Immunoactive prophylaxis of recurrent urinary tract infections: a meta-analysis

Secondary Analysis of Interstitial Cystitis/Bladder Pain Syndrome Patients Enrolled in a Recurrent Urinary Tract Infection Prevention Study Provides a Novel Paradigm for Etio-Pathogenesis and Practical Management of This Infection Phenotype

INTRODUCTION

A subset of interstitial cystitis/bladder pain syndrome (IC/BPS) patients experience recurrent urinary tract infection (rUTI) associated with symptom flares. Recurrent UTI subjects with associated IC/BPS were enrolled in the first North American early clinical experience trial evaluating a new sublingual UTI preventative vaccine, MV140. It has been shown that women with rUTI develop an imbalance in the T helper 1 and 2 (Th2 over-expression) in the bladder mucosa. Our hypothesis-generating secondary analysis will suggest that this infection subcategory of IC/BPS patients develop a similar imbalance of Th1-Th2 response type to bacteria present in their urinary microbiome, leading to a bladder hypersensitivity that responds to mucosal immune modulation.

METHODS

Female participants with ≥3 documented UTI/year underwent a 3-month vaccination treatment period with a 9-month efficacy period after completion of vaccine treatment (total 12 months). There were no exclusion criteria for subjects in relation to baseline urinary symptoms and/or discomfort/pain. Primary outcome was no UTI following vaccination. Secondary outcomes included change in UTI incidence, overall patient-reported subjective global assessment (SGA responder defined as moderately or markedly improved on 7-point scale), and safety.

RESULTS

Sixteen subjects with IC/BPS-related symptoms and rUTI (mean age 47; range 23-74 years; mean number of UTI episodes in previous year 6.1 +/- 4.2) were eligible to be included in the Health Canada-approved MV140 vaccine study for prevention of rUTI. All subjects completed the 3-month vaccination period. One subject was lost to follow-up after their 6-month visit. Six subjects were UTI-free, while all 16 subjects had a reduction in UTI episodes compared to the year pre-vaccination. The total post-vaccination reduction in UTI episodes compared to pre-vaccination was 80% (0.1 UTI/subject/month from 0.5 UTI/subject/month, respectively). At 12 months, 13 subjects (81%) were SGA responders (moderately or markedly improved), and the responders reported a reduction in IC/BPS symptoms, with 8 subjects reporting significant or almost complete resolution of their specific long-term bladder discomfort/pain and bothersome urinary frequency or urgency. Four subjects reported mild and self-limited adverse events during vaccination period, but none were related to MV140 vaccine.

CONCLUSION

Sublingual MV140 vaccine in IC/BPS patients with rUTI not only achieved UTI-free or reduced UTI incidence status but also, after approximately 9 months post vaccination, resolution of patients' long-term treatment-refractory IC/BPS symptoms. This suggests some cases of IC/BPS may be etiologically based on Th2-driven hypersensitivity to bacteria within or entering the urinary microbiome that responds to a vaccine whose mechanism of action is to normalize or balance the bladder Th1/Th2 mucosal immune system.

Progress toward a vaccine for extraintestinal pathogenic E. coli (ExPEC) II: efficacy of a toxin-autotransporter dual antigen approach

Extraintestinal pathogenic Escherichia coli (ExPEC) is a leading cause of worldwide morbidity and mortality, the top cause of antimicrobial-resistant (AMR) infections, and the most frequent cause of life-threatening sepsis and urinary tract infections (UTI) in adults. The development of an effective and universal vaccine is complicated by this pathogen's pan-genome, its ability to mix and match virulence factors and AMR genes via horizontal gene transfer, an inability to decipher commensal from pathogens, and its intimate association and co-evolution with mammals. Using a pan virulome analysis of >20,000 sequenced E. coli strains, we identified the secreted cytolysin α-hemolysin (HlyA) as a high priority target for vaccine exploration studies. We demonstrate that a catalytically inactive pure form of HlyA, expressed in an autologous host using its own secretion system, is highly immunogenic in a murine host, protects against several forms of ExPEC infection (including lethal bacteremia), and significantly lowers bacterial burdens in multiple organ systems. Interestingly, the combination of a previously reported autotransporter (SinH) with HlyA was notably effective, inducing near complete protection against lethal challenge, including commonly used infection strains ST73 (CFT073) and ST95 (UTI89), as well as a mixture of 10 of the most highly virulent sequence types and strains from our clinical collection. Both HlyA and HlyA-SinH combinations also afforded some protection against UTI89 colonization in a murine UTI model. These findings suggest recombinant, inactive hemolysin and/or its combination with SinH warrant investigation in the development of an E. coli vaccine against invasive disease.

Therapeutic strategies for uncomplicated cystitis in women

Uncomplicated cystitis is affecting many women of all ages and has a great impact on the quality of life, especially in women suffering from recurrent, uncomplicated cystitis. By far the most frequent uropathogen, E. coli, may have acquired increasing resistance against a variety of oral antibiotics, which may differ between countries and regions. Therefore, local resistance data are important to be considered. On the other hand, non-antibiotic therapy has also become an option which should be discussed and offered to the patient. In patients suffering from recurrent uncomplicated cystitis, individual risk factors and possible behavioral changes should first be taken into account. Non-antimicrobial prophylactic strategies shown to be successful in well-designed clinical studies are the next options. Long term antibiotic prophylaxis, however, should only be considered as a last option. For some of those patients self-diagnosis and self-treatment may be suitable, e.g. by using a recognized questionnaire.

Immunoactive Prophylaxis Protocol of Uncomplicated Recurrent Urinary Tract Infections in a Cohort of 1104 Women Treated with Uromune® Vaccine

BACKGROUND

A prospective, descriptive, and multicenter research that included 1104 women with three or more uncomplicated UTIs following immunoprophylaxis with Uromune® vaccine between 2011 and 2022 is presented.

METHODS

OBJECTIVE

to analyze the efficacy of Uromune® and perform a follow-up protocol.

VARIABLES

age; bacteria; number of UTIs at baseline and at 3, 6, and 12 months of follow-up; distribution according to age and months of the year; therapy with polybacterial vaccine or autovaccine. Efficacy was defined as 0-2 UTIs during follow-up. Patients were divided into Group 1, with 3-4 UTIs at baseline, and Group 2, with 5 or more.

RESULTS

Average age was 72. Escherichia coli represented 64.3% of infections. Overall efficacy was 91.7%, 82.3%, and 57.6% at 3, 6, and 12 months. Efficacy in patients treated with vaccines was 95.8%, 88.4%, and 56.1%, and with autovaccines it was 85.7%, 73.6%, and 60.2%. Results were statistically significant in relation to vaccines (p < 0.05). Group 1 represented 65.2% and Group 2 represented 34.8%. Group 1 had an efficacy of 97.7%, 91.1%, and 64.7% and Group 2 had an efficacy of 80.2%, 64.3%, and 40%. Results were statistically significant in Group 1 (p < 0.05).

CONCLUSIONS

Patients at baseline with less than five UTIs will have better result and would benefit from a prophylaxis protocol with Uromune®.

Autovaccine-Based Immunotherapy: A Promising Approach for Male Recurrent Urinary Tract Infections

BACKGROUND

Recurrent Urinary Tract Infections (UTIs) in men range from 0.9 to 2.4/1000 individuals in younger men to 7.7/1000 in those over 85, significantly impacting their quality of life. Preventive strategies include autovaccines, but limited evidence exists for males.

METHODS

A prospective monocentric, open-label observational study was conducted from August 2018 to August 2021, with follow-up until August 2023 including patients with recurrent UTIs treated with immunotherapy. We evaluated the incidence rate of UTIs per year, the incidence rate of episodes after two or three rounds of the autovaccine, and quality of life measured with the IPSS-QoL questionnaire.

RESULTS

A total of 49 patients fulfilled inclusion criteria. The mean age was 72 years (±15), and the median 61. The evolution of UTIs number of episodes after the autovaccine rounds: -37.74% for the first round from 5.3 to 3.3; -33.33% for the second round from 3.3 to 2.2; -45.45% for the third round from 2.2 to 1.2. The mean IPSS score improved from 10.69 to 7.27 after the treatment (32%). The mean QoL subscore enhancement was from 4.22 to 1.92 (54%). With a mean follow-up of 3 years, only nine patients required retreatment.

CONCLUSION

Autovaccine treatment significantly reduced the number of UTI episodes, with a cumulative effect observed after multiple rounds of treatment, demonstrating an enhancement in QoL and with sustained effectiveness and a low need for retreatment.

Antibiotic management of urinary tract infections in the post-antibiotic era: a narrative review highlighting diagnostic and antimicrobial stewardship

BACKGROUND

As one of the most common indications for antimicrobial prescription in the community, the management of urinary tract infections (UTIs) is both complicated by, and a driver of, antimicrobial resistance.

OBJECTIVES

To highlight the key clinical decisions involved in the diagnosis and treatment of UTIs in adult women, focusing on clinical effectiveness and both diagnostic and antimicrobial stewardship as we approach the post-antimicrobial era.

SOURCES

Literature reviewed via directed PubMed searches and manual searching of the reference list for included studies to identify key references to respond to the objectives. A strict time limit was not applied. We prioritised recent publications, randomised trials, and systematic reviews (with or without meta-analyses) where available. Searches were limited to English language articles. A formal quality assessment was not performed; however, the strengths and limitations of each paper were reviewed by the authors throughout the preparation of this manuscript.

CONTENT

We discuss the management of UTIs in ambulatory adult women, with particular focus on uncomplicated infections. We address the diagnosis of UTIs, including the following: definition and categorisation; bedside assessments and point-of-care tests; and the indications for, and use of, laboratory tests. We then discuss the treatment of UTIs, including the following: indications for treatment, antimicrobial sparing approaches, key considerations when selecting a specific antimicrobial agent, specific treatment scenarios, and duration of treatment. We finally outline emerging areas of interest in this field.

IMPLICATIONS

The steady increase in antimicrobial resistance among common uropathogens has had a substantial affect on the management of UTIs. Regarding both diagnosis and treatment, the clinician must consider both the patient (clinical effectiveness and adverse effects, including collateral damage) and the community more broadly (population-level antimicrobial selection pressure).

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.

An Effective Sublingual Vaccine, MV140, Safely Reduces Risk of Recurrent Urinary Tract Infection in Women

Uncomplicated recurrent urinary tract infections (rUTIs) in women are associated with episodic bothersome symptoms and have a significant impact on the mental and physical quality of life. Treatment with antibiotics (short- and long-term dosing) results in acute and chronic side effects and costs and promotes general antibiotic resistance. Improved nonantibiotic management of rUTI in women represents a true, unmet medical need. MV140 is a novel sublingual mucosal-based bacterial vaccine developed for the prevention of rUTI in women. Based on observational, prospective, and randomized placebo-controlled studies, MV140 has been shown to safely prevent (or reduce the risk of) UTIs, reduce antibiotic use, overall management costs, and patient burden while improving the overall quality of life in women suffering from rUTIs.

Prospective multicentre randomized double-blind placebo-controlled parallel group study on the efficacy and tolerability of StroVac® in patients with recurrent symptomatic uncomplicated bacterial urinary tract infections

PURPOSE

To evaluate efficacy and safety of vaccination with StroVac compared to placebo in patients with recurrent urinary tract infections (rUTI).

MATERIAL AND METHODS

We performed a prospective, double-blinded, placebo-controlled study in patients with uncomplicated rUTI. Patients received three single intramuscular injections with StroVac every two weeks. Primary endpoint was the number of bacterial urinary tract infections (UTI) over 13.5 months after randomization and adjusted by the respective "baseline" value when comparing verum and placebo group. Secondary endpoints were the number of patients with non-recurrence, time to first recurrence, frequency of recurrences, and patients' self-assessment of quality of life using a validated questionnaire.

RESULTS

376 patients were randomized to both groups between January 2012 and March 2015. Mean age was 44.4 years. Patients were mainly female (98.4%). In the StroVac group (n = 188), the number of UTIs was reduced from 5.5 to 1.2, in the placebo group (n = 188) from 5.4 to 1.3 (p = 0.63). In patients with ≥ 7 UTIs prior to study inclusion, StroVac was statistically significantly superior to placebo (p = 0.048). However, in all other secondary endpoints, no statistical differences between the two groups could be seen (all p > 0.3).

CONCLUSION

StroVac reduced the number of clinically relevant UTIs like in former studies but did not show statistically significant better results than the chosen placebo. Most likely, that was due to a, since confirmed, prophylactic effect of the chosen placebo itself. Therefore, placebo-controlled and double-blinded studies using a different ineffective placebo preparation are needed to determine the importance of StroVac in prophylaxis of rUTI.

Guideline of guidelines: management of recurrent urinary tract infections in women

OBJECTIVE

To compare recurrent urinary tract infection (rUTI) guidelines from major urological and non-urological organisations internationally and identify areas of consensus and discrepancy.

METHODS

PubMed, Google Scholar and the official webpages of major urological, gynaecological, infectious diseases and general practice organisations were searched for rUTI guidelines in March 2022. Nine guidelines were included for review: European Association of Urology, National Institute for Health and Care Excellence (NICE), Society of Obstetricians and Gynaecologists of Canada, American Academy of Family Physicians, Mexican College of Gynaecology and Obstetrics Specialists, Swiss Society of Gynaecology and Obstetrics, Spanish Society of Infectious Diseases and Clinical Microbiology, German Association of Scientific Medical Societies, and the combined American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction.

RESULTS

The definition and evaluation of rUTIs, and antibiotic prophylaxis strategies, were mostly consistent across guidelines, and emphasised the importance of obtaining urine cultures and limiting cystoscopy and upper tract imaging in women without risk factors. Variable recommendations were noted for symptomatic treatment, self-initiated antibiotics, and antibiotic-sparing preventative strategies such as cranberry, vaginal oestrogen, immunoactive prophylaxis with OM-89, intravesical glycosaminoglycan instillation, and phytotherapeutics. Recent randomised evidence supports the use of methenamine hippurate. Either continuous or post-coital prophylactic antibiotics were supported by all guidelines. None of the guidelines were tailored to the management recurrent complicated UTI.

CONCLUSION

Multiple rUTI guidelines were identified and mostly limited their recommendations to otherwise healthy non-pregnant women with uncomplicated cystitis. Variation was noted, particularly in antibiotic-sparing preventative strategies. Some conflicting recommendations are due to more recent guidelines including updated evidence. Future guidelines should consider recommendations to assist management of complex patient groups, such as recurrent complicated UTI.

The effect of anal hygiene method in prevention from recurrent lower urinary tract infections in women

Aim: To evaluate the effects stopping the use of water and hands on preventing urinary tract infections (UTI) for a group of female patients having recurrent UTIs (rUTI). Material and Method: A retrospective observational study conducted in a tertiary care hospital between February 2017 and March 2018. 273 female patients which had rUTIs without any concomitant risk factors were included. In the study, 2 or more bacteriologically documented UTIs in the last 6 months were accepted as rUTI. The groups of the study defined as using their hands, using water only and using toilet paper (using either one of these two methods and then using toilet paper). Patients were observed for an average time of 10.4 months after stopping the use of water and hands for anal cleansing after defecation. Instead they were all given toilet education and started wiping for anal hygiene. Results: There was a statistically significant relationship between previous history of UTI and washing with hands + water (p=0.021). The rate of previous UTIs were significantly higher in the group of patients using their hands for anal washing (69% vs 31%). No relation was found between previous UTI history variable for using toilet paper and flushing with water only (p>0.05). Our results showed a statistically significant decrease of UTIs after stopping the use of water and hands in the patient group who had a previous UTI history (p=0.001). Conclusion: We managed to underline that washing with hands for anal cleansing as a risk factor for rUTIs in women. Also showed the positive effect of stopping the use of water and hands for anal cleansing after defecation for prevention from rUTIs. We encourage all clinicians for further studies to investigate this issue in the future.

Adherence to European Association of Urology Guidelines and State of the Art of Glycosaminoglycan Therapy for the Management of Urinary Tract Infections: A Narrative Review and Expert Meeting Report

Context

Urinary tract infections (UTIs) have a significant impact on patient's quality of life and society. Antibiotic therapy is the primary approach for the management of UTIs; however, it has major limits in the prevention of recurrent UTIs (rUTIs), also increasing the risk of development of multidrug-resistant micro-organisms.

Objective

The aim of this paper is to discuss the European Association of Urology guidelines for the management of UTIs/rUTIs, the level of adherence to these recommendations, and the available evidence on the use of glycosaminoglycans (GAGs) as a possible alternative treatment to prevent rUTIs.

Evidence acquisition

This narrative review and expert meeting report is based on a literature search concerning the currently available UTI guidelines, the results of a survey administered to 227 urologists, and the opinion of an expert panel in the field of UTIs.

Evidence synthesis

Results obtained from the literature search showed that adherence to guidelines is not optimal. The survey demonstrated that antibiotics remain one of the treatments of UTIs. However, most of the urologists are aware of the problem caused by the resistance to antibiotics and prefer alternative methods for the prophylaxis of UTIs. Considering the alternative methods, the authors concluded that GAG therapy is highly effective in preventing rUTIs.

Conclusions

Adherence to the international guidelines is important to align the clinical practice and avoid the spreading of antibiotic resistance. The survey outlines that the misuse and overuse of antibiotics are major problems; an analysis of clinical evidence confirms that GAG therapy is a valuable therapeutic approach to prevent the recurrence of episodes of UTIs and to limit the onset of antibiotic resistance.

Patient summary

Although antibiotic therapy is primarily used for the management of urinary tract infections (UTIs), misuse and overuse of antibiotics are of concern. Adherence to the international guidelines is important to prevent the spreading of antibiotic resistance. Clinical evidence confirms that the use of glycosaminoglycans is a valuable therapeutic approach to prevent UTI recurrence and limit the onset of antibiotic resistance.

Rezidivierende Harnwegsinfektionen – was tun?

Nicht antibiotische Therapieregime Neben allgemeiner Aufklärung und Beratung über Risikofaktoren von Harnwegsinfektionen sind vor allem die nichtantibiotischen Therapie-Optionen zur Rezidivreduktion wichtig. Das Ziel hierbei ist es, Resistenzentwicklungen und den entsprechenden unerwünschten Nebenwirkungen von Antibiotika vorzubeugen. Zu den nicht antibiotischen Strategien zählen allen voran eine persönliche Beratung mit Vermittlung von Verhaltensempfehlungen, die Immunoprophylaxe, Phytotherapeutika, sowie eine lokale Östrogensubstitution

Antibiotische Prävention Bei hohem Leidensdruck der Patientinnen ist jedoch nach entsprechender Abwägung auch eine antibiotische Prophylaxe in Betracht zu ziehen. Zusammenfassend sollte eine individuelle Beratung erfolgen und es sollte mit einem multimodalen Therapieansatz behandelt werden.

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.

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.

Sublingual MV140 for Prevention of Recurrent Urinary Tract Infections

Sublingual MV140 for Prevention of Recurrent UTIThis randomized placebo-controlled trial tested MV140, a sublingual preparation of whole-cell inactivated bacteria, in women with recurrent urinary tract infection (UTI). MV140 administered sublingually for either 3 or 6 months decreased UTI incidence and prevented recurrence for up to 1 year compared with placebo, without serious adverse events.

Quality appraisal of clinical guidelines for recurrent urinary tract infections using AGREE II: a systematic review

Introduction and hypothesis

Recommendations for preventing and diagnosing recurrent urinary tract infection (UTI) tend to vary between clinical practice guidelines (CPGs) because of low-quality scientific evidence, potentially leading to practice variation and suboptimal care. We assessed the quality of existing CPGs for recurrent UTI.

Methods

A systematic search was performed from January 2000 to June 2021 in PubMed and EMBASE for CPGs on recurrent UTI prevention or hospital diagnostics in Dutch, English, and Spanish. Each CPG was assessed by four appraisers in a multidisciplinary review team, using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) instrument.

Results

We identified and assessed eight CPGs published between 2013 and 2021. The scope and purpose (mean and standard deviation: 67.3 ± 21.8) and clarity of presentation (74.8 ± 17.6) domains scored highly. However, issues with methods, patient participation, conflict of interests, and facilitators and barriers were common and resulted in lower scores for the rigour of development (56.9 ± 25.9), applicability (19.6 ± 23.4), stakeholder involvement (50.4 ± 24.6), and editorial independence (62.1 ± 23.1) domains. Overall, two CPGs were recommended, three were recommended with modifications, and three were not recommended.

Conclusions

Significant room for improvement exists in the quality of CPGs for recurrent UTI, with most displaying serious limitations in the stakeholder involvement, rigour of development, and applicability domains. These aspects must be improved to decrease diagnostic and therapeutic uncertainty. Developers could benefit from using checklists and following guidelines when developing de novo CPGs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-022-05089-6.

[Non-antibiotic Prophylaxis of Infections]

Non-antibiotic Prophylaxis of Infections Abstract. The increasing resistance to antibiotics makes the search for non-antibiotic alternatives for the treatment and prevention of - above all - respiratory and urinary tract infections crucial. Potential non-antibiotic approaches include phytopharmaceuticals (Echinacea purpurea, Pelargonium sidoides, cranberry extract), zinc, immunostimulants (OM-85 BV, OM-89), and behavior modifications. Some of these approaches are promising options; however, a high level of evidence is required before specific recommendations for their use can be made.

Immunomodulation for primary prevention of urinary tract infections in patients with spinal cord injury during primary rehabilitation: protocol for a randomized placebo-controlled pilot trial (UROVAXOM-pilot)

BACKGROUND

Urinary tract infections (UTIs) are common in individuals with neurogenic lower urinary tract dysfunction (NLUTD) following spinal cord injury (SCI). They are not only a great burden for affected individuals, but also cause considerable health costs. Furthermore, recurrent antibiotic treatments of UTIs contribute to the growing problem of bacterial resistance to antimicrobial compounds. Even though there is a multitude of different measures to prevent UTIs in individuals with NLUTD, no clear evidence exists for any of these. Oral immunomodulation with UTI-relevant Escherichia coli lysate may be a promising preventative measure with a good safety profile in individuals with NLUTD. However, currently available data are sparse.

METHODS

This is a randomized, quasi-blinded, placebo-controlled, mono-centric pilot trial investigating the feasibility of a main trial regarding the effects of a lyophilized lysate of E. coli strains for oral application (Uro-Vaxom®, OM Pharma SA, Meyrin, Switzerland). There will be two parallel groups of 12 participants each. Individuals with acute SCI (duration SCI ≤ 56 days) from 18 to 70 years of age admitted for primary rehabilitation will be eligible. Blood and urine samples will be taken prior to intervention start, at the end of the intervention, and 3 months after intervention termination. The trial intervention will last 90 days. The participants will not be informed regarding the treatment allocation (quasi-blinded). The nursing staff will prepare the daily dose of the allocated treatment from the original packaging. The trial personnel and the biostatistician will be blinded. Feasibility (e.g., recruitment rate, patient attrition), clinical (e.g., number of symptomatic UTIs), and laboratory parameters (e.g., urinary culture, urinary proteo- and microbiome, blood cell counts) as well as adverse events will be collected.

DISCUSSION

Effective and efficient measures for the prevention of UTIs in individuals with NLUTD are urgently needed. If the conclusion of this pilot is positive regarding feasibility, the effects of oral immunomodulation with a E. coli lysate will be investigated in a larger, sufficiently powered, multi-center trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04049994 . Registered on 8 August 2019.

Examining GP online consultation in a primary care setting in east midlands, UK

Background

Increasing pressure threatens to overwhelm primary care services, affecting the quality of care and their role as gatekeepers to specialised care services. This study investigated healthcare users’ acceptability of – and the effectiveness of – an e-consultation system in primary care services.

Methods

Seven GP practices in East-Midlands, all of whom use online consultation system participated in the study, with a retrospective review being undertaken of 189 electronic patients’ records (age range of 18–76 years) over 5 months. The focus was on the electronic records of patients who accessed the service for five different conditions identified as presenting common conditions seen by the GPs practices. Statistical analysis was done using SPSS to perform an exploratory data analysis and descriptive statistics.

Results

The results showed a positive reception of the online consultation platform, with an average satisfaction score of 4.15 (most likely to recommend score = 5). Given the nature of the conditions, 47.6% of patients had experienced a previous episode of the health condition they were seeking consultation for, and a total of 72% had existing comorbidities. Follow-up activity occurred for 87.3% of patients, 66.1% of which included at least one follow-up visit for the same condition as the initial online consultation.

Conclusion

The results suggest that online consultation is convenient for patients, and it also has the potential to relieve pressure placed on primary care services. Although a number of challenges were identified, such as patient verification, this study gives insight into – and enhances our understanding of – the use of online GP consultations.

Efficacy of vaccination with StroVac for recurrent urinary tract infections in women: a comparative single-centre study

PURPOSE

To assess the efficacy of prophylaxis for urinary tract infections (UTI) in a two-year follow-up in women with StroVac compared to a therapy with Nitrofurantoin over three months.

MATERIALS AND METHODS

All patients with documented recurrent urinary tract infections (rUTI) were offered vaccination with StroVac or therapy with three months Nitrofurantoin 100 mg once daily for three months at patient's choice. Only patients with a follow-up of at least 24 months were included. All episodes with signs of UTI were documented and urine culture was performed. Success was defined as one or none UTI per 12 months, documented by urine culture. StroVac booster injection was offered 12 months after primary vaccination at patient's choice.

RESULTS

173 patients were included in this study, 124 in the StroVac group, 49 chose Nitrofuratoin. In the first 12 months, 86.8% of patients in the StroVac group and 91.8% in Nitrofurantoin group were successful (p = 0.22). Side effects were noted in 2.3% in the StroVac group causing discontinuation of therapy, whereas in the Nitrofurantoin group 18.4% stopped medication premature, mostly due to mild diarrhoea. In the second year 79.3% of patients in the StroVac group were still successful, most of them had undergone booster injection. In contrast, in the Nitrofurantoin group only 59.2% of patients were still successful (p = 0.03).

CONCLUSION

StroVac is an effective and lasting non-antibiotic prophylaxis for rUTI, easy to administer with low rates of adverse events and should be offered to patients with rUTI.

Prospective Study in Children with Complicated Urinary Tract Infection Treated with Autologous Bacterial Lysates

Antimicrobial bacteria resistance is an important problem in children with recurrent urinary tract infections (rUTI), thus it is crucial to search for alternative therapies. Autologous bacterial lysates (ABL) may be a potential treatment for rUTI. Twenty-seven children with rUTI were evaluated for one year, urine and stool cultures were performed, 10 colonies of each culture were selected and those identified as Escherichia coli were characterized by serology. For patients who presented ≥105 UFC/mL, an ABL was manufactured and administered orally (1 mL/day) for a month. Twelve children were monitored for ≥1-year, 218 urine and 11 stool samples were analyzed. E. coli (80.5%) was the main bacteria isolated from urine and feces (72%). E. coli of classical urinary serotypes (UPEC), O25:H4, O75:HNM, and O9:HNM were identified in patients with persistent urinary infection (pUTI). In 54% of patients treated with ABL, the absence of bacteria was observed in urine samples after 3 months of treatment, 42% of these remained without UTI between 10-12 months. It was observed that the use of ABL controlled the infection for almost 1 year in more than 60% of the children. We consider it necessary to develop a polyvalent immunogen for the treatment and control of rUTI.

[What to do about recurrent urinary tract infections]

Urinary tract infections are among the most common bacterial infections. A significant proportion of urinary tract infections recur, which leads to impairments in patients' physical intimacy, social contacts and ability to work. The standardised ACSS questionnaire can provide help in establishing a diagnosis and assessing the course of the disease. In addition to general education and counselling on risk factors for urinary tract infections, non-antibiotic treatment options are particularly important for reducing recurrence. This aims to prevent the development of resistance to antibiotics and their undesirable side-effects. Non-antibiotic strategies most notably include personal counselling with communication of behavioural recommendations, immunoprophylaxis, phytotherapeutics and local oestrogen substitution. However, in cases of high patient suffering, antibiotic prophylaxis should also be considered after due deliberation. In summary, individual counselling should take place and treatment should be given in a multimodal therapeutic approach.

Antimicrobial pharmacokinetics and preclinical in vitro models to support optimized treatment approaches for uncomplicated lower urinary tract infections

INTRODUCTION

Urinary tract infections (UTIs) are extremely common. Millions of people, particularly healthy women, are affected worldwide every year. One-in-two women will have a recurrence within 12-months of an initial UTI. Inadequate treatment risks worsening infection leading to acute pyelonephritis, bacteremia and sepsis. In an era of increasing antimicrobial resistance, it is critical to provide optimized antimicrobial treatment.

AREAS COVERED

Literature was searched using PubMed and Google Scholar (up to 06/2020), examining the etiology, diagnosis and oral antimicrobial therapy for uncomplicated UTIs, with emphasis on urinary antimicrobial pharmacokinetics (PK) and the application of dynamic in vitro models for the pharmacodynamic (PD) profiling of pathogen response.

EXPERT OPINION

The majority of antimicrobial agents included in international guidelines were developed decades ago without well-described dose-response relationships. Microbiology laboratories still apply standard diagnostic methodology that has essentially remained unchanged for decades. Furthermore, it is uncertain how relevant standard in vitro susceptibility is for predicting antimicrobial efficacy in urine. In order to optimize UTI treatments, clinicians must exploit the urine-specific PK of antimicrobial agents. Dynamic in vitro models are valuable tools to examine the PK/PD and urodynamic variables associated with UTIs, while informing uropathogen susceptibility reporting, optimized dosing schedules, clinical trials and treatment guidelines.

Recurrent urinary tract infections: from pathogenesis to prevention

Urinary tract infections are highly prevalent among women and when they are recurrent they can lead to patient discomfort and high healthcare costs, and they represent one of the most frequent causes of antibiotic consumption. There are several options to prevent RUTI which include both antibiotic treatment (continuous or postcoital antibiotic prophylaxis) and non-antibiotic measures (hygienic measures, vitamin D, blueberries, D-mannose, probiotics, oestrogens, vaccines, intravesical instillations), but with different levels of evidence, sometimes of poor quality, and therefore new randomized and comparative studies are needed to choose the best strategy.

Immunotherapy to reduce frequency of urinary tract infections in people with neurogenic bladder dysfunction; a pilot randomised, placebo-controlled trial

Objective:

To establish the feasibility of a randomized, placebo-controlled trial to investigate the effect of a specific immunotherapy bacterial lysate OM-89 (Uro-Vaxom^®) in reducing the frequency of urinary tract infections in people with neurogenic bladder dysfunction.

Design:

A parallel-group, double-blind, randomized, placebo-controlled trial.

Setting:

Patients at home, recruited through out-patient contact, social media and patient support groups.

Subjects:

People with a spinal cord injury, multiple sclerosis, transverse myelitis or cauda equina syndrome who had suffered three or more clinically diagnosed urinary tract infections treated with antibiotics over the preceding 12 months.

Interventions:

All participants took one capsule of oral OM-89 immunotherapy (6 mg) or matching Placebo (randomisation ratio 1:1), once daily in the morning for 3 months.

Main measures:

The primary outcome was occurrence of a symptomatic urinary tract infection treated with an antibiotic, assessed at 3 and 6 months. Feasibility measures included recruitment, retention and practical difficulties.

Results:

Of 115 patients screened, 49 were recruited, one withdrew before randomization, and 23 were allocated to the control group receiving matching placebo. Six participants, all in the control group, discontinued the intervention; all participants provided full data at both follow-up times. Over 6 months, 18/25 active group patients had 55 infections, and 18/23 control group patients had 47 infections. Most research and clinical procedures were practical, and acceptable to participants.

Conclusion:

It is feasible to undertake a larger trial. We recommend broader inclusion criteria to increase eligibility and generalizability.

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.

The EAU and AUA/CUA/SUFU Guidelines on Recurrent Urinary Tract Infections: What is the Difference?

For diagnosis of urinary tract infection (UTI), low bacterial counts in urine culture need to be considered more often. Non-antibiotic prophylaxis should be prioritized before antibiotic prophylaxis in patients with uncomplicated, recurrent UTI. Immunoprophylaxis in patients with rUTI deserves better consideration.

How can we improve investigation, prevention and treatment for recurrent urinary tract infections - ICI-RS 2018

BACKGROUND

Recurrent urinary tract infection (rUTI) is a chronic condition and has a significant impact on health-related quality of life. The commonly used definition for rUTI is greater than three episodes in a year or more than two in 6 months. Current diagnostic methods have been used worldwide for over five decades, despite well evidenced criticism. Enhanced culture techniques demonstrate that the microbiome of the bladder is far more complex than previously thought and begs a reappraisal of our current testing. Treatment of rUTI is based on a small number of antibiotic trials with some evidence showing a reduction in the number of positive cultures, but one must be cautious in interpreting the results and weigh against the risk of generation of antimicrobial resistance (AMR).

AIM

The International Consultation on Incontinence-Research Society think tank reviewed the literature with a view to improving investigation, prevention and treatment of rUTI.

METHODS

A multidisciplinary team of experts were invited to present evidence regarding the current diagnostic methods, recent advances related to bladder biome mapping and current treatment strategies, including antibiotic and nonantibiotic options. Current guidelines regarding antibiotic stewardship and concerns regarding AMR were discussed.

DISCUSSION

Outcome of the think tank discussions are summarised with a set of recommendations to inform future research. Particular consideration is given to bacterial survival in the bladder after treatment as well as defects in urothelial barrier function which may play a significant part in the failure to eradicate UTI.

Acquisition, Divergence, and Personalization of the Female Perineal Microbiomes Are Driven by Developmental Milestones and Disrupted by Urinary Tract Infection: A Pilot Study

Introduction: The pediatric perineal microbiomes inhabit a dynamic environment with changes related to diet, toileting habits, and hormonal development. We hypothesized that next-generation sequencing would reveal different perineal bacterial signatures associated with developmental milestones in premenstrual females. Furthermore, we predicted that these microbial changes would be disrupted in premenstrual females with a history of urinary tract infection (UTI). Study Design: Healthy females were recruited at well-child visits. Subjects were divided into 4 developmental groups: (1) 0-3 month old newborns; (2) 4-10 month old infants transitioning to solid foods; (3) 2-6 year old toddlers peri-toilet training; and (4) 7-12 year old premenstrual girls. A separate group of females with a history of culture proven UTI and off antibiotics >1 month was also recruited. DNA was isolated from swabs of the perineum and subjected to 16S rRNA sequencing. The diversity and species changes between developmental cohorts and age matched children with history of UTI was determined. Results: A total of 75 subjects were recruited: 15 in each group. There was a clear evolution of the perineal microbiomes with development. There was a significant microbial disruption in girls with a history of UTI, irrespective of developmental milestone age group. The periurethral/perivaginal site displayed greater changes in microbiome structure than other sites in girls with a history of UTI. Discussion: This pilot study evaluates the normal microbiome of the premenstrual girl at specific developmental milestones. Although the number of children per cohort was limited to 15, we observed statistical significance corresponding with developmental milestones. This study provides the first, culture independent delineation of the development of the perineal microbiome in girls. Furthermore, the sites closest to the site of infection appear to be more sensitive to antibiotic remodeling than those more distant. The factors that remodel the perineal microbiomes and predispose females, particularly girls, to UTIs (e.g., increase in uropathogen presence, absence of protective organisms) are unclear. Identification of specific signatures that increase susceptibility to UTI and their sequelae will improve patient care and promote personalized medicine.

Active immunoprophyilaxis with uromune® decreases the recurrence of urinary tract infections at three and six months after treatment without relevant secondary effects

Background

To prospectively analyze the efficacy of uromune® in the prevention of uncomplicated recurrent urinary tract infections at 3 and 6 months, and according to gender and menopause.

Methods

From September 2011 to December 2017 uromune® was administered sublingually every 24 h along 3 months to 784 patients with history of three or more uncomplicated urinary tract infections in the 12 months prior to the first visit.

The variables analyzed with statistical package system for science version 15.0 were age, gender, number of urinary tract infections with positive urine culture in the first consultation, and 3 and 6 months after the end of treatment.

The results with positive urine culture were registered at 3 and 6 months after the end of the treatment according to gender and also in the menopausal group with respect to pre-menopausal women.

Results

Mean age was 73.5 years. 82.7% were women and 94.3% menopausal.

The number of episodes of urinary tract infections in the 12 months prior to uromune® were 3 in 37.2%, 4 in 28.1%, 5 in 19.5%, 6 in 9.6%, 7 in 4%, 8 in 1.4%, 9 in 0.1% and 10 in 0.1%.

Three months after uromune® 44.1% had 0 urinary tract infections and 27.6% had 1. After 6 months the results were 0 urinary tract infections in 32.3% and 1 in 32.4%.

Women had 0 urinary tract infections after 3 months in 45.4% and 1 in 28.5%. At 6 months the female had 0 episodes in 32.7% and 1 in 33.2%.

Menopausal women had 0 urinary tract infections at 3 months in 46.5% and 1 in 28% and at 6 months scored 0 episodes in 33.6% and 1 in 32.9%.

Conclusions

Uromune® was highly effective to reduce the number of episodes of urinary tract infections at three and six months of follow-up. Uromune® reduced the number of episodes to zero or one in 71.7 and 64.7% at three and six months with minimal side effects.

The best results were observed in women over 50 years old.

Sublingual immunoprophylaxis with uromune® could be the treatment of first choice in the prevention of uncomplicated recurrent urinary tract infections according to the sample analyzed.

Latin American consensus on uncomplicated recurrent urinary tract infection-2018

An estimated 20-30% of adult women who experience an initial urinary tract infection (UTI) will have recurrent infection. In these patients, prophylaxis may be considered to improve their quality of life and control overuse of antibiotics. Despite this need, there is currently no Latin American consensus on the treatment and prophylaxis of recurrent UTIs. This consensus, signed by a panel of regional and international experts on UTI management, aims to address this need and is the first step toward a Latin American consensus on a number of urogynecological conditions. The panel agrees that antibiotics should be considered the primary treatment option for symptomatic UTI, taking into account local pathogen resistance patterns. Regarding prophylaxis, immunoactive therapy with the bacterial lysate OM-89 received a grade A recommendation and local estrogen in postmenopausal women grade B recommendation. Lower-grade recommendations include behavior modification and D-mannose; probiotics (Lactobacilli), cranberries, and hyaluronic acid (and derivatives) received limited recommendations; their use should be discussed with the patient. Though considered effective and receiving grade A recommendation, antimicrobial prophylaxis should be considered only following prophylaxis with effective non-antimicrobial measures that were not successful and chosen based on the frequency of sexual intercourse and local pathogen resistance patterns.

Nonantibiotic prevention and management of recurrent urinary tract infection

Urinary tract infections (UTIs) are highly prevalent, lead to considerable patient morbidity, incur large financial costs to health-care systems and are one of the most common reasons for antibiotic use worldwide. The growing problem of antimicrobial resistance means that the search for nonantibiotic alternatives for the treatment and prevention of UTI is of critical importance. Potential nonantibiotic measures and treatments for UTIs include behavioural changes, dietary supplementation (such as Chinese herbal medicines and cranberry products), NSAIDs, probiotics, D-mannose, methenamine hippurate, estrogens, intravesical glycosaminoglycans, immunostimulants, vaccines and inoculation with less-pathogenic bacteria. Some of the results of trials of these approaches are promising; however, high-level evidence is required before firm recommendations for their use can be made. A combination of these agents might provide the optimal treatment to reduce recurrent UTI, and trials in specific population groups are required.

Prevention and treatment of uncomplicated lower urinary tract infections in the era of increasing antimicrobial resistance-non-antibiotic approaches: a systemic review

Purpose

Urinary tract infections (UTIs) are one of the more common infections encountered in everyday clinical practice. They account for 10–20% of all infections treated in primary care units and 30–40% of those treated in hospitals. The risk of UTI in the female population is considered to be 14 times higher than in the male population. The prevalence of bacterial etiology results in a large consumption of broad-spectrum antibiotics, which in turn leads to increased rates of resistant uropathogens. Therefore, non-antibiotic prevention and treatment options are now of great importance.

Methods

A systematic literature search was performed for the last 20 years (1999–2019) and the efficiencies of these eight different non-antibiotic interventions were analysed and discussed.

Results

This article provides an overview on non-antibiotic options for management of UTI, including the application of cranberry products, the phytodrug Canephron N, probiotics, nonsteroidal anti-inflammatory drugs (NSAID), d-mannose, estrogens, vitamins, and immunotherapy.

Conclusions

The last 20 years of research on non-antibiotic approaches in UTI have not brought conclusive evidence that antibiotic usage can be replaced completely by non-antibiotic options. Hence, antibiotics still remain a gold standard for UTI treatment and prevention. However, changing the therapeutic strategy by including non-antibiotic measures in the management of UTI could be successful in avoiding antimicrobial resistance at least to some extent.

Prevention of recurrent urinary tract infections: bridging the gap between clinical practice and guidelines in Latin America

The branches of the immune system work in concert to defend against pathogens and prevent tissue damage due to excessive inflammation. Uropathogens in general, and uropathogenic Escherichia coli (UPEC) in particular, have evolved a diverse range of virulence mechanisms to avoid detection and destruction by the mucosal immune system of the urinary tract. Research towards a vaccine active against UPEC continues but has yet to be successful. Orally administered immunomodulatory bacterial lysates both stimulate and modulate the immune response in the urinary tract via the integrated mucosal immune system. The 2018 European Association of Urology (EAU) guidelines on treating acute uncomplicated cystitis recommend aiming for rapid resolution of symptoms, reduction of morbidity, and prophylaxis against reinfection. Recommended short-term antibiotic therapy has the advantage of good compliance, low cost, few adverse events, and low impact on bacterial flora. Antibiotic treatment of asymptomatic bacteriuria is only indicated during pregnancy and before invasive interventions. For recurrent infection, prophylaxis using behavioral modification and counseling should be employed first, then nonantibiotic prophylaxis, and, finally, low-dose continuous or postcoital antibiotic prophylaxis. The 2018 EAU guidelines give a strong recommendation for the oral bacterial lysate immunomodulator OM-89. All other nonantibiotic prophylactic strategies require more data, except for topical estrogen for postmenopausal women. For last-resort antibiotic prophylaxis, nitrofurantoin or fosfomycin trometamol are recommended. Guidelines for Latin America are currently being drafted, taking into account the unique ethnicity, availability of medicines, prevalence of antibiotic resistance, and healthcare practices found throughout the region.

Recent advances in managing lower urinary tract infections

Urinary tract infections (UTIs) are among the most common bacterial infections. Traditionally, all symptomatic UTIs are tested and treated. The use of antibiotics has resulted in an antibiotic resistance crisis, and we have limited options for managing UTIs. Currently, we live in the era of antimicrobial resistance and may live in other eras like the era of the microbiome. New insights might provide an opportunity to prevent the overuse and misuse of antibiotics and could enable the development of innovate managing strategies.

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.

Appropriate use of antibiotics: an unmet need

Increasing bacterial resistance combined with a steady decline in the discovery of new antibiotics has resulted in a global healthcare crisis. Overuse of antibiotics, for example, in the poultry and cattle industry, and misuse and improper prescription of antibiotics are leading causes of multidrug resistance (MDR). The increasing use of antibiotics, particularly in developing countries, is a big concern for antibiotic resistance and can cause other health threats such as increased risk of recurrent infections and increased risk of cardiovascular death with chronic use of macrolides. Carbapenems are the last line of defense in many cases of resistant infection, but trends show that resistance against these agents is also increasing. This narrative review is based on relevant literature according to the experience and expertise of the authors and presents an overview of the current knowledge on antibiotic resistance, the key driving factors, and possible strategies to tackle antibiotic resistance. Collectively, studies show that hospital-wide antibiotic stewardship programs are effective in decreasing the spread of antibacterial resistance. As resistance varies according to local patterns of use, it is essential to observe the epidemiology at both a regional and an institutional level. Furthermore, adaptation of clinical guidelines is necessary, particularly for inpatient care. Future guidelines should include a justification step for continued treatment of antibiotic treatments and criteria for selection of antibiotics at the start of treatment. Nonantibiotic prevention strategies can limit infections and should also be considered in treatment plans. Vaccines against MDR organisms have shown some efficacy in phase II trials in critical care patients. Nonimmunogenic and microbiologic treatment options such as fecal transplants may be particularly important for elderly and immune-compromised patients.

Community-Acquired Urinary Tract Infection by Escherichia coli in the Era of Antibiotic Resistance

Urinary tract infections (UTIs) caused by Escherichia coli (E. coli) are the most common types of infections in women. The antibiotic resistance of E. coli is increasing rapidly, causing physicians to hesitate when selecting oral antibiotics. In this review, our objective is to ensure that clinicians understand the current seriousness of antibiotic-resistant E. coli, the mechanisms by which resistance is selected for, and methods that can be used to prevent antibiotic resistance.

Vaccine Development for Urinary Tract Infections: Where Do We Stand?

Urinary tract infections (UTIs) are among the most common bacterial infections. Its management has become increasingly challenging due to antimicrobial resistance. The four mainstays to tackle this crisis rely on the development of new antibiotic agents, the introduction of preventive and alternative antimicrobial strategies, the concept of antimicrobial stewardship, and effective hygiene measures. One of the most effective approaches to prevent UTIs is the design of a potent vaccine. OM-89 is a lyophilised preparation of membrane proteins from 18 different uropathogenic Escherichia coli strains. The safety and efficacy of this immunoactive agent is well documented; therefore, it is recommended for the prophylaxis of UTI according to the current European Association of Urology guidelines on urological infections. In terms of a true vaccine designed to target specifically pathogenic bacteria, no substance is currently available. ExPEC4V, a novel tetravalent bioconjugate vaccine against extraintestinal pathogenic E. coli, was evaluated for safety, immunogenicity, and clinical efficacy in a randomised, single-blinded, placebo-controlled phase 1b trial. The vaccine was well tolerated and elicited a robust antibody response in patients suffering from recurrent UTIs. Although the first clinical data suggested a reduced incidence of UTIs after vaccination, especially for higher bacterial loads, further randomised controlled trials are necessary to determine its true clinical benefit.

The role of nonantibiotic treatment of community-acquired urinary tract infections

PURPOSE OF REVIEW

To summarize evidence on the efficacy of nonantibiotic treatments in the prevention of recurrent urinary tract infections (UTIs). The need for antibiotic-free regimens seems to be imperative given the worldwide rates of resistance of uropathogens to available antibiotics.

RECENT FINDINGS

In the recently published literature, cranberry products and probiotics are the focus of research. They both seem to be effective in preventing recurrent UTIs compared with placebo, but their benefit becomes less clear when they are compared with antibiotics.

SUMMARY

A number of nonantibiotic-containing alternatives are available for the prevention of recurrent UTIs. For the majority of these alternatives, contradictory results have been published. These can be, at least partially, explained by variation in doses administered and duration of treatment. Selection of patients more likely to benefit from these interventions seems to be a realistic approach from a clinical-practice perspective, as well a worthwhile focus for future research.

Social and economic burden of recurrent urinary tract infections and quality of life: a patient web-based study (GESPRIT)

BACKGROUND

Uncomplicated lower urinary tract infections (UTIs) occur in approximately 50% of women, and 20-30% experience recurrent UTI. Data on UTIs and quality of life (QoL) in Europe are limited.

METHODS

This was an anonymous, self-administered web-based survey conducted in 5 countries (Germany, Switzerland, Poland, Russia and Italy), on adult women who had experienced recurrent UTI and were affected by acute UTI currently or within 4 weeks of study entry. Questions covered disease course; management; social and economic burden; education, income, and health insurance status. QoL was evaluated using the SF-12v2.

RESULTS

Participants reported a mean of 5.15 UTI symptoms, ranging from 4.85 - 5.38 in Russia and Germany. There was a mean of 2.78 doctor visits per year (1.74 - 3.71 in Russia and Germany; p < 0.0001). 80.3% of participants had been treated with antibiotics, mean prescriptions ranged from 2.17 (Poland) to 3.36 (Germany) per person per year. A mean of 3.09 days sick leave due to UTIs, and 3.45 days of limited activities, were reported. Although 73.8% of participants had tried prophylaxis recurrence was common and associated with mental stress for a high proportion of women.

CONCLUSIONS

Our results indicate that recurrent UTIs have a significant impact on QoL of women in Europe.

Non-surgical management of recurrent urinary tract infections in women

One in three women will experience a clinically significant urinary tract infection (UTI) by age twenty-four and almost half will have at least one in their lifetime. Recurrent UTIs (rUTIs) are defined as having greater than two infections in a 6-month period, or three infections over twelve months, with complete resolution for at least two weeks. These may be due to relapse from incomplete treatment (persistence) or re-infection (new source). It may be difficult to distinguish between the two, where the same organism is cultured. There are several risk factors for rUTIs including an impairment of the body's immune system and virulence factors. Reversible or treatable causes are sought and excluded in the patient's initial review. Patient's with rUTI are often complex and difficult to manage. The long-term management options in women are multimodal and should focus on prevention of relapse and recurrence. Behavioural factors include adequate hydration, care with sexual hygiene, reducing one's body mass index (BMI) and post-void residual (PVR) volume. There are several non-antimicrobial options for rUTIs which have become a multi-billion-dollar business. Unfortunately, there are numerous studies which fail to show any major benefit or having conflicting data. Vaccines are currently being explored as a prevention strategy, delivered through injection, intra-nasal sprays, or vaginal suppositories, which are made from combinations of heat killed uro-pathogenic strains. There are no widely available vaccines at present due to limited clinical success. It is well established that appropriate antibiotic therapy results in higher rates of symptom relief and bacterial eradication in women with uncomplicated cystitis. There are several options for antimicrobial use which have been shown to be highly effective in reducing the risk of rUTI in women. The pain and discomfort of the UTI must be balanced with the cost and risk of developing resistance when using antimicrobials. Continuous prophylaxis, pre- and post-coital voiding, and self-starting are the three commonly accepted options for prophylaxis. The choice between these will depend upon patient preference, cultures and previous pattern of infection. Intra-vesical instillation of hyaluronic acid and chondroitin sulphate have been used for glycosaminoglycan (GAG) layer replenishment for many indications, including interstitial cystitis, overactive bladder syndrome, radiation cystitis and prevention of rUTI. At present, intra-vesical therapies are reserved for only those with the most unresponsive rUTIs. The principles of treating rUTI are to break the cycle and to treat any reversible causes. With our ever-expanding research knowledge, there are now many useful products that may be used for the successful treatment of rUTI. A management plan including a combination of a non-antimicrobial and selective antimicrobial regime for a minimum of six months should be considered. It is a prudent clinician that clearly defines this management plan, with reassurance of a finite period of therapy.

MV140, a sublingual polyvalent bacterial preparation to treat recurrent urinary tract infections, licenses human dendritic cells for generating Th1, Th17, and IL-10 responses via Syk and MyD88

Recurrent urinary tract infections (RUTIs) are one of the most common bacterial infectious diseases, especially in women. Antibiotics remain the mainstay of treatment, but their overuse is associated with antibiotic-resistant infections and deleterious effects in the microbiota. Therefore, alternative approaches are fully demanded. Sublingual immunization with MV140 (Uromune), a polyvalent bacterial preparation (PBP) of whole heat-inactivated bacteria, demonstrated clinical efficacy for the treatment of RUTIs, but the involved immunological mechanisms remain unknown. Herein, we demonstrated that MV140 endorses human dendritic cells (DCs) with the capacity to generate Th1/Th17 and IL-10-producing T cells by mechanisms depending on spleen tyrosine kinase (Syk)- and myeloid differentiation primary response gene 88 (MyD88)-mediated pathways. MV140-induced activation of nuclear factor κB (NF-κB) and p38 in human DCs is essential for the generated Th1/Th17 and IL-10 immune responses whereas c-Jun N-terminal Kinase (JNK) and extracellular-signal regulated kinase (ERK) contribute to Th1 and IL-10 responses, respectively. Sublingual immunization of BALB/c mice with MV140 also induces potent systemic Th1/Th17 and IL-10 responses in vivo. We uncover immunological mechanisms underlying the way of action of MV140, which might well also contribute to understand the rational use of specific PBPs in other clinical conditions with potential high risk of recurrent infections.

[Recurrent and catheter-associated urinary tract infections : Prophylaxis and prevention]

Urinay tract infection (UTI) as one of the most frequent bacterial infections in humans is of utmost relevance. Because of the rising prevalence of antimicrobial resistance, urinalysis should always include urine culture and a resistogram in order to avoid an unspecific selection and overuse of antibiotics. Prevention of recurrent UTI must first of all rule out predisposing uropathogenic conditions. Nowadays, a great variety of drugs, behavioral, and supportive treatment options can effectively minimize UTI recurrence. The growing importance of vaccines (immunotherapy), probiotics (lactobacilli), and standardized herbal preparations meets the need of reducing antibiotic use and the development of antimicrobial resistance. Around 80% of all nosocomial UTIs (nUTIs) are associated with indwelling urinary catheters. It is estimated that up to 70% of all nUTIs occurring in Germany may be avoided by using appropriate preventative measures. Therefore, profound knowledge about the basics of catheter-associated nUTIs and the correct management of urinary catheters are of utmost individual and socioeconomic importance.

Drug and Vaccine Development for the Treatment and Prevention of Urinary Tract Infections

Urinary tract infections (UTI) are among the most common bacterial infections in humans, affecting millions of people every year. UTI cause significant morbidity in women throughout their lifespan, in infant boys, in older men, in individuals with underlying urinary tract abnormalities, and in those that require long-term urethral catheterization, such as patients with spinal cord injuries or incapacitated individuals living in nursing homes. Serious sequelae include frequent recurrences, pyelonephritis with sepsis, renal damage in young children, pre-term birth, and complications of frequent antimicrobial use including high-level antibiotic resistance and Clostridium difficile colitis. Uropathogenic E. coli (UPEC) cause the vast majority of UTI, but less common pathogens such as Enterococcus faecalis and other enterococci frequently take advantage of an abnormal or catheterized urinary tract to cause opportunistic infections. While antibiotic therapy has historically been very successful in controlling UTI, the high rate of recurrence remains a major problem, and many individuals suffer from chronically recurring UTI, requiring long-term prophylactic antibiotic regimens to prevent recurrent UTI. Furthermore, the global emergence of multi-drug resistant UPEC in the past ten years spotlights the need for alternative therapeutic and preventative strategies to combat UTI, including anti-infective drug therapies and vaccines. In this chapter, we review recent advances in the field of UTI pathogenesis, with an emphasis on the identification of promising drug and vaccine targets. We then discuss the development of new UTI drugs and vaccines, highlighting the challenges these approaches face and the need for a greater understanding of urinary tract mucosal immunity.