoms plus pyuria) were met when antibiotics were initiated.

RESULTS

Among 236 ED encounters, overtreatment occurred in 80% of cases in which antibiotics were initiated (47% of the entire cohort). Pyuria with <2 urologic symptoms was the most important factor associated with overtreatment (OR 9.6). Non-Hispanic White race was associated with decreased odds of overtreatment (OR 0.3).

CONCLUSIONS

Overtreatment of presumed UTI among patients with spina bifida was common. Pyuria, which is not specific to UTI in this population, was the main driver of overtreatment. Symptoms are a cornerstone of UTI diagnosis among children with spina bifida, should be collected in a standardized manner, and considered in a decision to treat.

Effectiveness and patient perspective on the use of intravesical gentamicin instillations to treat recurrent urinary tract infections in neurogenic lower urinary tract dysfunction

INTRODUCTION

Patients with neurogenic lower urinary tract dysfunction (NGLUTD) who require catheterization either with clean intermittent catheters (CIC) or indwelling catheters suffer with frequent urinary tract infections (UTIs). This study assessed the efficacy, patient persistence, satisfaction, and the impact on quality of life (QoL) of gentamicin nightly bladder instillations with 15 mg.

METHODS

This is a prospective survey of 36 patients with NGLUTD and recurrent UTIs prescribed long-term gentamicin to prevent UTIs. Eligible patients completed a questionnaire about their use and satisfaction with gentamicin therapy, as well as survey questionnaires to address QoL. A retrospective chart review was also performed to obtain medical history, confirm drug persistence, and obtain accurate UTI data for the 12 months preceding and after starting instillations.

RESULTS

The rate of laboratory proven symptomatic UTI requiring antibiotic treatment decreased from 3.9 to 1.1 infections per year with no increase in antibiotic resistance and no significant side effects reported by patients. Eight patients stopped therapy before a full year for various reasons, but the remaining 72% of patients have continued to use the therapy now with a mean of 4.2 years later. Satisfaction among those continuing the medication was very high.

CONCLUSION

Gentamicin bladder instillations with 15 mg nightly in patients with indwelling catheters or CIC with NGLUTD are very effective and safe with high patient satisfaction. This therapy can be maintained long-term with continued efficacy.

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

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

VesiX cetylpyridinium chloride is rapidly bactericidal and reduces uropathogenic Escherichia coli bladder epithelial cell invasion in vitro

Management of urinary tract infection (UTI) in postmenopausal women can be challenging. The recent rise in resistance to most of the available oral antibiotic options together with high recurrence rate in postmenopausal women has further complicated treatment of UTI. As such, intravesical instillations of antibiotics like gentamicin are being investigated as an alternative to oral antibiotic therapies. This study evaluates the efficacy of the candidate intravesical therapeutic VesiX, a solution containing the cationic detergent Cetylpyridinium chloride, against a broad range of uropathogenic bacterial species clinically isolated from postmenopausal women with recurrent UTI (rUTI). We also evaluate the cytotoxicity of VesiX against cultured bladder epithelial cells and find that low concentrations of 0.0063% and 0.0125% provide significant bactericidal effect toward diverse bacterial species including uropathogenic Escherichia coli (UPEC), Klebsiella pneumoniae, Enterococcus faecalis, Pseudomonas aeruginosa, and Proteus mirabilis while minimizing cytotoxic effects against cultured 5637 bladder epithelial cells. Lastly, to begin to evaluate the potential utility of using VesiX in combination therapy with existing intravesical therapies for rUTI, we investigate the combined effects of VesiX and the intravesical antibiotic gentamicin. We find that VesiX and gentamicin are not antagonistic and are able to reduce levels of intracellular UPEC in cultured bladder epithelial cells.

IMPORTANCE

When urinary tract infections (UTIs), which affect over 50% of women, become resistant to available antibiotic therapies dangerous complications like kidney infection and lethal sepsis can occur. New therapeutic paradigms are needed to expand our arsenal against these difficult to manage infections. Our study investigates VesiX, a Cetylpyridinium chloride (CPC)-based therapeutic, as a candidate broad-spectrum antimicrobial agent for use in bladder instillation therapy for antibiotic-resistant UTI. CPC is a cationic surfactant that is FDA-approved for use in mouthwashes and is used as a food additive but has not been extensively evaluated as a UTI therapeutic. Our study is the first to investigate its rapid bactericidal kinetics against diverse uropathogenic bacterial species isolated from postmenopausal women with recurrent UTI and host cytotoxicity. We also report that together with the FDA-approved bladder-instillation agent gentamicin, VesiX was able to significantly reduce intracellular populations of uropathogenic bacteria in cultured bladder epithelial cells.

Unmet needs in the management of neurourological disorders within the last 50 years

PURPOSE

This abstract aims to assess the evolution of neurogenic patient management over the past century, with a focus on persistent unmet needs in the field. We reflect on the history of neurourology and its key principles, highlighting urgent needs for research and progress.

METHODS

This review is based on a non-systematic search of MEDLINE databases. We explore the historical context, innovations, and challenges in neurological patient care, using keywords such as "Neurourology", "history" and "future", as well as specific treatment modalities.

RESULT

Several unmet needs in the field of neurourology have been identified. These include the need to strike a balance between spontaneous micturition and continence, the search for solutions to restore spontaneous micturition in patients with acontractile bladders, the imperative to improve and personalize renal and bladder function monitoring, mitigation of the side effects of long-term treatments, strategies to manage recurrent urinary tract infections, and efforts to overcome organizational barriers in patient care.

CONCLUSION

The care of neurological patients has made remarkable progress over the past 50 years. However, persistent unmet needs underline the need for ongoing research and collaboration to improve the quality of care in this field.

Alternative Antimicrobial Irrigation Strategies for the Treatment of Infections in Children: A Review of the Existing Literature

As a synergistic treatment approach with systemic antimicrobial therapy or a systemic antibiotic-sparing strategy, the local administration of antimicrobial agents has been proposed as an alternative route for complicated infections. With the rationale of concentrating the active principle in the desired target site, avoiding potentially toxic systemic levels and bypassing anatomical and physiological barriers, local irrigation or infusion of antibiotics may effectively shorten the antimicrobial therapy course and reduce both infection-related and systemic therapy-related complications. Although evidence from the adult population supports its use in selected patients with an acceptable safety profile, data specifically focused on the pediatric population are limited. To provide a rapid and easily accessible tool for clinical practice, we synthesized the most relevant evidence on the use of local antimicrobial agents in common severe infections in children: meningitis, mediastinitis, pleural infections, recurrent urinary infections, and peritonitis. A literature search was performed using predefined combined keywords through an electronic research database (PubMed). Described molecules, dosages, routes, treated age groups, and related efficacy have been summarized for prompt application to clinical practice. It should, however, be noted that the evidence for the pediatric population remains limited, and the local administration of several molecules remains off-label. A careful multidisciplinary and patient-tailored evaluation, as well as a rational use of available guidelines, should always be the basis of clinical decision making in settings where local administration of antibiotics may be considered.

The management of recurrent urinary tract infections within a nurse-led urology team

The aim of this article is to share experience and learning of managing recurrent urinary tract infections (UTIs) within a specialist urology nurse-led team based at a district general hospital. It looks at current practice and supporting evidence for how to manage and treat recurrent UTIs in both male and female patients. Two case studies are presented to illustrate the management strategies and outcomes, demonstrating a planned approach that informs the design of a local management guideline to organise patients' care.

Intravesical gentamicin instillation in the prevention of recurrent urinary tract infections in children with neurogenic bladder- a single-center retrospective observational study

BACKGROUND

Recurrent urinary tract infections (UTI) in children with neurogenic bladder (NGB) put them at high risk of morbidity and mortality from urosepsis and end-stage renal disease (ESRD). Since the efficacy of low-dose prophylactic antibiotics to prevent these recurrences has been declining since the emergence of extended-spectrum beta-lactamase (ESBL) organisms, intravesical gentamicin instillation has also been used, but only scarce data in children is available in the literature.

OBJECTIVE

We evaluate the efficacy of intravesical gentamicin instillation to reduce UTIs in children with NGB, compare it with oral antibiotic prophylaxis and determine its effect on pathogens resistance to antibiotics.

STUDY DESIGN

Retrospective observational study of 17 children with NGB managed in a tertiary center. Intravesical gentamicin instillation followed an initial period of oral antibiotic prophylaxis. In a conditional negative binomial regression model, a matched comparison of the rate of UTIs, the identified pathogens and their antibiotics susceptibility between the two therapies was performed for each individual child, RESULTS: When compared to antibiotic prophylaxis, intravesical gentamicin instillation showed no significant difference in the yearly rate of UTI, symptomatic UTI, or admissions for intravenous antibiotic therapy. However, it was associated with a 38% reduction in the incidence rate ratio of UTI (p = 0.04) and 75% of asymptomatic UTI (p = 0.006) After intravesical gentamicin instillation, five children (31%) had a gentamicin-resistant UTI, similar to before that treatment (p = 0.76).

DISCUSSION

Although the overall rate of UTI and of asymptomatic infections were significantly lower with intravesical gentamicin instillation than during oral antibiotic therapy, there was no significant difference in the rate of symptomatic UTIs or UTIs requiring admissions, probably because of the small sample size. In addition, neither an emergence of ESBL pathogens nor the rate of pathogens resistance to gentamicin was observed with intravesical gentamicin instillation. As to the potential nephrotoxicity of aminoglycosides, the calculated GFR for all children remained normal. Strengths of our study include the use of a matched paired comparison of each participant with him/herself with each treatment modality, thus eliminating potential confounding by some individual characteristics. In addition, and unlike previous studies, we have also used a robust multivariate statistical analysis to compare counts and rates of outcomes. Limitations include the absence of gentamicin serum levels monitoring, of hearing testing, and also the small sample size.

CONCLUSION

Intravesical gentamicin instillation decreases the overall rate of UTI and asymptomatic infections in children with NGB without increasing the rate of bacterial resistance to gentamicin.

Is There Any Benefit to the Use of Antibiotics with Indwelling Catheters after Urologic Surgery in Adults

Antibiotic stewardship in urologic reconstruction is critically important, as many patients will require indwelling catheters for days to weeks following surgery and thus are at risk of both developing catheter-associated urinary tract infections (CAUTI) as well as multi-drug resistant (MDR) uropathogens. Accordingly, limiting antibiotic use, when safe, should help reduce antibiotic resistance and the prevalence of MDR organisms. However, there is significant heterogeneity in how antibiotics are prescribed to patients who need indwelling urethral catheters post-operatively. We performed a literature review to determine if there are benefits in the use of antibiotics for various clinical scenarios that require post-operative indwelling catheters for greater than 24 h. In general, for patients undergoing prostatectomy, transurethral resection of the prostate, and/or urethroplasty, antibiotic administration may be limited without increased risk of CAUTI. However, more work is needed to identify optimal antibiotic regimens for these and alternative urologic procedures, whether certain sub-populations benefit from longer courses of antibiotics, and effective non-antibiotic or non-systemic therapies.

Unmet Needs in Complicated Urinary Tract Infections: Challenges, Recommendations, and Emerging Treatment Pathways

While urinary tract infections (UTIs) are one of the most common types of infections globally, the wide variety of presentations and of severity of disease can make it difficult to manage. The definition for uncomplicated UTIs (uUTIs) is generally regarded as UTIs in healthy, non-pregnant women whereas all other UTIs are considered complicated. There is, however, a lack of consensus definition of complicated UTIs (cUTIs), leading to global differences in management. In addition, the patients who develop complicated UTIs generally have other comorbidities that warrant more urgent intervention. One of the biggest challenges in treating cUTIs is the rise of antimicrobial resistance (AMR). While there have been recent drug approvals for new antibiotic to treat these resistant organisms, a multidisciplinary approach, including regulatory frameworks, provider education and public awareness campaigns, is crucial to limiting unnecessary treatments for asymptomatic bacteriuria (ASB) and uUTIs that can ultimately lead to more severe infections.

Intravesical gentamicin treatment for recurrent urinary tract infections: A systematic review over the last two decades

Objectives:

Recurrent urinary tract infections (rUTIs) have a significant effect on a patient’s quality of life and frequent use of antibiotics increases multi-drug resistance. Previous research on intravesical antibiotics suggests that this has a local effect on bacteria with reduced systemic absorption and associated side effects. We conducted a systematic review to assess the effectiveness and adverse effects of intravesical gentamicin treatment.

Methods:

Systematic review of all English published articles from January 2001 to October 2021 according to the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards.

Results:

A total of 139 studies were identified, 20 full-text articles were screened and 6 subsequently included totalling 166 patients. All studies reported a decrease in the mean number of urinary tract infections (UTIs) with a significant reduction ( p = 0.0025 and p < 0.004) in two studies. When the number of breakthrough UTIs on prophylactic gentamicin installations was assessed, 65% ( n = 86/133) remained UTI free. Throughout treatment, 99% of serum gentamicin levels were <0.3 ng/dL, and reported instances of increased creatinine were low (2%). A decrease in the growth of multi-drug-resistant bacteria was reported in two papers ( p = 0.065 and p = 0.04).

Conclusion:

Intravesical gentamicin seems to be an effective treatment in patients with symptomatic rUTIs. The evidence suggests it also reduces UTIs caused by multi-drug-resistant bacteria with no systemic absorption and minimal renal toxicity.

Level of evidence:

2a

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Intravesical Gentamicin: An Option for Therapy and Prophylaxis against Recurrent UTIs and Resistant Bacteria in Neurogenic Bladder Patients on Intermittent Catheterization

This is a retrospective study of our experience with Gentamicin intravesical instillation as therapy and prophylaxis in patients with lower urinary tract infections (UTIs) undergoing clean intermittent catheterization because of a neurogenic bladder. It is an alternative therapy when all other systemic treatments have failed as it is still an off-label prescription.

Are Intravesical Aminoglycosides the New Gold Standard in the Management of Refractory Urinary Tract Infection: A Systematic Review of Literature

Background: Antibiotic resistance in urinary pathogens is increasingly common, leading to rising cases of complicated urinary tract infections. Conventional antimicrobial treatment may be insufficient in these cases and broad-spectrum systemic antibiotics contribute to the problem. Intravesical aminoglycoside instillation is an alternative treatment option that delivers localized and high-dose treatment to the source of infection. This study summarizes the existing evidence for the efficacy and safety of this treatment. Methods: A systematic search was conducted of worldwide literature according to PRISMA methodology and Cochrane standards for systematic review. Studies were included if they reported outcome data for the prevention and reduction in urinary tract infections, eradication of antimicrobial-resistant organisms, or change in sensitivities allowing conventional oral antimicrobial treatment after the administration of intravesical aminoglycoside with or without polymyxin therapy. Results: The search identified 826 articles, of which, 19 were included in the final data analysis and narrative synthesis. A successful outcome was identified in 80.7% (n = 289) of patients treated with aminoglycoside alone and 79.5% (n = 163) treated with an aminoglycoside in combination with polymyxin. Discontinuation was noted in 6.2% of patients. An increase in antimicrobial sensitivity was seen in 15.3% (n = 55) and 16.3% (n = 36) in the aminoglycoside and aminoglycoside/polymyxin groups, respectively. Conclusions: Current evidence supports the use of intravesical aminoglycoside instillation as an efficacious and safe treatment for refractory UTIs. Nevertheless, data is limited, and larger volume studies with longer follow-up periods are required.

Early warning model construction and validation for urinary tract infection in patients with neurogenic lower urinary tract dysfunction (NLUTD): a retrospective study

Background

This study was performed to construct and validate an early risk warning model of urinary tract infection in patients with neurogenic lower urinary tract dysfunction (NLUTD).

Methods

Eligible patients with NLUTD admitted to Shenzhen Longcheng hospital from January 2017 to June 2021 were recruited for model construction, internal validation and external validation. The first time point of data collection was within half a month of patients first diagnosed with NLUTD. The second time point was at the 6-month follow-up. The early warning model was constructed by logistic regression. The model prediction effects were validated using the area under the Receiver Operating Characteristic curve, the Boostrap experiment and the calibration plot of the combined data. The model was externally validated using sensitivity, specificity and accuracy.

Results

Six predictors were identified in the model, namely patients ≥65 years old (OR = 2.478, 95%CI [1.215- 5.050]), female (OR = 2.552, 95%CI [1.286-5.065]), diabetes (OR = 2.364, 95%CI) [1.182-4.731]), combined with urinary calculi (OR = 2.948, 95%CI [1.387-6.265]), indwelling catheterization (OR = 1.988, 95%CI [1.003 -3.940]) and bladder behavior training intervention time ≥2 weeks (OR = 2.489, 95%CI [1.233-5.022]); and the early warning model formula was Y = 0.907 ×  age+ 0.937 × sex + 0.860 × diabetes +1.081 × combined with urinary calculi+ 0.687 × indwelling catheterization+ 0.912 × bladder behavior training intervention time-2.570. The results show that the area under the ROC curve is 0.832, which is close to that of 1,000 Bootstrap internal validation (0.828). The calibration plot shows that the early warning model has good discrimination ability and consistency. The external validation shows the sensitivity is 62.5%, the specificity is 100%, and the accuracy is 90%.

Conclusion

The early warning model for urinary tract infection in patients with NLUTD is suitable for clinical practice, which can provide targeted guidance for the evaluation of urinary tract infection in patients with NLUTD.

Catheter-Associated Urinary Tract Infections: Current Challenges and Future Prospects

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection and cause of secondary bloodstream infections. Despite many advances in diagnosis, prevention and treatment, CAUTI remains a severe healthcare burden, and antibiotic resistance rates are alarmingly high. In this review, current CAUTI management paradigms and challenges are discussed, followed by future prospects as they relate to the diagnosis, prevention, and treatment. Clinical and translational evidence will be evaluated, as will key basic science studies that underlie preventive and therapeutic approaches. Novel diagnostic strategies and treatment decision aids under development will decrease the time to diagnosis and improve antibiotic accuracy and stewardship. These include several classes of biomarkers often coupled with artificial intelligence algorithms, cell-free DNA, and others. New preventive strategies including catheter coatings and materials, vaccination, and bacterial interference are being developed and investigated. The antibiotic pipeline remains insufficient, and new strategies for the identification of new classes of antibiotics, and rational design of small molecule inhibitor alternatives, are under development for CAUTI treatment.

Urinary Tract Infection in Parkinson's Disease

Urinary tract infection (UTI) is a common precipitant of acute neurological deterioration in patients with Parkinson's disease (PD) and a leading cause of delirium, functional decline, falls, and hospitalization. Various clinical features of PD including autonomic dysfunction and altered urodynamics, frailty and cognitive impairment, and the need for bladder catheterization contribute to an increased risk of UTI. Sepsis due to UTI is a feared consequence of untreated or undertreated UTI and a leading cause of morbidity in PD. Emerging research suggests that immune-mediated brain injury may underlie the pathogenesis of UTI-induced deterioration of PD symptoms. Existing strategies to prevent UTI in patients with PD include use of topical estrogen, prophylactic supplements, antibiotic bladder irrigation, clean catheterization techniques, and prophylactic oral antibiotics, while bacterial interference and vaccines/immunostimulants directed against common UTI pathogens are potentially emerging strategies that are currently under investigation. Future research is needed to mitigate the deleterious effects of UTI in PD.

Urinary Tract Infections in Kidney Transplant Recipients-Is There a Need for Antibiotic Stewardship?

(1) Background: Urinary tract infections (UTI) are the most common infections after kidney transplantation. Given the risk of urosepsis and the potential threat to the graft, the threshold for treating UTI and asymptomatic bacteriuria with broad spectrum antibiotics is low. Historically fluoroquinolones were prescription favorites for patients that underwent kidney transplantation (KT). After the recent recommendation to avoid them in these patients, however, alternative treatment strategies need to be investigated (2) Methods: We retrospectively analyzed the charts of 207 consecutive adult kidney transplantations that were performed at the department of General, Visceral and Transplantation Surgery of the University Hospital of Tuebingen between January 2015 and August 2020. All charts were screened for the diagnosis and treatment of asymptomatic bacteriuria (ASB) and urinary tract infections (UTI) and the patients' clinical characteristics and outcomes were evaluated. (3) Results: Of the 207 patients, 68 patients suffered from urinary tract infections. Patients who developed UTI had worse graft function at discharge (p = 0.024) and at the 12 months follow-up (p < 0.001). The most commonly prescribed antibiotics were Ciprofloxacin and Piperacillin/Tazobactam. To both, bacterial resistance was more common in the study cohort than in the control group. (4) Conclusions: Urinary tract infections appear to be linked to worse graft functions. Thus, prevention and treatment should be accompanied by antibiotic stewardship teams.

Bladder instillation for urinary tract infection prevention in neurogenic bladder patients practicing clean intermittent catheterization: A systematic review

OBJECTIVE

To assess the efficacy and safety of different modalities of bladder instillation in patients with neurogenic bladder practicing intermittent catheterization.

METHODS

A systematic review of the literature were conducted using two databases: Medline via PubMed and Scopus. Articles evaluating bladder instillation in patients with neurogenic bladder, who are practicing intermittent catheterization, were collected and assessed for the efficacy and safety of the studied agent by two different reviewers.

RESULTS

Among the 1896 studies, eight involving 346 patients with neurogenic bladder, were included in this systematic review according to the PRISMA protocols. Gentamicin, Hyaluronic acid, and Lactobacillus rhamnosus was found to decrease the incidence of urinary tract infections, the former reduced multidrug-resistant organisms. Kanamycin-colistin, showed a drop in the mean incidence of bacteriuria in males only. Trisdine, the only studied antiseptic, significantly reduced bacteriuria. Neomycin, however, showed no efficacy in term of bacteriuria. Regarding safety, when evaluated, no major adverse events were reported with any of the studied modalities.

CONCLUSION

Bladder instillations of either antibiotics, antiseptics, hyaluronic acid, or Lactobacillus rhamnosus GG are efficient and safe in patients having neurogenic bladder, with recurrent urinary tract infections and practicing clean intermittent catheterization, with gentamicin being the most recommended product among the different studied agents.

Contemporary management considerations of urinary tract infections for women with spina bifida

INTRODUCTION AND HYPOTHESIS

Urinary tract infections (UTIs) are one of the leading health concerns and causes of hospitalization for adults with spina bifida (SB). The risk factors, evaluation, management, and prevention of UTIs in women with SB must take into consideration their unique pelvic anatomy and function as well as the desire for pregnancy or the occurrence UTI during pregnancy. This article reviews published literature regarding this topic and offers recommendations for UTI evaluation, management, and prevention in the context of the unique pelvic floor health needs of women with SB.

METHODS

A systematic review was conducted using the following keywords: spinal dysraphism, spina bifida, myelomeningocele, meningocele, urinary tract infections, females, and adults. Articles were included if they were in English, published during or after 2000, peer reviewed, included women with spina bifida aged 18 or greater, and included outcomes related to urinary tract infection.

RESULTS

No articles met inclusion criteria.

CONCLUSION

As no articles were found based on the initial search criteria, articles pertaining to neurogenic bladder UTI risks, evaluation, and management were discussed to develop consensus recommendations for the unique care of UTIs in women with SB.

Bilateral emphysematous pyelonephritis

A 57-year-old man presenting with bilateral flank pain and hematuria was found to have severe bilateral emphysematous pyelonephritis. The patient was managed with a conservative approach consisting of systemic antimicrobials and decompression via percutaneous nephrostomy tubes with piperacillin-tazobactam instillations via nephrostomy and made a full recovery.

Intravesical gentamicin instillation for the treatment and prevention of urinary tract infections in complex paediatric urology patients: evidence for safety and efficacy

BACKGROUND

Little has been reported to date on the instillation of antimicrobials directly into the bladder in children. Children with complex urinary tract anomalies struggle frequently with recurrent urinary tract infections (UTI), with frequent emergence of antibiotic resistance. Gentamicin bladder instillation to treat and prevent UTI was described in children since 2006.

OBJECTIVE

We adopted gentamicin bladder instillation in 2016 and evaluate herein our intermediate-term experience with it.

STUDY DESIGN AND METHODS

This study is a retrospective review of a prospectively initiated database and a clinical audit of our practice. The gentamicin bladder instillation was employed in 24 cases. A treatment regime was initiated for symptomatic documented UTI when resistance patterns precluded an oral alternative (14 cases), avoiding hospitalisation for parenteral antibiotics. A prophylaxis regime (19 cases-including 9 of the 14 who received an initial treatment regime) followed at least one breakthrough UTI while receiving oral prophylactic antibiotics. Two instillation volumes (8 mg gentamicin in 20 mL 0.9% NaCl or 20 mg gentamicin in 50 mL 0.9% NaCl) were used to suit different bladder capacities. The irrigation is given twice a day for 7 days in the treatment regime or once a day, every other day, in the prophylactic regime. Gentamicin serum levels (all cases) and audiology/audiometry testing (17/24 cases) were checked to assess the safety of this method.

RESULTS

The median age when either the treatment course or prophylaxis regime was started was 3.8 years. The treatment regime was 86% successful (12/14) to suppress an acute UTI. The mean duration of prophylaxis was 252 days (median: 256 days). The percentage of patients on the prophylactic regime who had no breakthrough UTI was 58%. No serum gentamicin was detectable secondary to the intravesical instillation. No attributable cases of sensorineural hearing loss were detected. Gentamicin resistance emerged in one case (4.16%).

DISCUSSION

Intravesical administration was feasible via various routes for a spectrum of complex lower urinary tract abnormalities (see Summary Figure). Concerns regarding systemic absorption, nephrotoxicity or ototoxicity were investigated and safety ensured. Limitations include being a small series of non-identical pathologies, albeit categorically similar and being a single-arm study, however, statistical significance was proven descriptively and analytically.

CONCLUSION

In selected cases and with the appropriate specialist support and logistics, intravesical gentamicin instillation is well-tolerated and safe to treat and/or prevent urinary tract infections in pateints with complex bladder conditions and lower urinary tract pathologies.

Bladder irrigation with povidone-iodine prevent recurrent urinary tract infections in neurogenic bladder patients on clean intermittent catheterization

AIMS

To determine if daily povidone-iodine (PI) bladder irrigation in neurogenic lower urinary tract dysfunction (NLUTD) patients doing clean intermittent catheterization (CIC) can reduce the rate of symptomatic urinary tract infections (UTIs), emergency department (ED) visit for UTIs, and hospitalization for UTIs.

METHODS

We prospectively reviewed the records of patients with NLUTD on CIC who had recurrent symptomatic UTIs and who were placed on daily intravesical instillations of PI. This trial was conducted from January 2014 to January 2020 on 119 patients.

RESULTS

After using daily PI bladder irrigation, the rate of symptomatic UTIs was reduced by 99.2% (incidence rate ratio [IRR]: 0.008, 95% confidence interval [CI]: 0.001-0.059; p < .001), the rate of ED visits was reduced by 99.2%% (IRR: 0.008, 95% CI: 0.001-0.059; p < .001), and the rate of inpatient hospitalizations for UTI was reduced by 99.9% (IRR: 0.0008, 95% CI: 0.0002-0.0035; p < .001). There was also a significant decrease in multidrug resistance in UTI organisms with the use of PI bladder instillation.

CONCLUSIONS

Daily intravesical PI instillation is a well-tolerated approach to prevent UTIs and related ED visits and hospitalizations in NLUTD patients doing CIC.

Intravesical Antibiotic Administration in the Treatment of Recurrent Urinary Tract Infections: Promising Results From a Case Series

OBJECTIVE

Intravesical antibiotic administration for the treatment of recurrent urinary tract infections (UTIs) provides targeted therapy that may be a useful alternative to oral antibiotics. The objective of the study was to assess the rate of UTIs before and after intravesical antibiotic instillations in community-dwelling postmenopausal women with recurrent UTIs.

METHODS

Patients with recurrent UTI who underwent antibiotic bladder instillations were included. Instillation was performed in the office by trained nursing staff using either gentamycin or tobramycin. Every instillation was preceded by bladder irrigation with sterile water. Retrospective chart review was performed to compare rates of UTIs for 6 months before and after intervention. Descriptive and nonparametric statistics were used for data analysis.

RESULTS

Twelve patients were evaluated. The average rate of UTIs decreased from a median of 2.5 to 1.5 infections (P = 0.025) after intravesical instillations. The number of pathogen types decreased from a median of 2.5 to 1.5 after therapy (P = 0.025). There was a reduction in bacterial antibiotic resistance after completion of instillations, with an estimated median difference of -5.250 (P = 0.065). There were no adverse effects reported during instillations.

CONCLUSIONS

Intravesical instillations offer a promising therapy for the treatment of recurrent UTIs in postmenopausal women who failed oral antibiotic therapy. Future prospective studies are needed to further elucidate the clinical utility and long-term benefits of antibiotic instillations.

Cystoscopy with antibiotic irrigation during pelvic reconstruction and minimally invasive gynecologic surgery: A double-blind randomized controlled trial

AIMS

After pelvic reconstructive surgery, the risk of postoperative urinary tract infection (UTI) is significant; intraoperative cystoscopy may contribute to this risk. Intravesical antibiotics are used in the ambulatory setting and may be applied to the surgical arena. Our objective was to evaluate the efficacy of antibiotic irrigation during intraoperative cystoscopy to prevent postoperative UTI.

METHODS

This double-blind randomized controlled trial enrolled 216 women undergoing cystoscopy with elective surgery for pelvic organ prolapse, stress urinary incontinence, or laparoscopic gynecologic surgery at an academic medical center 2016-2019. Participants were randomized to cystoscopic irrigation fluid type: normal saline (control) or 200,000 U polymyxin B + 40 mg neomycin solution in normal saline (antibiotic). Patients and providers who treated UTIs were blinded. The primary outcome was treatment of UTI within 6 weeks postoperatively, defined as positive culture or treatment for a symptomatic UTI. χ² and multivariable logistic regression analyses were performed.

RESULTS

We enrolled 216 women: 111 control (51.4%) and 105 antibiotic (48.6%). Mean age was 51.6 years. Groups were well matched in medical comorbidities and surgery type. Primary vaginal surgery was most common (n = 127, 58.8%). Overall, 10.7% of patients developed a postoperative UTI with no difference in incidence between groups: 9.9% of control (n = 11, 95% confidence interval [CI]: 4.0%-16.0%) versus 11.4% of antibiotic subjects (n = 12, 95% CI: 5.0%-18.0%), on χ² (p = .718) and logistic regression analysis (adjusted odds ratio, 1.3; CI: 0.53-3.16; p = .569).

CONCLUSION

When cystoscopy is performed during elective pelvic surgery, use of antibiotic irrigation does not impact the rate of postoperative UTI.

Voiding conditions, renal and bowel function in a cohort of adults with spina bifida

AIM

To map voiding patterns, degree of continence, use of drugs for voiding disorders, kidney function and surgical interventions but also the bowel function in a near-total regional cohort of adults with spina bifida aged more than or equal to 18 years.

METHODS

All individuals more than or equal to 18 years of age with spina bifida registered at a regional outpatient clinic (n = 219) were invited to participate, of which 196 persons were included. Bladder and bowel function were assessed according to questions used by the Nordic Spinal Cord Injury Registry by structured interviews and questionnaires in combination with review of patient charts including kidney function.

RESULTS

Twenty percent of the patients voided spontaneously. Fifty-four percent used clean intermittent catherization (CIC) and of these, 14% had also undergone augmentation of the bladder and/or implantation of an artificial sphincter or sling, 23% had undergone major urological surgery, and 3% had an indwelling catheter. Seventeen percent of patients voiding spontaneously or using CIC reported total continence but as many as 36% reported daily leakage. Anticholinergics was the most common drug, used by 21% in the total cohort. About 13% of the patients had a reduced kidney function but only 1.5% had end stage renal failure. Seventy-three percent had problems emptying the bowel and 18% experienced fecal leakage weekly or even daily.

CONCLUSION

We found a large variation in problems with bladder and bowel function in this adult group of persons with spina bifida. A structured customized program for follow-up seems necessary to optimize their health status in these areas.

Complications in adulthood for patients with paediatric genitourinary reconstruction

BACKGROUND

Caring for adults with prior paediatric genitourinary reconstruction remains a challenge for adult providers. Reconstructions typically have occurred decades before; surgical records are not always available and patients and families may be unable to convey procedures performed. Spina bifida (SB) patients are vulnerable to cognitive decline which may compound these challenges. Changes in patient body habitus and loss of function may contribute to problems with previous reconstructions.

METHODS

This is a non-systematic review of the literature and represents expert opinion where data are non-existent. This review focuses on the evaluation and management of complications arising from genitourinary reconstruction in congenital neurogenic bladder patients.

RESULTS

Common complications experienced by congenital neurogenic bladder patients include recurrent urinary tract infection, incontinence of catheterizable channel and urinary reservoir as well as malignancy as this population ages. Preservation of renal function and prevention of urinary tract infection while optimizing continence are essential guiding principles in the care of these patients. Many of the recommendations, however, are gleaned from available data in the adult spinal cord patient (a more commonly studied population) or the paediatric urologic literature due to limited studies in adult management of such patients.

CONCLUSION

Close follow-up and vigilance is warranted to monitor for infectious, mechanical and malignant complications while optimizing preservation of the upper urinary tracts and patient quality of life.

Outcome of Different Approaches to Reduce Urinary Tract Infection in Patients With Spinal Cord Lesions: A Systematic Review

Neurogenic bladder disorders are common among patients with spinal cord lesions, which often result in upper and lower urinary tract complications. Urinary tract infection has remained the most frequent type of infection in this population. Our aim is to review systematically the literature on the outcome of different intervention methods to reduce urinary tract infection incidence. A literature search was conducted in the database of Medline, PubMed, Embase, and Scopus. After screening 1559 articles, 42 were included in this review. The intervention methods can be categorized into the four following groups: (1) indwelling catheterization and intermittent catheterization, (2) medications, (3) surgery, and (4) others. Intermittent catheterization is still the most recommended treatment for persons with spinal cord lesions. Hydrophilic catheters are more suitable for adults than children because of complex handling. Bladder management with spontaneous voiding is initially considered for infants and toddlers with spina bifida. Antibiotics treatment should be based on the results of urine cultures. Shortening the course of antibiotics treatment can reduce its adverse effects but may increase urinary tract infection recurrence. Because botulinum toxin injections and bladder surgery can improve urodynamic function, both are conducive toward lowering urinary tract infection incidence.

A risk prediction model of urinary tract infections for patients with neurogenic bladder

Objectives: To develop a nomogram to evaluate the risk of urinary tract infections (UTI) in patients with neurogenic bladder (NGB)Methods: A retrospective analysis was conducted on 337 patients with NGB admitted to three hospitals. Collected data included clinical symptoms, patients' general characteristics, laboratory examinations and imaging findings. Multivariate logistic regression analysis was conducted to develop the risk prediction nomogram of UTIs for NGB patients. C index was used for the internal and external validation of that model.Results: The occurrence of UTIs was 45.7% (154 of 337), 52.6% (102 of 194), and 36.4% (52 of 143) in the overall, training and validation data sets, respectively. The prediction nomogram was developed with 5 prognostic factors which included white blood cell (WBC) in blood, Leukocyte (LEU) in urine, Urinary pH, length of stay and urination mode. The nomogram presented good discrimination with a C-index value of 0.921 (95% confidence interval: 0.87396 - 0.96804) and good calibration. The C-index values of the interval validation and external validation were 0.8905541 and 0.817, respectively. The results of decision curve analysis (DCA) demonstrated that the model was clinically useful.Conclusions: The prediction nomogram we developed is a simple and accurate tool for early prediction of UTIs in patients with NGB. This tool can assess risk of UTIs early, allowing for timely initiation of appropriate preventive measures.

Augmentation cystoplasty in the patient with neurogenic bladder

PURPOSE

To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries.

METHODS

PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB.

RESULTS

AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel.

CONCLUSIONS

Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Neomycin-polymyxin or gentamicin bladder instillations decrease symptomatic urinary tract infections in neurogenic bladder patients on clean intermittent catheterization

INTRODUCTION

Recurrent urinary tract infections (UTIs) are common in patients with neurogenic bladder (NGB) performing clean intermittent catheterization (CIC) treated with or without oral antibiotic prophylaxis.

OBJECTIVE

The authors aim to determine if daily neomycin-polymyxin or gentamicin bladder instillations reduce the rate of symptomatic UTIs, the need for oral antibiotic prophylaxis, emergency department (ED) visits for UTI, and inpatient hospitalizations for UTI in patients with NGB on CIC. The authors also aim to investigate resistance patterns in urine microorganisms in patients treated with antibiotic bladder instillations.

STUDY DESIGN

The authors retrospectively reviewed the records of all-age patients cared for in the pediatric urology clinic with NGB on CIC having symptomatic UTIs and on daily intravesical instillations of neomycin-polymyxin or gentamicin between 2013 and 2017. Symptomatic UTIs were defined as a positive urine culture with greater than 10,000 colony forming units/mL associated with one or more of the following patient complaints: cloudy/foul-smelling urine, fevers, chills, increase in bladder spasms, pain, urinary leakage, or physician decision for antibiotic treatment. Multidrug-resistant organisms were resistant to two or more classes of antibiotics.

RESULTS

Fifty-two patients with a median age of 14.5 years and 192 distinct urine cultures were identified. 90.4% and 9.6% of patients received neomycin-polymyxin and gentamicin instillations, respectively. After initiation of intravesical antibiotics, the rate of symptomatic UTIs was reduced by 58% (incidence rate ratio [IRR]: 0.42, 95% confidence interval [CI]: 0.31-0.56; P < 0.001), the rate of ED visits was reduced by 54% (IRR: 0.46, 95% CI: 0.30-0.71; P < 0.001), and the rate of inpatient hospitalizations for UTI was reduced by 39% (IRR: 0.61, 95% CI: 0.37-0.98; P = 0.043). Fewer patients received oral antibiotic prophylaxis after initiation of antibiotic instillations (odds ratio: 0.12, 95% CI: 0.02-0.067; P = 0.016). There was a trend toward a decrease in multidrug resistance and no change in gentamicin resistance in urine microorganisms.

DISCUSSION

This study describes a feasible alternative treatment for patients with NGB on CIC who have persistent UTIs despite oral antibiotic prophylaxis, and for some patients, it may suggest a possibility of discontinuing oral prophylaxis. Limitations include a retrospective design with a small cohort of patients and varying dosages of neomycin-polymyxin.

CONCLUSIONS

Antibiotic bladder instillations appear to decrease frequency of symptomatic UTIs, ED visits for UTI, inpatient hospitalizations for UTI, and the need for oral antibiotic prophylaxis in patients with NGB on CIC. There was no increase in multidrug resistance or gentamicin resistance in UTI organisms with use of intravesical antibiotic instillation.

Urinary tract infections in patients with neurogenic bladder

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.

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.

Systematic review and practice policy statements on urinary tract infection prevention in adults with spina bifida

Urinary tract infection (UTI) is a source of morbidity and healthcare costs in adults with spina bifida (ASB). UTI prevention strategies are often recommended, but the evidence of various approaches remains unclear. We performed a systematic review to inform a best practice policy statement for UTI prevention in ASB. On behalf of the Neurogenic Bladder Research Group (NBRG.org), we developed an a priori protocol and searched the published English literature for 30 outcomes questions addressing UTI prevention in ASB. The questions spanned the categories of antibiotics, oral supplements, bladder management factors and social support. Where there was little literature in ASB, we included literature from similar populations with neurogenic bladder (NB). Data was abstracted and then reviewed with recommendations made by consensus of all authors. Level of Evidence (LoE) and Grade of Recommendation (GoR) were according to the Oxford grading system. Of 6,433 articles identified by our search, we included 99 publications. There was sufficient evidence to support use of the following: saline bladder irrigation (LoE 1, GoR B), gentamicin bladder instillation (LoE 3, GoR C), single-use intermittent catheterization (IC) (LoE 2, GoR B), hydrophilic catheters for IC (LoE 2, GoR C), intradetrusor onabotulinumtoxinA injection (LoE 3, GoR C), hyaluronic acid (HA) instillation (LoE 1, GoR B), and care coordination (LoE 3, GoR C). There was sufficient evidence to recommend against use of the following: sterile IC (LoE 1, GoR B), oral antibiotic prophylaxis (LoE 2, GoR B), treatment of asymptomatic bacteriuria (LoE 2, GoR B), cranberry (LoE 2, GoR B), methenamine salts (LoE 1, GoR B), and ascorbic acid (LoE1, GoR B). There was insufficient evidence to make a recommendation for other outcomes. Overall, there are few studies in UTI prevention in the specific population of ASB. Research in populations similar to ASB helps to guide recommendations for UTI prevention in the challenging patient group of ASB. Future studies in UTI prevention specific to ASB are needed and should focus on areas shown to be of benefit in similar populations.