Prevention of recurrent bacterial urinary tract infections by intravesical instillation of hyaluronic acid

Novel Key Ingredients in Urinary Tract Health-The Role of D-mannose, Chondroitin Sulphate, Hyaluronic Acid, and N-acetylcysteine in Urinary Tract Infections (Uroial PLUS®)

Urinary tract infections represent a common and significant health concern worldwide. The high rate of recurrence and the increasing antibiotic resistance of uropathogens are further worsening the current scenario. Nevertheless, novel key ingredients such as D-mannose, chondroitin sulphate, hyaluronic acid, and N-acetylcysteine could represent an important alternative or adjuvant to the prevention and treatment strategies of urinary tract infections. Several studies have indeed evaluated the efficacy and the potential use of these compounds in urinary tract health. In this review, we aimed to summarize the characteristics, the role, and the application of the previously reported compounds, alone and in combination, in urinary tract health, focusing on their potential role in urinary tract infections.

The efficacy and safety of intravesical chondroitin sulphate solution in recurrent urinary tract infections

BACKGROUND

Urinary tract infections are among the most common indications for antibiotic therapy. The emergence of resistant uropathogens indicates the need for treatment alternatives. Replenishment of the glycosaminoglycan layer of the bladder, achieved by intravesical instillation of e.g. chondroitin sulphate (CS), is described to be a cornerstone in the therapy of cystitis. To retrospectively evaluate the efficacy of a therapy with 0.2% CS in patients suffering recurrent urinary tract infections (rUTI) in comparison to a treatment with low-dose long-term antibiotics (LDLTAB) and a combination of both.

METHODS

A total of 151 patients with recurrent UTI who underwent intravesical therapy at Diaconesse hospital in Leiden, The Netherlands were included. 50 patients had been treated with CS, 51 patients had received LDLTAB, and 50 patients had received a combination therapy (LDLTABCS). Data recorded for baseline, after 6, and 12 months of treatment were evaluated. Descriptive statistics were calculated. Exploratory comparisons between groups and within groups were performed by using one-tailed and paired t-tests. Patients filled in a standardized quality of life questionnaire (EQ-5D).

RESULTS

We found a statistically significant reduction of number of infections from 7.10 ± 0.50 SEM to 0.45 ± 0.07 SEM after 12 months therapy with CS compared to 12 months therapy with LDLTAB (from 7.04 ± 0.47 SEM to 1.8 ± 0.15 SEM). The number of visits to the urologist significantly decreased in the CS group from 7.46 ± 0.80 SEM to 1.28 ± 0.11 SEM and from 4.10 ± 0.29 SEM to 1.35 ± 0.11 SEM in the LDLTABCS group. In addition, a significant increase in Quality of life (QoL) was seen in the CS-group (from 58.2 ± 0.82 SEM to 80.43 ± 0.82 SEM) and in the LDLTABCS group (from 62.4 ± 0.97 SEM to 76.73 ± 1.06 SEM). There was no improvement in QoL with LDLTAB (from 58.24 ± 1.08 SEM to 58.96 ± 1.19 SEM). Evaluation's evidence is limited due to its retrospective character.

CONCLUSIONS

Retrospective analysis of data from patients that underwent therapy for rUTIs confirms the safety and efficacy of CS and indicate a superiority to antibiotic treatment of rUTIs.

A post-trial follow-up study of pentosan polysulfate monotherapy on preventing recurrent urinary tract infection in women

For women with recurrent urinary tract infection (UTI), previous U101 study has shown that pentosan polysulfate sodium (PPS) monotherapy for 16 weeks significantly reduced UTI episodes in the treatment group throughout the trial period. In this follow-up study, we aimed to assess whether the effects of PPS would last after completion of the trial to prevent recurrent UTIs. Conducted from 2018 to 2019, the U101 study was a multicenter, prospective, phase 2a, randomized trial, enrolling women with recurrent UTI to study the effects of a 16-week oral PPS monotherapy. After approximately two years, the follow-up was conducted by phone interview, obtaining data including self-reported UTI events, quality of life questionnaire, and adverse events. The primary endpoint of follow-up study was UTI recurrence-free survival and the secondary endpoints were quality of life and adverse events. Approximately two years after completion of the trial, the rate of recurrent UTI was 25% (3 of the 12 patients) in the PPS group and 85.7% (12 of the 14 patients) in the control group. Over the entire follow-up period, the UTI recurrence-free survival was significantly better in the PPS group than in the control group (log-rank test p < 0.001). The quality of life at two years was significantly improved in the PPS when compared to the control group (91.7 vs. 77.5, p < 0.001). No late adverse event was observed after cessation of the treatment. In this study, sixteen weeks of PPS monotherapy in women with recurrent UTI significantly reduced the numbers of recurrent UTI episodes during the 2-year follow-up.

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.

Hyaluronic acid and chondroitin sulphate treatment for recurrent severe urinary tract infections due to multidrug-resistant gram-negative bacilli in a patient with multiple sclerosis: case report and literature review

Urinary tract infections (UTIs) are the most common bacterial infections in patients with neurogenic lower urinary tract dysfunction. Antibiotic options for prophylaxis or curative treatment in case of recurrent UTIs, especially due to multidrug-resistant organisms (MDRO), are scarce. We present the case of a 72-year-old man with neurogenic lower urinary tract dysfunction and history of frequent recurrent UTIs due to multiple MDROs who was successfully treated with hyaluronic acid (HA) and chondroitin sulfate (CS) bladder instillations. We also provide a literature review on the efficacy of HA-CS intravesical instillations for prevention of UTI among this population.

Efficacy of antimicrobial intravesical treatment for uncomplicated recurrent urinary tract infections: a systematic review

INTRODUCTION AND HYPOTHESIS

Intravesical antimicrobials (IVA) provide a localized modality of treatment for recurrent urinary tract infections (rUTIs). Owing to the sporadic use of these treatments, we conducted a systematic review on the efficacy of IVA in the management of uncomplicated rUTIs.

METHODS

A systematic review was conducted for all English language articles from inception to April 2021 utilizing the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards with the following databases: PubMed, OVID Embase, Biomed Central, and Scopus. References were cross-examined for further articles. Risk of bias was assessed in the articles included using the Cochrane and Joanna Briggs Institute tools.

RESULTS

The initial search resulting in 476 titles led to 15 full-text articles. Of the 13 in the final review (2 RCTs), 3 used gentamicin and 10 used hyaluronic acid IVA. These included 764 participants, mostly women, with a mean age range of 27-80 (median: 53.1). There was a reduction in UTI frequency in 12 out of 13 studies, with 10 studies showing a statistically significant decrease. Dosages of 80 mg of gentamicin per instillation and both 40 mg and 800 mg of hyaluronic acid per instillation were found to be effective in reducing the frequency of UTIs in most studies. Eleven participants reported gentamicin-resistant infections after IVA treatment. Despite high levels of bias in selected categories, the 13 studies were designated to be of high quality for inclusion.

CONCLUSIONS

The IVAs gentamicin and hyaluronic acid with chondroitin sulphate demonstrated efficacy in the management of uncomplicated rUTIs, mostly in women.

Intravesical Glycosaminoglycans Experience for Chronic Lower Urinary Tract Pathology Treatment

Objective Intravesical glycosaminoglycans (GAG) treatment is one of the therapeutic options for chronic bladder pathologies and is approved for Bladder Pain Syndrome (BPS), radiation cystitis, and recurrent urinary tract infections (UTIs). The purpose of this study is to describe the demographic characteristics of patients with such pathologies in our population and to evaluate treatment response.

Methods It is a retrospective study of patients with the aforementioned pathologies, who received treatment with GAG. Demographic characteristics and subjective improvement with treatment were evaluated. A bivariate analysis was performed to study possible improvement predictors.

Results 53 patients were evaluated. Of them, 33 (62.3%) with BPS, 12 (22.6%) with recurrent UTIs, and 8 (15.1%) with radiation cystitis. The dose range received was between 4 - 20 instillations, with a median of 6 doses. 67.9% of patients showed improvement of symptoms with treatment, this percentage being even higher for the group of patients with recurrent UTIs (91%). No treatment response predictors were found.

Conclusions Intravesical GAG treatment is a therapeutic alternative for patients with chronic bladder pathologies, with satisfactory results in the medium term. Prospective studies are needed to support the findings of this study.

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.

Intravesical hyaluronic acid treatment in recurrent urinary tract infections in children with spina bifida and neurogenic bladder

INTRODUCTION

Damage to the glycosaminoglycan layer of the urothelium, which is composed of hyaluronic acid (HA), may increase the possibility of bacterial adherence and infections. Patients with neurogenic bladder (NB) who perform clean intermittent catheterization (CIC) 4-6 times a day are also under great risk for recurrent urinary tract infections (RUTIs).

OBJECTIVE

The aim of this study was to assess the efficacy and safety of intravesical HA in reducing the frequency of RUTIs in patients with spina bifida (SB) and NB, who perform CIC.

MATERIALS AND METHODS

Ten patients (nine girls, one boy) with SB and NB affected by RUTIs received intravesical instillation of HA. Ten patients (seven girls, three boys) with SB and NB who did not accept the intravesical HA therapy were included in the control group. All patients developed symptomatic RUTIs, which occurred at least three times in the previous 12 months. The study group was treated with intravesical 40 mg HA (Hyacyst®) weekly for four weeks, then monthly for the consequent three months. Recurrence of UTIs before and after the treatment was analyzed.

RESULTS

The mean age of the study group and the controls were 11.1 ± 4.8 (3.2-18.6) and 9.3 ± 5.4 (2.1-16.2) years, respectively. The mean UTIs per patient-month in the study group and the controls were 0.34 ± 0.05 and 0.35 ± 0.06, respectively. The mean follow-up time after the treatment was 16.6 ± 6.9 months in the study group and 16 ± 6.1 months in the controls. The mean UTIs per patient-month significantly decreased in the study group after the treatment (p < 0.001) but showed no significant difference in the control group (p = 0.174). When study and control groups were compared, the mean UTIs per patient-month showed no significant difference before treatment (p = 0.77) but significantly decreased in the study group after the treatment (p < 0.001).

DISCUSSION

To the best of the authors' knowledge, this study is the first one evaluating the efficacy of intravesical HA in the treatment of RUTIs in children with SB and NB. However, this study has several limitations, such as the small sample size and short follow-up time.

CONCLUSION

The findings of the present study indicate that intravesical HA is an effective and safe treatment that reduces RUTIs in patients with SB and NB, who perform CIC.

The efficacy of pentosan polysulfate monotherapy for preventing recurrent urinary tract infections in women: A multicenter open-label randomized controlled trial

BACKGROUND/PURPOSE

Pentosan polysulfate sodium (PPS), a semi-synthetic polysaccharide that adheres to bladder mucosa, is effective in treating interstitial cystitis. We evaluated the clinical benefit of PPS for the prevention of recurrent urinary tract infection (UTI) in women.

METHODS

We conducted a multicenter, open-label, prospective, phase II, randomized controlled trial enrolling women with recurrent UTI ≥ 2 times in the past 6 months or ≥ 3 times in the past 12 months. Patients received oral PPS monotherapy for 16 weeks in treatment group. All patients were followed every 28 days until UTI recurrence or up to 112 days. The primary endpoint was the UTI recurrence-free survival. Adverse events were recorded as secondary endpoint.

RESULTS

A total of 26 women were eligible for analysis. In the PPS group, none (0%) of the 12 patients had UTI recurrence during the study period. However, 9 (64%) of 14 patients had UTI recurrence in the control group. The UTI recurrence-free survival was significantly higher in the PPS group than in the control group (log-rank test p = 0.0004). One adverse event which led to discontinuation of the trial regimen was regarded as irrelevance of PPS treatment. The limitation was the small number of cases.

CONCLUSION

Among women with recurrent UTI, 16-week PPS monotherapy significantly reduced UTI recurrence when compared with the control group.

Intravesical sodium hyaluronate reduces severity, frequency and improves quality of life in recurrent UTI

Purpose

Urinary tract infections (UTI) occur in nearly half of all women at least once, with around 35% experiencing recurrences. Bladder mucosal glycosaminoglycan (GAG) layer damage is postulated to contribute. Sodium hyaluronate (SH) replenishes the GAG layer and is believed to be protective. However, there is limited literature on patient-reported outcomes and quality of life (QoL) after treatment. Our objective was to observe changes in UTI severity and QoL after treatment with intravesical SH.

Methods

In this retrospective, observational patient-reported outcome study, we examined outcomes in UTI patients treated with intravesical SH. SH was instilled weekly for 6 weeks. If symptoms persisted, patients received further instillations on demand. Patients were sent postal questionnaires to score symptoms before and after treatment. Patient-reported UTI occurrences before treatment were compared with recurrences after treatment collected from their primary care providers.

Results

There were 18 (58.1%) valid replies. The median age was 75. The median duration of illness before treatment was 4.5 (IQR 2.8–7) years. The median number of infections fell from ten per year (IQR 7–10) before treatment to two per year (IQR 0–5) after treatment. Pain improved by 34%, urgency 30%, nocturia 30%, frequency 32%, ‘inability to carry out daily activities due to UTI related ill-health’ 37% and ‘loss of sleep’ by 38%. Patients reported a 76% improvement in ‘UTI-related QoL.’ No adverse events were reported.

Conclusion

SH is safe and useful for managing patients with recurrent UTI, with improvements in symptoms, QoL, a decrease in the number of UTI episodes and in the best interests of antimicrobial stewardship.

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.

Effect of twice-daily oral administration of a chondroitin sulfate-containing supplement on urine chondroitin sulfate concentrations in dogs

OBJECTIVE

To quantify the magnitude and duration of changes in urine chondroitin sulfate concentration (uCS) as a result of oral administration of a chondroitin sulfate-containing supplement in dogs.

ANIMALS

8 healthy privately owned dogs.

PROCEDURES

A urine sample was collected from each dog via cystocentesis on day 1; free-catch midstream urine samples were collected once daily on days 2 through 5. Pretreatment uCS was established from those samples. Each dog then received a chondroitin sulfate-containing supplement (20 to 30 mg/kg, PO, q 12 h) for 8 days (on days 7 through 14). Urine samples were collected on days 8 through 12 and day 15. For each sample, uCS was quantified by liquid chromatography-tandem mass spectrometry. Variable urine concentration was accounted for by dividing the uCS by urine creatinine concentration (uCrea) to determine the uCS:uCrea ratio. Pretreatment uCS:uCrea ratios were compared with treatment uCS:uCrea ratios to calculate the fold change in uCS after supplement administration.

RESULTS

Among the study dogs, oral administration of the chondroitin sulfate-containing supplement resulted in a 1.9-fold increase in the median uCS:uCrea ratio. Data obtained on days 8 through 12 and day 15 indicated that the daily increase in uCS remained consistent and was not additive.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that oral administration of supplemental chondroitin sulfate to dogs modestly increased uCS within 24 hours; however, subsequent supplement administration did not have an additive effect. A potential therapeutic benefit of persistently increased uCS in preventing recurrent urinary tract infections in dogs warrants investigation.

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.

Intravesical hyaluronic acid and chondroitin sulfate for recurrent urinary tract infections: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The objective was to assess the efficacy of intravesical hyaluronic acid (HA) and chondroitin sulfate (CS), alone or in combination, for recurrent urinary tract infections (RUTIs) in adult female patients using a systematic review and meta-analysis.

METHODS

English-language articles were obtained from the MEDLINE, Embase, and Cochrane databases through November 2016, by manual searching and cross-referencing. Randomized and nonrandomized trials of adult female patients with a documented history of RUTIs who received HA, CS or HA plus CS were included. The random effects model was applied to all pooled analyses. Risk of bias was assessed for individual studies and across studies.

RESULTS

Two randomized (n = 85) and six nonrandomized (n = 715) studies met the inclusion criteria. These studies assessed HA ± CS; studies of CS alone were not identified in the search. HA ± CS decreased the UTI rate per patient-year (pooled mean difference [MD] -2.56; 95% confidence interval [CI] -3.86, -1.26; p < 0.001) and increased the time to first UTI recurrence (pooled MD 130.05 days; 95% CI 5.84, 254.26; p = 0.04). There was heterogeneity in most outcomes considered, and publication bias in many studies. The standard of trial reporting was low. The patient population size, and the number of studies included, were small.

CONCLUSIONS

HA ± CS appears to reduce the rate of UTI and increase the time to recurrence in women with RUTI. As randomized controlled studies are available only for HA plus CS, the quality of evidence is higher for the combination than for HA alone.

Intravesical instillations for the treatment of refractory recurrent urinary tract infections

Background

Treatment options for refractory recurrent urinary tract infections (UTI) are limited; therefore, we sought to determine if intravesical instillations with heparin effectively treat recurrent UTIs.

Methods

Patients at an academic medical center who received intravesical instillations with heparin for recurrent UTIs/chronic cystitis between January 2011 and December 2015 were identified via International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) procedure codes. All cases were analyzed for frequency of UTIs during the treatment phase as well as for the subsequent 6 months after completion of therapy. Demographic, clinical and treatment related factors were then collected from the medical records to draw associations with success or failure of treatment.

Results

Thirty-nine women were treated with heparin intravesical instillations for recurrent UTIs. The average age of the cohort was 68.38 years [range 25-88, standard deviation (SD) 12.92], with mean parity 2.38 (range 0-7, SD 1.55) and mean body mass index 27.85 (range 19.5-37.9, SD 4.84). A total of 84.6% completed the recommended 6-week treatment course while 69.2% went on to an additional maintenance phase. Twelve patients (30.8%) had a culture-proven UTI during the treatment phase. In the 6-month follow-up period, 46.2% of patients had at least one UTI with only seven patients (17.9%) meeting criteria for recurrent UTIs (two or more UTIs in 6 months). On univariable assessment, development of recurrent UTIs after completion of instillation therapy was associated with increasing age and vaginal estrogen use during the instillation treatment course.

Conclusions

Intravesical instillation with heparin is an effective option to consider for the treatment of refractory recurrent UTIs.

No. 250-Recurrent Urinary Tract Infection

OBJECTIVE

To provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women.

OPTIONS

Continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives.

EVIDENCE

A search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions.

VALUES

This update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

OPTIONS

Recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patient's characteristics.

RECOMMENDATIONS

Hyaluronic Acid and Its Composites as a Local Antimicrobial/Antiadhesive Barrier

Living in biofilms is probably the most common condition for bacteria and fungi and biofilm-related infections account for the majority of bacterial infectious diseases worldwide. Among others biofilm-related infections, those associated with implanted biomaterials have an enormous and still largely underestimated impact in orthopaedics and trauma, cardio-surgery and several other surgical disciplines. Given the limited efficacy of existing antibiotics in the prevention and treatment of bacterial biofilms, new strategies are needed to protect implants and host tissues, overcoming the striking ability of the microorganisms to adhere on different surfaces and to immediately protect themselves by forming the biofilm matrix. Adhesion is a necessary first step in microbial colonization and pathogenesis and provides a potential target for new preventive and treatment approach. Among various polymers, tested as antibacterial coatings, hyaluronic acid and some of its composites do offer a well-established long-term safety profile and a proven ability to reduce bacterial adhesion and biofilm formation. Aim of the present review is to summarize the available evidence concerning the antiadhesion/antibiofilm activity of hyaluronic acid and some of its derivatives to reduce/prevent bacterial adhesion and biofilm formation in various experimental and clinical settings.

Managing chronic bladder diseases with the administration of exogenous glycosaminoglycans: an update on the evidence

Although the pathophysiology of acute chronic cystitis and other 'sensory' disorders, i.e. painful bladder syndrome (PBS) or interstitial cystitis (IC), often remains multifactorial, there is a wide consensus that such clinical conditions may arise from a primary defective urothelium lining or from damaged glycosaminoglycans (GAGs). A 'cascade' of events starting from GAG injury, which fails to heal, may lead to chronic bladder epithelial damage and neurogenic inflammation. To restore the GAG layer is becoming the main aim of new therapies for the treatment of chronic cystitis and PBS/IC. Preliminary experiences with GAG replenishment for different pathological conditions involving the lower urinary tract have been reported. There is a range of commercially available intravesical formulations of these components, alone or in combination. Literature evidence shows that exogenous intravesical hyaluronic acid markedly reduces recurrences of urinary tract infections (UTIs). Patients treated with exogenous GAGs have fewer UTI recurrences, a longer time to recurrence and a greater improvement in quality of life. Exogenous intravesical GAGs have been used for the treatment of PBS/IC. Despite the limitations of most of the studies, findings confirmed the role of combination therapy with hyaluronic acid and chondroitin sulfate as a safe and effective option for the treatment of PBS/IC. To prevent and/or treat radiotherapy and chemotherapy induced cystitis, GAG replenishment therapy has been used showing preliminary encouraging results. The safety profile of exogenous GAGs has been reported to be very favourable, without adverse events of particular significance.

Intravesical administration of combined hyaluronic acid (HA) and chondroitin sulfate (CS) for the treatment of female recurrent urinary tract infections: a European multicentre nested case-control study

OBJECTIVES

To compare the clinical effectiveness of the intravesical administration of combined hyaluronic acid and chondroitin sulfate (HA+CS) versus current standard management in adult women with recurrent urinary tract infections (RUTIs).

SETTING

A European Union-based multicentre, retrospective nested case-control study.

PARTICIPANTS

276 adult women treated for RUTIs starting from 2009 to 2013.

INTERVENTIONS

Patients treated with either intravesical administration of HA+CS or standard of care (antimicrobial/immunoactive prophylaxis/probiotics/cranberry).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was occurrence of bacteriologically confirmed recurrence within 12 months. Secondary outcomes were time to recurrence, total number of recurrences, health-related quality of life and healthcare resource consumption. Crude and adjusted results for unbalanced characteristics are presented.

RESULTS

181 patients treated with HA+CS and 95 patients treated with standard of care from 7 centres were included. The crude and adjusted ORs (95% CI) for the primary end point were 0.77 (0.46 to 1.28) and 0.51 (0.27 to 0.96), respectively. However, no evidence of improvement in terms of total number of recurrences (incidence rate ratio (95% CI), 0.99 (0.69 to 1.43)) or time to first recurrence was seen (HR (95% CI), 0.99 (0.61 to 1.61)). The benefit of intravesical HA+CS therapy improves when the number of instillations is ≥ 5.

CONCLUSIONS

Our results show that bladder instillations of combined HA+CS reduce the risk of bacteriologically confirmed recurrences compared with the current standard management of RUTIs. Total incidence rates and hazard rates were instead non-significantly different between the 2 groups after adjusting for unbalanced factors. In contrast to what happens with antibiotic prophylaxis, the effectiveness of the HA+CS reinstatement therapy improves over time.

TRIAL REGISTRATION NUMBER

NCT02016118.

The use of intravesical hyaluronic acid for recurrent urinary tract infections in children: a case-series study

BACKGROUND

This is the first study performed to evaluate the effects of intravesical hyaluronic acid (IHA) instillation on diminishing the frequency of recurrent urinary tract infections (UTIs) in children.

METHODS

Fifteen children (10 girls, 5 boys) with recurrent UTIs were divided into two groups as either complicated (group 1) (with accompanying disorders including vesicoureteral reflux or neurogenic bladder) or uncomplicated patients (group 2). After administration of weekly four sessions of IHA therapy the patients were followed-up monthly for 2 years and classified as responsive (complete/partial) or unresponsive to treatment.

RESULTS

53.3% of the patients with recurrent UTIs were complicated. In group 1 (n = 8), complete and partial response rates were 62.5% (n = 5) and 25% (n = 2), respectively. There was no response in 12.5% (n = 1) of the cases in group 1. In group 2 (n = 7), complete and partial response rates were 71.4% (n = 5) and 14.3% (n = 1), respectively. In this group, 14.3% (n = 1) of the patients were found to be unresponsive to IHA treatment. No side effects were observed in any of the patients.

CONCLUSIONS

IHA administration is considered as an effective treatment modality which significantly reduces the prevalence of or even provides complete recovery from recurrent UTIs in childhood. Therefore, it is believed that this approach can be used as a promising alternative to widespread use of antibiotics in this patient group.

Intravesical hyaluronic acid treatment improves bacterial cystitis and reduces cystitis-induced hypercontractility in rats

OBJECTIVE

To investigate the effect of intravesical hyaluronic acid on Escherichia coli-induced cystitis and cystitis-induced hypercontractility in rats.

METHODS

Bacterial cystitis was induced in Wistar female rats by intravesical inoculation of E. coli. Isotonic saline was instilled in the control group (n = 6). The rats were either non-treated, treated with gentamycin (4 mg/kg, 5 days) or treated intravesically with hyaluronic acid (0.5 mL, 0.5%). On the eighth day, the bladder tissues were excised for histological examination, and the measurements of myeloperoxidase, superoxide dismutase and catalase activities. Contraction/relaxation responses to carbachol, isoprotrenol and papaverine were studied.

RESULTS

Tissue myeloperoxidase activity was increased, but superoxide dismutase and catalase activities were decreased in bacterial cystitis, while hyaluronic acid treatment reversed these changes. In the hyaluronic acid-treated group, healing of the uroepithelium was observed, while decreased inflammatory cell infiltration was obvious in gentamycin-treated group. E. coli-induced cystitis in all rats resulted in increased contraction responses to carbachol compared with controls (P < 0.01). Treatment with hyaluronic acid, but not gentamycin, significantly (P < 0.05) depressed hypercontractility at maximum carbachol concentrations. In all rats with cystitis, papaverine-induced relaxation was increased, whereas isoproterenol-induced relaxation curves were not different between the studied groups.

CONCLUSION

Gentamycin treatment, despite its ameliorative effect on inflammation, had no impact on the contractile dysfunction of the injured bladder. Intravesical hyaluronic acid, in addition to its supportive role in the healing of the epithelium, seems to lower the increased threshold for contraction and to reduce oxidative stress. These findings support a potential role for hyaluronic acid in the treatment of bacterial cystitis.

Intravesical treatment with highly-concentrated hyaluronic acid and chondroitin sulphate in patients with recurrent urinary tract infections: Results from a multicentre survey

INTRODUCTION

We assess the effectiveness of intravesical instillation of hyaluronic acid (HA) and chondroitin sulphate (CS) as a non-antibiotic treatment option for prophylaxis of recurrent urinary tract infections (UTIs) in female patients.

METHODS

This was a retrospective cohort study involving 7 European institutions. We included patients with recurrent UTIs who received intravesical instillations of Ialuril (IBSA International) (50 mL HA 1.6% and CS 2% solution) between January 2010 and March 2012. Medication schedule, length of follow-up, recurrence infection time, number of UTIs/patients/year, patient quality of life, subjective symptoms score, and treatment-emergent side effects were recorded and analyzed.

RESULTS

In total, 157 women (mean age: 54.2 ± 4.1 years) were included in the analysis. All patients had at least 12 months follow-up. After 4 weekly and 5 monthly HA-CS bladder instillations, UTI episodes decreased from 4.13 ± 1.14 to 0.44 ± 0.50 (p = 0.01) at 12 months, while recurrent UTI time prolonged from 94.8 ± 25.1 days to 178.4 ± 37.3 days (p = 0.01) at 12 months. An improvement in symptoms and quality of life was achieved. A medium-depth pain after medication instillation was the most reported side effect. Regression model analysis showed significant risk factors in developing new UTI episodes: being more than 50 years old and having more than 4 UTI episodes per year (OR 3.41; CI 95%; 1.51-7.71, p = 0.003 and OR 3.31; CI 95% 1.51-7.22; p = 0.003, respectively). Retrospective design and lack of a control group represent two main limitations of the study.

CONCLUSIONS

Restoring glycosaminoglycans bladder layer therapy is a promising non-antibiotic therapy to prevent recurrent UTIs.

Prevention of recurrent urinary tract infections by intravesical administration of heparin: a pilot study

OBJECTIVE

To assess the effect of bladder instillations using heparin on the rate of urinary tract infections in women resistant to standard therapy.

PATIENTS AND METHODS

The medical records of all women who received bladder instillations between May 2009 and January of 2010 at the University of Wisconsin urogynecology clinic were reviewed. Eighteen women (mean age 67 years) with a history of recurrent urinary tract infections received intravesical instillations (heparin 40,000 U, 2% lidocaine 8 ml, sodium bicarbonate 4 ml) once weekly for 6 weeks. Patients were considered resistant to standard therapy if their condition failed to respond to chronic suppression antibiotic therapy; they had chronic infections and for this reason could not be placed on chronic suppression; or they were not candidates for chronic suppression due to drug allergies. The number of urinary tract infections was monitored during treatment and for 6 months after therapy. The urinary tract infection rates were compared with the rates of urinary tract infection in the 6 months before treatment.

RESULTS

Seventy-eight percent of patients responded to therapy. Subjects were thought to have responded to therapy if there was a greater than 50% reduction in the rate of urinary tract infection. Other variables reviewed included evidence of chronic infection, hormonal status, glomerular filtration rate, age, body mass index, antibiotic allergies, diabetes, hypertension, and chronic antibiotic therapy during bladder instillations. None of these variables were found to be statistically significant.

CONCLUSION

Bladder instillations decreased the rate of urinary tract infection in this pilot study; this effect persisted into the post-treatment period. More research is needed to confirm these preliminary findings.

GAGs and GAGs diseases: when pathophysiology supports the clinic

The urinary epithelium has been the subject of considerable interest and much research in recent years. What has radically changed in the last decade is the concept of what the bladder epithelium really is. It is currently no longer considered just a simple barrier and a non-specific defence against infections, and it has been recognized as a specialized tissue regulating complex bladder functions and playing a fundamental and active role in the pathogenesis of cystitis. Researchers have been focussing on the receptors and mediators that are active in the sub-epithelial layer, with the hope that understanding the role of the urothelium defect will offer the opportunity for new therapeutic strategies. On the surface of the urothelial umbrella-cells there is a thick layer of glycoproteins and proteoglycans, which together are called Glycosaminoglycans (GAGs). They constitute a hydrophilic mucosal coating and act as a barrier against solutes found in urine. In recent years they have received special attention because injury to Gags, due to different noxae, has been identified as the first step in the genesis of chronic inflammatory bladder diseases, such as recurrent urinary tract infections, chemical or radiation cystitis, interstitial cystitis and/or Bladder Pain Syndrome. Aim of this study is to define the importance of the urothelium starting from the anatomy and physiology of the bladder wall. Furthermore, we will underline the role of glycosaminoglycans, focusing both on their pathophysiological role in the principal bladder diseases and on the therapeutic aspects from the clinical point of view.

Intravesical therapy in recurrent cystitis: a multi-center experience

Approximately 20-30% of women suffer from recurrent cystitis. Recently, the problem of bacterial internalization, especially by Escherichia coli, has been significantly emerging as the main cause of recurrent episodes. It is believed that such a process is favored by damage to the urothelial mucous membrane. Concerning this, intravesical therapy with hyaluronic acid alone or in association with chondroitin sulfate was shown to improve urothelium thickness and reduction of bacterial load in the urine. The aim of our study was to assess whether intravesical therapy with hyaluronic acid (HA) and chondroitin sulfate (CS) is more effective than antibiotic therapy in reducing episodes and symptoms of recurrent urinary tract infections. We compared the number of recurring episodes in three groups of patients affected by recurrent urinary tract infections assigned to three different therapeutic regimens: the first group was treated only with HA and CS, the second group with HA and CS associated with fosfomycin, and the third group was treated only with fosfomycin (F). We assessed the number of recurrent episodes for each patient that occurred during a 6- to 12-month follow-up. The results showed 72.7% of patients in the HA-CS group, 75% in the fosfomycin + HA-CS group, and only 30.4% in the fosfomycin group were event free at follow-up. The results were analyzed using the Fisher's exact test. In conclusion, intravesical therapy with hyaluronic acid and chondroitin sulfate is an effective therapeutic approach to treat and prevent episodes of recurrent cystitis.

The role of hyaluronic acid in the management of uncomplicated recurrent female urinary tract infections: literature review and practical experience

Aim:

To assess the efficacy and safety of intravesical hyaluronic acid (HA) in the management of female patients with recurrent urinary tract infections (UTIs) in our hospital. Also to perform a literature review about the use of Glycosaminoglycan (GAGs) such as hyaluronic acid (HA) and chondroitin sulphate (CS) in the management of female recurrent UTI and compare our findings to the published evidence available.

Method:

We performed a literature review of studies using HA or CS for the management of recurrent UTIs. We retrospectively reviewed the outcome of 22 female patients who were treated at our district general hospital for recurrent UTIs refractory to first line management and compared our experience of using this treatment to the recently published literature.

Results:

Literature review showed growing evidence for the use of intravesical HA and HA-CS for the prevention of female recurrent UTIs including three recently published prospective randomised controlled trials (RCTs). These studies show a reduction in UTIs by over 70% in comparison to placebo and that intravesical treatment is more effective than low dose antibiotic prophylaxis. In our experience, intravesical HA was an effective second line treatment for females with recurrent UTIs. Of 22 patients with recurrent UTIs (aged 17 - 72 years), 64% (14 patients) remained recurrence free one year after treatment. In our experience, this treatment was tolerated well by the patients with minimal side effects.

Conclusion:

HA offers an effective management option for female patients with recurrent UTIs. It is a safe and effective second line treatment for female patients with recurrent urinary tract infections that may be refractory to first line management strategies.

Morphological Changes of Bladder Mucosa in Patients Who Underwent Instillation with Combined Sodium Hyaluronic Acid-Chondroitin Sulphate (Ialuril®)

<b><i>Objective:</i></b> To investigate what changes are endoscopically evident after glycosaminoglycans (GAGs) therapy by hyaluronic acid (HA) and chondroitin sulphate (CS) (Ialuril®) in female patients affected by bladder pain syndrome(BPS)/ interstitial cystitis (IC) or recurrent urinary tract infections (rUTIs). <b><i>Patients and Methods:</i></b> 21 female patients over 18 years affected by rUTIs or BPS/IC received intravesical instillation of HA and CS (4 weekly instillations followed by 2 instillations every 2 weeks and 2 instillation monthly). Post-treatment evaluation included cystoscopy and patient assessment of improvement in symptoms and satisfaction on a visual analogue scale (VAS) from 0 to 10. <b><i>Results:</i></b> The post-treatment endoscopy showed a positive effect on bladder mucosa morphology. In 2 cases, treatment did not change endoscopic findings and clinical symptoms. In the other patients, when macroscopic features of the bladder mucosa normalized, the clinical picture improved. <b><i>Conclusions:</i></b> GAGs therapy by HA and CS (Ialuril) improves the morphology of bladder mucosa in patients with rUTI or BPS/IC.

Effectiveness of intravesical hyaluronic acid with or without chondroitin sulfate for recurrent bacterial cystitis in adult women: a meta-analysis

INTRODUCTION AND HYPOTHESIS

Glycosaminoglycan hyaluronic acid (HA) and chondroitin sulphate (CS) protect the urothelium. Damage to the urothelium may increase bacterial adherence and infection risk. This meta-analysis evaluated the effect of intravesical HA and HA and CS (HA-CS) combination therapy in recurrent bacterial cystitis (RBC) in adult women.

METHODS

A systematic literature search was performed. Primary outcomes were urinary tract infection (UTI) rate per patient-year, and UTI recurrence time (days). Secondary outcomes were 3-day voids and Pelvic Pain and Urgency/Frequency (PUF) symptom scale total score.

RESULTS

Four studies involving a total of 143 patients were retrieved and assessed in this analysis. Two were randomized, and two were nonrandomized. A significantly decreased UTI rate per patient-year [mean difference (MD) -3.41, 95 % confidence interval (CI) -4.33 to -2.49, p < 0.00001) was found. Similarly, pooled analysis showed a significantly longer mean UTI recurrence time (days) using either HA or HA-CS therapy (MD 187.35, 95 % CI 94.33-280.37, p < 0.0001). Two studies using HA and HA-CS therapy reported outcomes on 3-day voids, which were not significantly improved after therapy (MD -3.59, 95 % CI -8.43-1.25, p = 0.15), but a significantly better PUF total score (MD -7.17, 95 % CI -9.86 to -4.48, p < 0.00001) was detected in HA-CS groups.

CONCLUSIONS

Intravesical HA and HA-CS in combination significantly reduced cystitis recurrence, mean UTI recurrence time, and PUF total score. Study limitations include the small number of patients and possible bias. Further studies are needed to validate this promising treatment modality.

The clinical effectiveness of intravesical sodium hyaluronate (cystistat®) in patients with interstitial cystitis/painful bladder syndrome and recurrent urinary tract infections

OBJECTIVE

Painful bladder syndrome/interstitial cystitis (PBS/IC) and recurrent urinary tract infections (UTI) are clinically challenging conditions to manage in patients. We evaluate the clinical use of intravesical sodium hyaluronate (Cystistat®) in both these patient groups who have completed treatment.

PATIENTS AND METHODS

Thirteen patients with recurrent UTIs (Group I) and 8 patients with PBS/IC (Group II) received intravesical sodium hyaluronate (Cystistat®). Preinstallation demographic parameters were statically comparable in both groups. The mean age of presentation was 54.6 years in Group I and 57.5 years in Group II (p = 0.9). All 13 patients in Group I were on low dose antibiotics. The mean number of installations completed in both groups was 9 (range 4-21).

RESULTS

Data was collected prospectively using a standard pre- and post-treatment questioner with the pelvic pain and urinary/frequency patient symptom scale. At a mean follow-up of 21 months a significant improvement in bladder pain (p = 0.05), daytime frequency (p = 0.03) and quality of life (p = 0.02) was noted in patients in Group I. Two patients had breakthrough UTIs during treatment. Within Group I, 7 (53%) patients responded well to treatment. Patients in Group II had a significant improvement in bladder pain (p = 0.02), urgency (p = 0.01), nocturia (p = 0.01) and quality of life (p = 0.04). Within Group II, 6 patients (75%) responded to treatment.

CONCLUSION

Intravesical sodium hyaluronate (Cystistat®) can be used with minimal side effects and good compliance in both groups of patients with PBS and recurrent UTIs. Longer follow-up and larger patient numbers in both groups will be required to confirm the long-term efficacy of these two clinically challenging groups of patients.

GAG layer replenishment therapy for chronic forms of cystitis with intravesical glycosaminoglycans--a review

AIMS

Glycosaminoglycan (GAG) layer replenishment is a cornerstone in the therapy of interstitial cystitis (IC). During the last years intravesical GAG layer replenishment has proven to be an effective treatment for overactive bladder (OAB), radiation cystitis, and recurrent urinary tract infections (UTIs).

METHODS

Examination of different substances available for intravesical GAG replenishment and evaluation of the evidence for the treatment of the above-mentioned conditions.

RESULTS

We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) database for studies on intravesical GAG replenishment. A total of 27 clinical studies remain relevant to this topic, many of them with mixed patient selection and suboptimal definition of symptom improvement/success. Two placebo controlled studies with hyaluronic acid failed to show superiority and have not been published. One active controlled randomized study has been published showing that chondroitin sulphate 0.2% has a clear benefit for OAB patients. Another study with chondroitin sulphate 2.0% failed to show statistically significant evidence, but was underpowered.

CONCLUSIONS

A short number of randomized controlled studies confirm efficacy of intravesical GAG layer replenishment therapy. Concluded from the study background (which comprises also uncontrolled studies), so far chondroitin sulphate 0.2% is in favor for intravesical GAG layer replenishment therapy. In general, large-scale trials are urgently needed to underline the benefit of this type of therapy.

Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study

INTRODUCTION AND HYPOTHESIS

The glycosaminoglycan hyaluronic acid (HA) protects the urothelium; damage may increase bacterial adherence and infection risk. This study evaluated the effect of intravesical HA in recurrent bacterial cystitis (RBC).

METHODS

Women with RBC were randomized to intravesical HA 800 mg and chondroitin sulfate (CS) 1 g (IALURIL, IBSA) in 50 mL of saline solution once weekly for 4 weeks then once every 2 weeks twice more (group 1) or long term antibiotic prophylaxis using sulfamethoxazole 200 mg and trimethoprim 40 mg once weekly for 6 weeks (group 2; control). Evaluations included: cystitis recurrence at 2 and 12 months; subjective pain symptoms (visual analog scale [VAS]); 3 day voiding; sexual function; quality of life (King's Health Questionnaire [KHQ]); frequency symptoms/frequency symptoms (PUF symptom scale); and maximum cystometric capacity (MCC). Means ± standard deviations were reported, with Mann-Whitney test for between-group comparison (significance P < .05).

RESULTS

Of 28 women (mean age 60 ± 13 y) randomized, 26 completed follow-up (mean follow-up 11.5 mo). Group 1 showed a significant improvement in all evaluations; cystitis recurrence (1 ± 1.2 versus 2.3 ± 1.4, P = .02); 3-day voiding (mean 17.8 ± 3.5 vs 24.2 ± 8.3, P = .04); symptom VAS (1.6 ± 0.8 vs 7.8 ± 1.6, P < .001); PUF score (11.2 ± 2.7 vs 19.6 ± 2.2, P < .001), KHQ score (18.4 ± 7.2 vs 47.3 ± 13.6, P < .001), and MCC (380 ± 78 vs 229 ± 51 mL, P < .001) vs group 2 at 12 mo. No adverse effects were recorded.

CONCLUSIONS

Intravesical HA and CS in combination significantly reduced cystitis recurrence and improved urinary symptoms, quality of life, and cystometric capacity in RBC patients at 12 mo follow-up versus antibiotic prophylaxis. Study limitations include a small sample and relatively short follow-up.

The role of sodium hyaluronate and sodium chondroitin sulphate in the management of bladder disease

Bladder epithelium is not only a simple defence against infections, but it is also a specialized tissue regulating complex bladder functions and playing an active role in the pathogenesis of many bladder diseases. There is strong evidence that different chronic inflammatory bladder diseases, such as recurrent urinary tract infection (UTI), chemical or radiation cystitis and painful bladder syndrome/interstitial cystitis (PBS/IC), can be pathophysiologically linked in the first step of the disease to the loss of the glycosaminoglycan (GAG) mucous layer independently of the original cause of the inflammatory process. The aim of this article is to review the current evidence on the clinic applications of GAGs in urology, with particular emphasis on the therapeutic use of hyaluronic acid (HA) and chondroitin sulphate (CS). A comprehensive electronic literature search was conducted in May 2011 using the Medline database. Three studies supported the decrease of the rate of recurrent UTIs by restoring the GAG layer, showing a significant reduction of UTI rates and a prolonged median time to recurrence after HA intravesical instillations in women with recurrent UTI. We provide higher level evidence by reporting a prospective, randomized, double-blind, placebo-controlled study on the use of intravesical HA and CS in women with recurrent UTIs. A significant reduction of 77% in the UTI rate per patient per year versus placebo was observed at the end of the study. Nine studies were published between 2002 and 2011 on the use of HA and CS to treat PBS/IC. Three of them evaluated the use of GAGs bladder instillation to prolong the effects of bladder hydrodistension. In the other six studies the efficacy of HA bladder instillations to reduce symptoms score was assessed. Preliminary studies support data on the role of HA-CS in detrusor overactivity, nonbacterial cystitis and urological malignancies. Few data are available regarding the mode of action of HA-CS or its effectiveness in the management of bladder diseases. The major issue in interpreting the available evidence regarding HA-CS is that most of the reported studies are nonrandomized and without a control arm. HA-CS may be considered for further studies, including randomized, controlled trials with adequate power.

Recurrent urinary tract infection

OBJECTIVE

to provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women.

OPTIONS

continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives.

EVIDENCE

a search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions.

VALUES

this update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

OPTIONS

recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patient's characteristics.

Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate: a placebo-controlled randomised trial

BACKGROUND

Urinary tract infection (UTI) is a prevalent condition in women during their lifetime with a high rate of recurrence within 3-6 mo.

OBJECTIVES

Our aim was to investigate the efficacy and tolerability of the intravesical administration of combined hyaluronic acid (HA) and chondroitin sulphate (CS) in female patients with a history of recurrent UTI.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a prospective, randomised, double-blind, placebo-controlled study comparing the intravesical instillation of HA-CS with placebo in women with recurrent UTI.

INTERVENTION

Participants were randomised to receive 50 ml of sterile sodium HA 1.6% and CS 2.0% solution (IALURIL(®)) weekly for 4 wk and then monthly for 5 mo.

MEASUREMENTS

The primary end point of the study was defined as the mean number of UTI per patient per year. Participants were evaluated addressing UTI status/urinary symptoms and with a general health-related quality-of-life (QoL) questionnaire at baseline and after 3, 6, 9, and 12 mo.

RESULTS AND LIMITATIONS

In the intention-to-treat analysis, 57 women were randomly allocated to HA-CS (n=28) or placebo (n=29). The UTI rate per patient per year at the end of the study (12 mo) (mean±SD: -86.6%±47.6 vs -9.6%±24.6; mean difference: 77%; 95% confidence interval, 72.3-80.8; p=0.0002) and the mean time to UTI recurrence (52.7±33.4 vs 185.2±78.7 d; p<0.001) were significantly reduced after treatment with HA-CS compared with placebo. Overall urinary symptoms and QoL measured by questionnaires significantly improved compared with placebo (Pelvic Pain and Urgency/Frequency questionnaire symptom score: 14.53±4.32 vs 9.88±6.77; p=0.004; SF-36 QoL score: 78.6±6.44 vs 53.1±4.72; p<0.001). No serious adverse event was reported.

CONCLUSIONS

Compared with placebo, HA-CS intravesical instillations significantly reduced UTI rate without severe side effects while improving symptoms and QoL over a 12-mo period in patients with recurrent UTI.

TRIAL REGISTRATION

ISRCTN 76354426.

Preventive effects of hyaluronic acid on Escherichia coli-induced urinary tract infection in rat

OBJECTIVES

To investigate the effects of hyaluronic acid (HA) in rat with Escherichia coli-induced urinary tract infection and duration of its effect. HA is a component of the glycosaminoglycan layer, and is known to interfere with the attachment of E. coli to the urothelium.

METHODS

The rats were divided into various groups. The E. coli-only group in which phosphate-buffered saline was instilled before E. coli (fimH+, sfa+, papA+) inoculation; HA-1, HA-3, HA-5, and HA-7 groups in which HA (0.5 mL, 0.5%) was instilled 1, 3, 5, 7 days before E. coli inoculation, respectively. To assess the symptomatic changes, we examined the voiding interval (VI) of E. coli-only group and HA-1 group before and after E. coli inoculation. Atomic force microscopy was performed to investigate the change in the urothelium before and after HA treatment.

RESULTS

Bacterial growth rate in the bladder was significantly higher in the E. coli-only group (84.6%) than in the HA-1 (20.0%), HA-3 (23.5%), and HA-5 groups (7.7%) (P <.05). The VI in E. coli-only group decreased from the first to third day after the induction of cystitis. The VI in E. coli-only group was significantly shorter than in HA-1 group (P <.05). No pathological evidence of acute inflammation was observed in the bladder and kidney of culture-negative HA groups. Atomic force microscopy showed HA coating on the urothelium.

CONCLUSIONS

This study shows that HA has an effect on the protection mechanism against the invasion of E. coli and that its effect duration is about seven days.