Current Evidence on Nonantibiotic Prevention of Recurrent Urinary Tract Infections

Open questions on lower urinary tract infections: Results of a Delphi consensus study

BACKGROUND AND OBJECTIVE

This is a Delphi study that aims to explore expert consensus regarding open questions in current literature evidence on lower urinary tract infections (UTIs). This manuscript deals with adults and analyzed the most recent guidelines and meta-analysis on the topic.

METHODS

A panel of leading urologists and urogynaecologists participated in a consensus-forming project using a Delphi method to reach consensus on gray zone issues on recurrent lower UTIns (rUTIs), asymptomatic bacteriuria (AB) in pregnant women, and catheter-associated UTIs (CAUTI) in adults. All the panelists were invited to participate the four phases consensus. Consensus was defined as ≥75% agreement. An ordinal scale (0-10) was used. A systematic literature review was analyzed for diagnostic workup and prevention of rUTIs, AB, and CAUTI.

RESULTS

In total, 37 experts participated. All panelists participated in the four phases of the consensus process. Consensus was reached if ≥75% of the experts agreed on the proposed topic. Online meetings and a face-to-face consensus meeting was held in Milan in March 2023. Formal consensus was achieved for 12/13 items.

CONCLUSIONS

This manuscript is a Delphi survey of experts that showed interest on some debated points on rUTIs, AB in pregnancy, and prevention of CAUTI. There is still little data on nonantibiotic prevention of UTIs and CAUTI; quite old studies have been reported on AB in pregnancy. The emerging problem of antibiotic resistance is relevant and nonantibiotic prophylaxis may play a role in its prevention.

A practical guide on the non-antibiotic options available in the prevention of recurrent urinary tract infections in women

Urinary Tract infection (UTI) is one of the most common infections worldwide, patients present to multiple different specialities in the community, primary and secondary care. Antibiotics are considered standard first line therapy in the treatment of urinary tract infections, however there is an alarming rise in global antibiotic resistance rates, so much so that the World Health Organisation has labelled antibiotic resistance as one of the biggest challenges to public health in our lifetime, publishing a global action plan to tackle this challenge. As a result, there is an increasing need to discover non-antibiotic alternatives, recently a number of novel therapies have been introduced into clinical practice. These are divided into oral, topical, intravesical and immunomodulation therapies. The aim of this paper is to summarise the current non-antibiotic treatments as a practical guide to utilise in patient care.

Do or Don't: Results of a Multinational Survey on Antibiotic Prophylaxis in Urodynamics

Antibiotic prophylaxis contributes substantially to the increase in antibiotic resistance rates worldwide. This investigation aims to assess the current standard of practice in using antibiotic prophylaxis for urodynamics (UDS) and identify barriers to guideline adherence. An online survey using a 22-item questionnaire designed according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was circulated among urologists and gynecologists in Austria, Germany, and Switzerland between September 2021 and March 2022. A total of 105 questionnaires were eligible for analysis. Out of 105 completed surveys, most responders (n = 99, 94%) regularly perform dipstick urine analysis prior to urodynamics, but do not perform a urine culture (n = 68, 65%). Ninety-eight (93%) participants refrain from using antibiotic prophylaxis, and sixty-eight (65%) use prophylaxis if complicating factors exist. If asymptomatic bacteriuria is present, approximately 54 (52%) participants omit UDS and reschedule the procedure until antimicrobial susceptibility testing is available. Seventy-eight (78%) participants do not have a standard procedure for antibiotic prophylaxis in their department. Part of the strategy against the development of bacterial resistance is the optimized use of antibiotics, including antibiotic prophylaxis in urodynamics. Establishing a standard procedure is necessary and purposeful to harmonize both aspects in the field of urological diagnostics.

Non-Antibiotic Prophylaxis for Recurrent UTIs in Neurogenic Lower Urinary Tract Dysfunction (NAPRUN): Study Protocol for a Prospective, Longitudinal Multi-Arm Observational Study

INTRODUCTION

Patients with neurogenic lower urinary tract dysfunction (NLUTD) reliant on intermittent self-catheterization for bladder emptying are at an increased risk of recurrent urinary tract infections (rUTI). So far, the most common practice in the prevention of rUTIs is long-term low-dose antibiotic prophylaxis, phytotherapy, and immunomodulation, whereby antibiotic prophylaxis inevitably leads to the emergence of drug-resistant pathogens and difficulty in treating infections. Therefore, non-antibiotic alternatives in the prevention of rUTIs are urgently required. We aim to identify the comparative clinical effectiveness of a non-antibiotic prophylaxis regimen in the prevention of recurrent urinary tract infections in patients with neurogenic bladder dysfunction who practice intermittent self-catheterization.

METHODS AND ANALYSIS

In this multi-centre, prospective longitudinal multi-arm observational study, a total of 785 patients practising intermittent self-catheterisation due to NLUTD will be included. After inclusion, non-antibiotic prophylaxis regimens will be instilled with either UroVaxom^® (OM-89) standard regimen, StroVac^® (bacterial lysate vaccine) standard regimen, Angocin^®, D-mannose (oral dose 2 g), bladder irrigation with saline (once per day). The management protocols will be pre-defined, but the selection of the protocol will be at the clinicians' discretion. Patients will be followed for 12 months from the onset of the prophylaxis protocol. The primary outcome is to identify the incidence of breakthrough infections. The secondary outcomes are adverse events associated with the prophylaxis regimens and the severity of breakthrough infections. Other outcomes include the exploration of change in susceptibility pattern via the optional rectal and perineal swab, as well as health-related quality of life over time (HRQoL), which will be measured in a random subgroup of 30 patients.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the ethical review board of the University Medical Centre Rostock (A 2021-0238 from 28 October 2021). The results will be published in a peer-reviewed journal and presented at relevant meetings.

STUDY REGISTRATION NUMBER

German Clinical Trials Register: Number DRKS00029142.

Emerging Non-Antibiotic Options Targeting Uropathogenic Mechanisms for Recurrent Uncomplicated Urinary Tract Infection

Urinary tract infections (UTIs) are the most frequent bacterial infections in the clinical setting. Even without underlying anatomic or functional abnormalities, more than 40% of women experience at least one UTI in their lifetime, of which 30% develop recurrent UTIs (rUTIs) within 6 months. Conventional management with antibiotics for rUTIs may eventually lead to the development of multidrug-resistant uropathogens. Targeting of the pathogenicity of rUTIs, the evolution of uropathogenic Escherichia coli (UPEC), and inadequate host defenses by immune responses should be explored to provide non-antibiotic solutions for the management of rUTIs. The adaptive evolution of UPEC has been observed in several aspects, including colonization, attachment, invasion, and intracellular replication to invade the urothelium and survive intracellularly. Focusing on the antivirulence of UPEC and modulating the immunity of susceptible persons, researchers have provided potential alternative solutions in four categories: antiadhesive treatments (i.e., cranberries and D-mannose), immunomodulation therapies, vaccines, and prophylaxis with topical estrogen therapy and probiotics (e.g., Lactobacillus species). Combination therapies targeting multiple pathogenic mechanisms are expected to be a future trend in UTI management, although some of these treatment options have not been well established in terms of their long-term efficacy. Additional clinical trials are warranted to validate the therapeutic efficacy and durability of these techniques.

Original Article Phytotherapy in Adults With Recurrent Uncomplicated Cystitis

BACKGROUND

Uncomplicated urinary tract infections are among the commonest bacterial infections. Because antibiotic resistance is on the rise, there is growing interest in alternative, non-antimicrobial treatment options. This systematic review presents the current evidence on phytotherapy for the treatment and prevention of recurrent uncomplicated cystitis.

METHODS

A systematic search of the relevant literature from January 2011 to August 2021 was carried out in the MEDLINE, Embase, and Cochrane Library databases and in two clinical trial registries. The trials included in the present review are ran - domized controlled trials (RCTs) of phytotherapeutic agents as monotherapy or combination therapy, in comparison to placebo, no treatment, non-pharmacological treatment, or drug treatment without any phytotherapeutic component. Two of the authors independently selected the publications, extracted the data, and estimated the risk of bias using the Cochrane Risk of Bias Tool.

RESULTS

12 RCTs with a total of 1797 female patients were included. A trial of acute therapy with Chinese plant-based medicine revealed non-inferiority to antibiotic treatment. Six trials of prophylaxis with cranberry products yielded mixed results with regard to efficacy against recurrent urinary tract infections. A trial of Seidlitzia rosmarinus for the prevention of cystitis showed that its use was associated with a lower cystitis rate than placebo (at 6 months: 33 vs. 73%, p <0.001). In all trials but one, the risk of bias was unclear or high. No standardized assessment of adverse events was carried out.

CONCLUSION

Phytotherapeutic agents are an option for the treatment and prevention of recurrent cystitis in women. Given the heterogeneous state of the evidence on phytotherapy, no dependable recommendations can now be made for the clinical management of these patients with respect to phytotherapeutic agents.