A randomised, double-blind, placebo-controlled trial of a herbal medicinal product containing Tropaeoli majoris herba (Nasturtium) and Armoraciae rusticanae radix (Horseradish) for the prophylactic treatment of patients with chronically recurrent lower urinary tract infections

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.

Isothiocyanates in medicine: A comprehensive review on phenylethyl-, allyl-, and benzyl-isothiocyanates

In recent years, isothiocyanates (ITCs), bioactive compounds primarily derived from Brassicaceae vegetables and herbs, have gained significant attention within the biomedical field due to their versatile biological effects. This comprehensive review provides an in-depth exploration of the therapeutic potential and individual biological mechanisms of the three specific ITCs phenylethyl isothiocyanate (PEITC), allyl isothiocyanate (AITC), and benzyl isothiocyanate (BITC), as well as their collective impact within the formulation of ANGOCIN® Anti-Infekt N (Angocin). Angocin comprises horseradish root (Armoracia rusticanae radix, 80 mg) and nasturtium (Tropaeoli majoris herba, 200 mg) and is authorized for treating inflammatory diseases affecting the respiratory and urinary tract. The antimicrobial efficacy of this substance has been confirmed both in vitro and in various clinical trials, with its primary effectiveness attributed to ITCs. PEITC, AITC, and BITC exhibit a wide array of health benefits, including potent anti-inflammatory, antioxidant, and antimicrobial properties, along with noteworthy anticancer potentials. Moreover, we highlight their ability to modulate critical biochemical pathways, such as the nuclear factor erythroid 2-related factor 2 (Nrf2)/Kelch-like ECH-associated protein 1 (Keap1), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), and signal transducer and activator of transcription (STAT) pathways, shedding light on their involvement in cellular apoptosis and their intricate role to guide immune responses.

Integrated traditional herbal medicine for recurrent urinary tract infection treatment and follow-up: A meta-analysis of randomized controlled trials

ETHNOPHARMACOLOGICAL RELEVANCE

Urinary tract infections (UTIs) with pathogenic strain resistance leading to a high recurrence rate affect health quality and have become a high-priority issue due to the economic burden on the health care system.

AIM OF THE STUDY

This study aimed to investigate the supportive benefits of traditional herbal medicines (THMs) for the treatment and prevention of recurrent UTIs through a meta-analysis of randomized controlled trials.

MATERIALS AND METHODS

Systematic searches of databases, including PubMed/Medline, the Cochrane Library, and China National Knowledge Infrastructure (CNKI), were conducted to collect eligible studies for meta-analysis. The inclusion criteria were randomized controlled trials that investigated UTI recurrence using THM treatment.

RESULTS

The results of 22 studies showed that THM treatment led to significantly fewer UTI events in the experimental group than in the control group (OR = 0.348; 95% confidence interval [CI] = 0.257 to 0.473; p < 0.001). Seventeen studies reported UTI events during the follow-up period, and the recurrence rate was lower in the experimental group than in the control group (OR, 0.326; 95% CI, 0.245-0.434; p < 0.01). Subgroup analysis further showed that compared to antibiotics alone, treatment with THM plus antibiotics significantly reduced UTI events in the acute phase (OR = 0.301; 95% CI = 0.201 to 0.431; p < 0.001) as well as in the follow-up period (OR = 0.347; 95% CI = 0.241 to 0.498; p < 0.001). However, THM treatment alone was not superior to antibiotics in the acute treatment phase (OR = 0.540; 95% CI = 0.250 to 1.166; p = 0.117) or in the follow-up period (OR = 0.464; 95% CI = 0.111 to 1.951; p = 0.295). Herbal ingredients for recurrent UTI events also showed benefits compared to placebo treatment in the acute phase (OR = 0.337; 95% CI = 0.158 to 0.717; p = 0.005) and during follow-up (OR = 0.238; 95% CI = 0.139 to 0.409; p < 0.001).

CONCLUSIONS

THM combined with antibiotics is helpful for people with acute UTIs and for reinfection prevention. THMs alone, although less effective for recurrent UTIs, could be considered a therapeutic alternative to antibiotics.

Natural Products in the Treatment of Lower Urinary Tract Dysfunction and Infection

The popularity of natural products for the treatment of lower urinary tract symptoms (LUTS) differs considerably between countries. Here we discuss the clinical evidence for efficacy in two indications, male LUTS suggestive of benign prostatic hyperplasia and urinary tract infections, and the mechanistic evidence from experimental studies. Most evidence for male LUTS is based on extracts from saw palmetto berries, stinging nettle roots, and pumpkin seeds, whereas most evidence for urinary tract infection is available for European golden rod and combined preparations although this field appears more fragmented with regard to extract sources. Based on differences in sample collection and extraction, extracts from the same plants are likely to exhibit at least quantitative differences in potential active ingredients, which makes extrapolation of findings with one extract to those of others potentially difficult. While only limited information is available for most individual extracts, some extracts have been compared to placebo and/or active controls in adequately powered trials.

Current state of research on the clinical benefits of herbal medicines for non-life-threatening ailments

Herbal medicines are becoming increasingly popular among patients because they are well tolerated and do not exert severe side effects. Nevertheless, they receive little consideration in therapeutic settings. The present article reviews the current state of research on the clinical benefits of herbal medicines on five indication groups, psychosomatic disorders, gynecological complaints, gastrointestinal disorders, urinary and upper respiratory tract infections. The study search was based on the database PubMed and concentrated on herbal medicines legally approved in Europe. After applying defined inclusion and exclusion criteria, 141 articles were selected: 59 for psychosomatic disorders (100% randomized controlled trials; RCTs), 20 for gynecological complaints (56% RCTs), 19 for gastrointestinal disorders (68% RCTs), 16 for urinary tract infections (UTI, 63% RCTs) and 24 for upper respiratory tract infections (URTI) (79% RCTs). For the majority of the studies, therapeutic benefits were evaluated by patient reported outcome measures (PROs). For psychosomatic disorders, gynecological complaints and URTI more than 80% of the study outcomes were positive, whereas the clinical benefit of herbal medicines for the treatment of UTI and gastrointestinal disorders was lower with 55%. The critical appraisal of the articles shows that there is a lack of high-quality studies and, with regard to gastrointestinal disorders, the clinical benefits of herbal medicines as a stand-alone form of therapy are unclear. According to the current state of knowledge, scientific evidence has still to be improved to allow integration of herbal medicines into guidelines and standard treatment regimens for the indications reviewed here. In addition to clinical data, real world data and outcome measures can add significant value to pave the way for herbal medicines into future therapeutic applications.

Urinary Tract Infections Caused by Uropathogenic Escherichia coli: Mechanisms of Infection and Treatment Options

Urinary tract infections (UTIs) are common bacterial infections that represent a severe public health problem. They are often caused by Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumonia), Proteus mirabilis (P. mirabilis), Enterococcus faecalis (E. faecalis), and Staphylococcus saprophyticus (S. saprophyticus). Among these, uropathogenic E. coli (UPEC) are the most common causative agent in both uncomplicated and complicated UTIs. The adaptive evolution of UPEC has been observed in several ways, including changes in colonization, attachment, invasion, and intracellular replication to invade the urothelium and survive intracellularly. While antibiotic therapy has historically been very successful in controlling UTIs, high recurrence rates and increasing antimicrobial resistance among uropathogens threaten to greatly reduce the efficacy of these treatments. Furthermore, the gradual global emergence of multidrug-resistant UPEC has highlighted the need to further explore its pathogenesis and seek alternative therapeutic and preventative strategies. Therefore, a thorough understanding of the clinical status and pathogenesis of UTIs and the advantages and disadvantages of antibiotics as a conventional treatment option could spark a surge in the search for alternative treatment options, especially vaccines and medicinal plants. Such options targeting multiple pathogenic mechanisms of UPEC are expected to be a focus of UTI management in the future to help combat antibiotic resistance.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

STUDY REGISTRATION NUMBER

German Clinical Trials Register: Number DRKS00029142.

Effectiveness of herbal medicines to prevent and control symptoms of urinary tract infections and to reduce antibiotic use: A literature review

Background

Antimicrobial resistance is a rapidly growing global issue affecting the effective treatment of infectious diseases. This provides a window of opportunity for the use and implementation of well researched effective complementary therapies such as herbal medicines. In this literature review, an overview is provided of the effectiveness of herbal medicine to control symptoms of urinary tract infections and reduce antibiotic use.

Methods

PubMed, CAM-Quest, CORE-Hom, ScienceDirect, CAMBase, Anthromedics.org and AnthroMedLibrary databases were searched for peer-reviewed meta-analyses, systematic reviews and randomized controlled trials from 2005 till 8 October 2020. Included were clinical studies on the use of herbal medicine for clinically diagnosed urinary tract infection with any control group except another herbal medicine. Study quality was assessed using the Joanna Briggs Institute critical appraisal tools.

Results

Of the 408 citations identified, 23 met the inclusion criteria: 5 meta-analyses, 3 systematic reviews and 15 randomized controlled trials. Of these studies 13 involved the use of cranberry products, 4 studies concerned traditional Chinese herbal medicines, and 6 studies dealt with other herbal medicines.

Conclusions

The latest published meta-analysis including 28 trials reports a clear benefit of Cranberry products for the prevention of recurrent UTIs in women. Five TCM formulas were found to be equally or more effective than antibiotics in the treatment of UTIs. Furthermore, Rosa canina seems to have the potential to prevent UTI in women undergoing a caesarean section. ‘Acidif Plus Tablets’ as well as ‘Canephron’ seem to be promising candidates for treating women with uncomplicated recurrent UTI.

Recurrent cystitis: patients' needs, expectations and contribution to developing an information leaflet - a qualitative study

OBJECTIVES

Recurring cystitis (RC) is a common complaint among women. It has a significant impact on patients' quality of life. The physical discomfort and psychological distress related to RC are rarely addressed and women's needs in terms of information and advice have not been sufficiently explored, particularly in France in spite of their frequent episodes of RC. This study aimed to assess women's needs and expectations in view of developing a patient information leaflet to help them understand and better cope with their condition, thus offering them more autonomy and empowering them to self-manage whenever possible.

METHOD

Qualitative study using recorded semistructured interviews with patients suffering from RC.

SETTING

Interviews conducted with women suffering from RC in Corsica, France.

PARTICIPANTS

26 patients interviewed between January 2018 and April 2018.

RESULTS

Knowledge of the condition was heterogeneous, but most women reported a major impact on daily life, a high level of anxiety, various management strategies and wished to avoid taking antibiotics, preferring alternative approaches. Patients reported a lack of understanding and sympathy on the part of physicians and society and wished for more autonomy with delayed/back-up prescriptions, a multidisciplinary follow-up and, most of all, appropriate information.

CONCLUSION

The information leaflet should improve patients' knowledge and capacity for self-care, contribute to standardise practice and limit inappropriate antibiotic use.

Contribution of Symptomatic, Herbal Treatment Options to Antibiotic Stewardship and Microbiotic Health

Epithelial surfaces in humans are home to symbiotic microbes (i.e., microbiota) that influence the defensive function against pathogens, depending on the health of the microbiota. Healthy microbiota contribute to the well-being of their host, in general (e.g., via the gut-brain axis), and their respective anatomical site, in particular (e.g., oral, urogenital, skin, or respiratory microbiota). Despite efforts towards a more responsible use of antibiotics, they are often prescribed for uncomplicated, self-limiting infections and can have a substantial negative impact on the gut microbiota. Treatment alternatives, such as non-steroidal anti-inflammatory drugs, may also influence the microbiota; thus, they can have lasting adverse effects. Herbal drugs offer a generally safe treatment option for uncomplicated infections of the urinary or respiratory tract. Additionally, their microbiota preserving properties allow for a more appropriate therapy of uncomplicated infections, without contributing to an increase in antibiotic resistance or disturbing the gut microbiota. Here, herbal treatments may be a more appropriate therapy, with a generally favorable safety profile.

Phytochemical and functional analysis of horseradish (Armoracia rusticana) fermented and non-fermented root extracts

BACKGROUND

The roots of horseradish (Armoracia rusticana) are used for infections of respiratory airway and for urinary tract infections due to isothiocyanates (ITC), enzymatically formed during fermentation of glucosinolates by myrosinase.

HYPOTHESIS/PURPOSE

The present study aims to present a comprehensive overview on the phytochemical composition of A. rusticana roots, especially concerning isothiocyanates and respective glucosinolates. The complex flavonoid spectrum of the herbal material is reviewed. Published data on in vitro activity of horseradish extracts and isolated compounds are summarized. These data indicate well-established use of horseradish as an antibacterial remedy against bacterial infections of the airway and urinary tract.

STUDY DESIGN

To answer the question if other compounds from A. rusticana beside ITC contribute to the antibacterial activity, non-targeted LC-MS studies were performed with fermented and non-fermented horseradish extracts, and detailed phytochemical profiles were established.

RESULTS

Comparative investigations on the antibacterial activity indicated that only ITC-containing extracts and fractions exert antibacterial activity. The huge variety of non-ITC compounds do not significantly contribute to the antibacterial activity, but can be used for analytical characterisation and quality control of the herbal material. Detailed phytochemical analysis additionally revealed a variety of compounds, not described until now for horseradish roots: the flavonol glycosides kaempferol-3-O-β-d-xylopyranosyl-(1''' → 2'')-β-d-galactopyranoside, kaempferol-3-O-α-l-rhamnopyranosyl-(1''' → 6'')-β-d-glucopyranoside, kaempferol-3-O-β-d-glucopyranoside, Kaempferol-3-O-β-d-xylopyranosyl-7-O-β-d-glucopyranoside, Kaempferol-3-O-β-d-xylopyranosyl-(1'''' → 2''')-β-d-galactopyranoside-7-O-β-d-glucopyranoside, the oxo-indole derivative spirobrassinin, the phenylthiazole 2-methylsulfanyl-4-phenyl-4,5-dihydro-1,3-thiazole, a series of lysophophatidylethanolamine and 13 different N-phenylpropenoyl-L-amino acids.

CONCLUSION

The antibacterial effects of horseradish are only due to the presence of glucosinolates resp. the corresponding ITC, and the detailed overall composition of horseradish extracts has been reported.

A global perspective on improving patient care in uncomplicated urinary tract infection: Expert consensus and practical guidance

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are a common problem in women. Management is mainly based on empirical prescribing, but there are concerns about overtreatment and antimicrobial resistance (AMR), especially in patients with recurrent uUTIs.

METHODS

A multidisciplinary panel of experts met to discuss diagnosis, treatment, prevention, guidelines, AMR, clinical trial design, and the impact of COVID-19 on clinical practice.

RESULTS

Symptoms remain the cornerstone of uUTI diagnosis, and urine culture is necessary only when empirical treatment fails, or rapid recurrence of symptoms or AMR is suspected. Specific antimicrobials are first-line therapy (typically nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, and pivmecillinam; dependent on availability and local resistance data). Fluoroquinolones are not first-line options for uUTIs due primarily to safety concerns, but also rising resistance rates. High-quality data to support most non-antimicrobial approaches are lacking. Local AMR data specific to community-acquired uUTIs are needed, but representative information is difficult to obtain; instead, identification of risk factors for AMR can provide a basis to guide empirical antimicrobial prescribing. The COVID-19 pandemic has impacted management of uUTIs in some countries and may have long-lasting implications for future models of care.

CONCLUSIONS

The management of uUTIs in women can be improved without increasing complexity, including simplified diagnosis, and empirical antimicrobial prescribing based on patient characteristics, including review of recent antimicrobial use and past pathogen resistance profiles, drug availability, and guidelines. Current data for non-antimicrobial approaches are limited. The influence of COVID-19 on telehealth could provide an opportunity to enhance patient care in the long term.

Management of uncomplicated recurrent urinary tract infections

OBJECTIVES

To discuss optimal management of recurrent urinary tract infections (UTIs) in women. About every second woman experiences at least one UTI in her lifetime, of those 30% experience another UTI, and 3% further recurrences. Especially young healthy women without underlying anatomical deficiencies suffer from recurrent UTIs (rUTI), which are associated with significant morbidity and reduction in quality of life.

METHODS

This is a narrative review, investigating publications dealing with recurrent UTI in women. Risk factors and options for management are discussed.

RESULTS

The increased susceptibility of women to rUTI is based on the female anatomy in addition to behavioural, genetic, and urological factors. However, why some women are more likely than others to develop and maintain rUTI remains to be clarified. Invasive characteristics of certain uropathogenic Escherichia coli that are able to form extra- and intracellular biofilms and may therefore cause delayed release of bacteria into the bladder, may play a role in this setting. Treatment recommendations for an acute episode of rUTI do not differ from those for isolated episodes. Given the nature of rUTI, different prophylactic approaches also play an important role. Women with rUTI should first be counselled to use non-antibiotic strategies including behavioural changes, anti-adhesive treatments, antiseptics, and immunomodulation, before antibiotic prophylaxis is considered. In addition to the traditional treatment and prophylactic therapies, new experimental strategies are emerging and show promising effects, such as faecal microbiota transfer (FMT), a treatment option that transfers microorganisms and metabolites of a healthy donor's faecal matter to patients using oral capsules, enemas, or endoscopy. Initial findings suggest that FMT might be a promising treatment approach to interrupt the cycle of rUTI. Furthermore, bacteriophages, infecting and replicating in bacteria, have been clinically trialled for UTIs.

CONCLUSION

Due to the limitation of available data, novel treatment options require further clinical research to objectify the potential in treating bacterial infections, particularly UTIs.

Temporal trends, risk factors and outcomes of infections due to extended-spectrum β-lactamase producing Enterobacterales in Swiss solid organ transplant recipients between 2012 and 2018

Background

The burden of antimicrobial resistance is high in solid organ transplant (SOT) recipients. Among Swiss SOT recipients, we assessed temporal trends of ESBL-producing Enterobacterales (ESBL-E), identified risk factors for ESBL-E, and assessed the impact of resistance on patient outcome.

Methods

Data from the Swiss Transplant Cohort Study (STCS), a nationwide prospective cohort of SOT-recipients, were analysed. Temporal trends were described for ESBL-detection among Escherichia coli and non-Escherichia coli. In a nested case–control study, cases with ESBL-E infection were 1:1 matched (by time since transplantation, organ transplant, pathogen) to controls infected with non-ESBL-E. Factors associated with resistance and with unfavourable 30-day outcome (death, infection relapse, graft loss) were assessed.

Results

From 2012 to 2018, we identified 1′212 infection episodes caused by Enterobacterales in 1′074 patients, thereof 11.4% (138/1′212) caused by ESBL-E. The proportion of ESBL-production among Escherichia coli remained stable over time (p = 0.93) but increased for non-E. coli (p = 0.02) Enterobacterales. In the case–control study (n = 102), antibiotic pre-treatment was independently associated with ESBL-production (aOR = 2.6, 95%-CI: 1.0–6.8, p = 0.046). Unfavourable outcome occurred in 24/51 (47%) cases and 9/51 (18%) controls (p = 0.003). Appropriate empiric antibiotic therapy was the only modifiable factor associated with unfavourable outcome.

Conclusions

In Swiss SOT-recipients, proportion of infections with ESBL-producing non-E. coli Enterobacterales increased in recent years. Antibiotic pre-treatment represents a risk factor for ESBL-E. Improving appropriateness of empiric antibiotic treatment might be an important measure to reduce unfavourable outcome, which was observed in almost half of SOT-recipients with ESBL-E infections.

[Uncomplicated urinary tract infections : Use of mustard oils]

BACKGROUND

Increasing rates of multidrug resistant bacteria demand a change in managing infectious diseases. New ways of antibiotic-free treatment in uncomplicated urinary tract infections (UTI) saving antibiotics for severe infections should be chosen.

OBJECTIVES

Beside analgesics for purely symptomatic treatment, herbal medicine can be used for uncomplicated UTI instead of antibiotics.

MATERIALS AND METHODS

Anti-infectious phytodrugs like isothiocyanates (ITC) from horseradish and cress (nasturtium) have been thoroughly examined scientifically.

RESULTS

ITC showed multitarget effects in many pharmacological studies. Beside anti-inflammatory effects, a broad spectrum of species, including multiresistant bacteria were covered. Positive results and good compatibility are documented in several studies for therapy of uncomplicated UTI and respiratory infections with horseradish and cress as well as for prophylaxis in recurrent UTI (recommendation in the German S3 guideline for uncomplicated urinary tract infections, AWMF registry 043/044, statement 8.1.d.4 on prophylaxis).

CONCLUSION

Using isothiocyanates (ITC) for therapy and prophylaxis in uncomplicated urinary tract infections is a rational approach and helps to save antibiotics. Even after long-term use, development of resistance has not yet been observed and is not probable due to the multimodal mechanism of action of ITC.

[Bacterial urinary tract infection and subclinical bacteriuria in the dog: a current review]

Bacterial urinary tract infection (UTI) is a common clinical presentation in dogs and a frequent reason for the prescription of antimicrobial drugs. UTI refers to adherence, multiplication and persistence of an infectious agent within the urogenital system. This causes an associated inflammatory response as well as the pertaining clinical signs. Depending on the site of infection, UTI's may be classified as bacterial cystitis, prostatitis or pyelonephritis. In contrast, subclinical bacteriuria (SB) is defined as the presence of a significant number of bacteria in the urine of an individual not showing clinical signs referrable to UTI. UTI's typically occur as a consequence of ascending pathogen migration from the host's own fecal or distal urogenital microbial flora. The most commonly isolated pathogen in cases of UTI and SB is Escherichia coli. The diagnosis is based on clinical signs and the results of urine examination and culture. The recently revised guidelines of the International Society for Companion Animal Infectious Diseases provide detailed recommendations for diagnosis and management of different forms of bacterial UTI's in dogs. Adherence to treatment guidelines will improve treatment success and is imperative in avoiding further deterioration of the antimicrobial resistance situation.

Antimicrobial effects of mustard oil-containing plants against oral pathogens: an in vitro study

Background

The present study examines the antimicrobial activity of nasturtium herb (Tropaeoli maji herba) and horseradish root (Armoraciae rusticanae radix) against clinically important oral bacterial pathogens involved in periodontitis, gingivitis, pulpitis, implantitis and other infectious diseases.

Methods

A total of 15 oral pathogens, including members of the genera Campylobacter, Fusobacterium, Prevotella, Parvimonas, Porphyromonas, Tanerella, Veillonella, and HACEK organisms, were exposed to [1] a combination of herbal nasturtium and horseradish using a standardized gas test and [2] a mixture of synthetic Isothiocyantes (ITCs) using an agardilution test. Headspace gas chromatography mass spectrometry was employed to quantify the amount of allyl-, benzyl-, and 2- phenyl- ethyl-ITC.

Results

With exception of Veillonella parvula, all tested species were highly susceptible to herbal nasturtium and horseradish in the gas test with minimal inhibitory concentrations (MICs) between 50/20 mg and 200/80 mg and to synthetic ITCs in the agardilution with MICs between 0.0025 and 0.08 mg ITC/mL, respectively. Minimal bactericidal concentrations extended from 0.005 mg ITC/mL to 0.34 mg ITC/mL.

Conclusions

ITCs may be considered an interesting alternative to antibiotics for prevention and treatment of oropharyngeal infections, periodontitis and related diseases. Furthermore, the suitability of ITCs for endocarditis prophylaxis in dental procedures might be worth further investigation.

Inhibition of urease activity in the urinary tract pathogens Staphylococcus saprophyticus and Proteus mirabilis by dimethylsulfoxide (DMSO)

AIMS

Urease is a virulence factor for the urinary tract pathogens Staphylococcus saprophyticus and Proteus mirabilis. Dimethylsulfoxide (DMSO) is structurally similar to urea, used as a solvent for urease inhibitors, and an effective treatment for interstitial cystitis/bladder pain syndrome (IC/BPS). The aims of this study were to test DMSO as a urease inhibitor and determine its physiological effects on S. saprophyticus and P. mirabilis.

METHODS AND RESULTS

Urease activity in extracts and whole cells was measured by the formation of ammonium ions. Urease was highly sensitive to noncompetitive inhibition by DMSO (K_i about 6 mmol l^-1 ). DMSO inhibited urease activity in whole cells, limited bacterial growth in media containing urea, and slowed the increase in pH which occurred in artificial urine medium.

CONCLUSIONS

DMSO should be used with caution as a solvent when testing plant extracts or other potential urease inhibitors. Because it can inhibit bacterial growth and delay an increase in pH, it may be an effective treatment for urinary tract infections.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first detailed study of the inhibition of urease by DMSO. Dimethylsulfoxide may be used to treat urinary tract infections that are resistant to antibiotics or herbal remedies.

Plant-Derived Products as Antibacterial and Antifungal Agents in Human Health Care

A number of papers reporting antimicrobial properties of extracts, essential oils, resins and various classes of compounds isolated from higher plants have been published in recent years; however, a comprehensive analysis of plant-derived antimicrobial agents currently applied in practice for the improvement of human health is still lacking. This review summarizes data on clinical efficacy, antimicrobial effects and the chemistry of commercially available antibacterial and antifungal agents of plant origin currently used in the prevention and treatment of gastrointestinal, oral, respiratory, skin, and urinary infections. As a result of an analysis of the literature, more than 40 plant-derived over-the-counter pharmaceuticals, dietary supplements, cosmetics, herbal medicines, and functional foods containing complex mixtures (e.g. Glycyrrhiza glabra extract, Melaleuca alternifolia essential oil, and Pistacia lentiscus resin), pure compounds (e.g. benzoic acid, berberine, eucalyptol, salicylic acid and thymol) as well as their derivatives and complexes (e.g. bismuth subsalicylate and zinc pyrithione) have been identified. The effectiveness of many of these products is illustrated by results of clinical trials and supported by data on there in vitro antimicrobial activity. A broad spectrum of various commercial products currently available on the market and their welldocumented clinical efficacy suggests that plants are prospective sources for the identification of new types of antimicrobial agents in future. Innovative approaches and methodologies for effective proof-of-concept research and the development of new types of plant-derived products effective against recently emerging problems related to human microbial diseases (e.g. antimicrobial resistance) are also proposed in this review.

Diverse Excretion Pathways of Benzyl Glucosinolate in Humans after Consumption of Nasturtium (Tropaeolum majus L.)-A Pilot Study

SCOPE

Different metabolic and excretion pathways of the benzyl glucosinolate breakdown products benzyl isothiocyanate and benzyl cyanide are investigated to obtain information about their multiple fate after ingestion. Detailed focus is on the so far underestimated transformation/excretion pathways-protein conjugation and exhalation.

METHODS AND RESULTS

Metabolites, protein conjugates, and non-conjugated isothiocyanates are determined in plasma, urine, and breath of seven volunteers after consuming freeze-dried nasturtium or bread enriched with nasturtium. Samples are collected up to 48 h at selected time points. The metabolites of the mercapturic acid pathway are detectable in plasma up to 24 h after consumption. Additionally, mercapturic acid is the main metabolite in urine, but non-conjugated benzyl isothiocyanate is detectable as well. Protein conjugates show high amounts in plasma even 48 h after consumption. In breath, benzyl isothiocyanate and benzyl cyanide are detectable up to 48 h after consumption.

CONCLUSION

Isothiocyanates are not only metabolized via the mercapturic acid pathway, but also form protein conjugates in blood and are exhaled. To balance intake and excretion, it is necessary to investigate all potential metabolites and excretion routes. This has important implications for the understanding of physiological and pharmacological effects of isothiocyanate-containing products.

Uncomplicated Bacterial Community-Acquired Urinary Tract Infection in Adults

BACKGROUND

Uncomplicated bacterial community-acquired urinary tract infection is among the more common infections in outpatient practice. The resistance level of pathogens has risen markedly. This S3 guideline contains recommendations based on current evidence for the rational use of anti - microbial agents and for the prevention of inappropriate use of certain classes of antibiotics and thus of the resulting drug resistance. The prevention of recurrent urinary tract infection is considered in this guideline for the first time.

METHODS

The guideline was updated under the aegis of the German Urological Society (Deutsche Gesellschaft für Urologie). A systematic literature search (period: 2008-2015) concerning the diagnosis, treatment, and prevention of uncomplicated urinary tract infections was carried out in the Cochrane Library, MEDLINE, and Embase databases. Randomized, controlled trials and systemic reviews were included. Relevant guidelines were identified in a guideline synopsis.

RESULTS

Symptom-oriented diagnostic evaluation is highly valued. For the treatment of cystitis, fosfomycin-trometamol, nitrofurantoin, nitroxolin, pivmecillinam and trimethoprim are all equally recommended. Fluorquinolones and cephalosporins are not recommended. Uncomplicated pyelonephritis with a mild to moderate clinical course ought to be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For acute, uncomplicated cystitis, with mild to moderate symptoms, symptomatic treatment alone may be considered instead of antibiotics after discussion of the options with the patient. Mainly non-antibiotic measures are recommended for prophylaxis against recurrent urinary tract infection.

CONCLUSION

Physicians who treat uncomplicated urinary tract infections should familiarize themselves with the newly revised guideline's recommendations on the selection and dosage of antibiotic treatment so that they can responsibly evaluate and plan antibiotic treatment for their affected patients.

[Urinary tract infections : What has been confirmed in therapy?]

Urinary tract infections (UTIs) affect approximately 150 million people worldwide per year, causing annual health costs of over three billion dollars just in the USA. Every second woman experiences at least one UTI in her lifetime, with every one in four experiencing recurrence. Uncomplicated infections like single or recurrent cystitis and pyelonephritis can be distinguished from complicated disease. UTIs in men can spread to the male glands, causing prostatitis and epididymitis. Antibiotic therapy is the standard procedure for UTIs. However, the extensive and sometimes irrational use of antibiotics for the treatment of infections has led to an increase in the incidence of multiresistant pathogens in recent years. Therefore, preventive nonantibiotic approaches are of great interest. This article provides an overview of the current management of urological infections as well as an outline of nonantibiotic preventive treatment modalities.

UroPathogenic Escherichia coli (UPEC) Infections: Virulence Factors, Bladder Responses, Antibiotic, and Non-antibiotic Antimicrobial Strategies

Urinary tract infections (UTIs) are one of the most common pathological conditions in both community and hospital settings. It has been estimated that about 150 million people worldwide develop UTI each year, with high social costs in terms of hospitalizations and medical expenses. Among the common uropathogens associated to UTIs development, UroPathogenic Escherichia coli (UPEC) is the primary cause. UPEC strains possess a plethora of both structural (as fimbriae, pili, curli, flagella) and secreted (toxins, iron-acquisition systems) virulence factors that contribute to their capacity to cause disease, although the ability to adhere to host epithelial cells in the urinary tract represents the most important determinant of pathogenicity. On the opposite side, the bladder epithelium shows a multifaceted array of host defenses including the urine flow and the secretion of antimicrobial substances, which represent useful tools to counteract bacterial infections. The fascinating and intricate dynamics between these players determine a complex interaction system that needs to be revealed. This review will focus on the most relevant components of UPEC arsenal of pathogenicity together with the major host responses to infection, the current approved treatment and the emergence of resistant UPEC strains, the vaccine strategies, the natural antimicrobial compounds along with innovative anti-adhesive and prophylactic approaches to prevent UTIs.

Limited effectiveness of over-the-counter plant preparations used for the treatment of urinary tract infections as inhibitors of the urease activity from Staphylococcus saprophyticus

AIMS

Urease is a key virulence factor for the Gram-positive urinary tract pathogen Staphylococcus saprophyticus and a potential target for antimicrobial therapy. The enzyme from S. saprophyticus is unusual in that it does not contain cysteine at the active site. The aims of this study were to test 14 over-the-counter plant preparations as inhibitors of this urease and to determine whether they can prevent the increase in pH that normally occurs in bacterial cultures containing urea.

METHODS AND RESULTS

Urease activity was measured colorimetrically by the formation of ammonium ions. The green tea and Uva-Ursi preparations reduced urease activity in a soluble extract of S. saprophyticus by more than 75%. Two herbal mixtures were weakly inhibitory and reduced activity by about 25%, but the other products had little or no effect. The green tea and Uva-Ursi extracts also inhibited urease activity in whole cells by more than 75%. One of the herbal products (WishGarden UTI) showed some inhibition of urease activity but the other (UTI Clear) did not. The green tea and Uva-Ursi preparations prevented the increase in pH that normally occurs when S. saprophyticus is grown in an artificial urine medium, but this was due primarily to bacterial death. The WishGarden UTI preparation could partially delay the pH increase while allowing some cells to remain viable.

CONCLUSION

These results indicate that only a few of the commercially available over-the-counter plant preparations commonly used for the treatment of urinary tract infections (UTIs) can inhibit the urease activity from S. saprophyticus.

SIGNIFICANCE AND IMPACT OF THE STUDY

While over-the-counter plant preparations may be considered an alternative to traditional antibiotics for the treatment of UTIs, they should be used with caution and a product should be matched to the properties of the virulence factors of the bacterial pathogen involved.

Results of a randomized, prospective, double-dummy, double-blind trial to compare efficacy and safety of a herbal combination containing Tropaeoli majoris herba and Armoraciae rusticanae radix with co-trimoxazole in patients with acute and uncomplicated cystitis

Objectives

To demonstrate non-inferiority of an herbal combination (horseradish root and nasturtium herb) to an antibiotic (co-trimoxazole) in acute uncomplicated cystitis.

Design

Randomized, prospective, double-blind, double-dummy, multicenter, phase III clinical study, using block randomization of 4 blocks (size 2).

Setting

Twenty-six centers in Germany, from May 2011 to June 2013.

Participants

Adult patients (median age, 38.5 years; 90% female) with acute uncomplicated cystitis confirmed via urinalysis and bacterial counts.

Interventions

Patients received the herbal combination (five tablets, four times per day) or the antibiotic (two tablets daily) for a period of 7 or 3 days, respectively, followed by a 21-days without drug treatment. Placebos ensured blinding.

Primary and secondary outcome measures

The primary endpoint was the percentage of responders, expressed as reduction of germ count from >10⁵ to <10³ CFU/mL of pathogens between visit 1 (day 0) and 3 (day 15). Secondary endpoints included change of symptom scores, duration of symptoms, efficacy assessments, relapse frequency, and safety. A sample size of 178 patients per group was estimated.

Results

Of the 96 randomized patients (intent-to-treat; 45 in the phytotherapy group, 51 in the antibiotic group), 51 were considered per-protocol patients (22 in the phytotherapy group, 29 in the antibiotic group). Responder rates were 10/22 (45.5%) for the phytotherapy group and 15/29 (51.1%) for the antibiotic group (group difference: −6.27% [95% CI: −33.90%–21.3%]). The study was terminated prematurely due to slow recruitment rates. Non-inferiority could not be assumed by predefined criteria. During the follow-up period, one relapse occurred in each group. Both treatments were well tolerated.

Conclusion

This clinical trial indicates comparable efficacy of the herbal combination and antibiotic, although non-inferiority was not proved. However, the results and lessons learned are important for the planning of future trials. Issues that led to the premature trial discontinuation were considered.

Evaluation of an Aqueous Extract from Horseradish Root (Armoracia rusticana Radix) against Lipopolysaccharide-Induced Cellular Inflammation Reaction

Horseradish (Armoracia rusticana) is a perennial crop and its root is used in condiments. Traditionally, horseradish root is used to treat bacterial infections of the respiratory tract and urinary bladder. The antiphlogistic activity, determined in activated primary human peripheral blood mononuclear cells (PBMC), was evaluated for an aqueous extract and its subfractions, separated by HPLC. Compound analysis was done by UHPLC-QToF/MS and GC-MS. The aqueous extract concentration-dependently inhibited the anti-inflammatory response to lipopolysaccharide (LPS) in terms of TNF-α release at ≥37 μg/mL. Further, the cyclooxygenase as well as lipoxygenase pathway was blocked by the extract as demonstrated by inhibition of COX-2 protein expression and PGE₂ synthesis at ≥4 μg/mL and leukotriene LTB4 release. Mechanistic studies revealed that inhibition of ERK1/2 and c-Jun activation preceded COX-2 suppression upon plant extract treatment in the presence of LPS. Chemical analysis identified target compounds with a medium polarity as relevant for the observed bioactivity. Importantly, allyl isothiocyanate, which is quite well known for its anti-inflammatory capacity and as the principal pungent constituent in horseradish roots, was not relevant for the observations. The results suggest that horseradish root exerts an antiphlogistic activity in human immune cells by regulation of the COX and LOX pathway via MAPK signalling.

Antibacterial in vitro effects of preparations from Anthroposophical Medicine

Background

Medications from Anthroposophical Medicine (AM) are clinically used for the treatment of infections within a whole medical system but have not yet been evaluated regarding antibacterial effects. The aims of this study was to investigate antibacterial activity of AM medications in cell culture.

Methods

Screening of AM drug registers for preparations used to treat any kind of infection and being available in dilutions ≤ D2 and without alcoholic content. Selected medications were screened for antimicrobial activity against Bacillus subtilis, Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa using the agar diffusion method. For antimicrobial active preparations growth kinetics (drop plate method) and minimal inhibitory concentrations (MIC, macrodilution method) were determined.

Results

Thirty-three preparations matched the selection criteria and were chosen for own experiments. One of them (Berberis Decoctum D2) exhibited bactericidal activities against Bacillus subtilis and Staphylococcus aureus, including methicillin resistant strains. The MIC could be determined as 5 mg/ml. The effects could be related to the content of berberine in the extract. No activity towards gram-negative bacteria was found. The other tested extracts had no antibacterial effects.

Conclusion

Berberis Decoctum D2 which is used in AM to treat infections exhibits bactericidal effects on Staphylococcus aureus, including methicillin resistant strains.

Novel Strategies in the Prevention and Treatment of Urinary Tract Infections

Urinary tract infections are one of the most common bacterial infections, especially in women and children, frequently treated with antibiotics. The alarming increase in antibiotic resistance is a global threat to future treatment of infections. Therefore, alternative strategies are urgently needed. The innate immune system plays a fundamental role in protecting the urinary tract from infections. Antimicrobial peptides form an important part of the innate immunity. They are produced by epithelial cells and neutrophils and defend the urinary tract against invading bacteria. Since efficient resistance mechanisms have not evolved among bacterial pathogens, much effort has been put into exploring the role of antimicrobial peptides and possibilities to utilize them in clinical practice. Here, we describe the impact of antimicrobial peptides in the urinary tract and ways to enhance the production by hormones like vitamin D and estrogen. We also discuss the potential of medicinal herbs to be used in the prophylaxis and the treatment of urinary tract infections.

Chinese herbal medicine for treating recurrent urinary tract infections in women

BACKGROUND

Acute urinary tract infection (UTI) is a common bacterial infection that affects 40% to 50% of women. Between 20% and 30% of women who have had a UTI will experience a recurrence, and around 25% will develop ongoing recurrent episodes with implications for individual well-being and healthcare costs. Prophylactic antibiotics can prevent recurrent UTIs but there are growing concerns about microbial resistance, side effects from treatment and lack of long-term benefit. Consequently, alternative treatments are being investigated. Chinese herbal medicine (CHM) has a recorded history of treating UTI symptoms and more recent research suggests a potential role in the management of recurrent UTIs. This review aimed to evaluate CHM for recurrent UTI.

OBJECTIVES

This review assessed the benefits and harms of CHM for the treatment of recurrent UTIs in adult women, both as a stand-alone therapy and in conjunction with other pharmaceutical interventions.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant's Specialised Register to 7 May 2015 through contact with the Trials Search Co-ordinator, using search terms relevant to this review. We also searched AMED, CINAHL and the Chinese language electronic databases Chinese BioMedical Literature Database (CBM), China Network on Knowledge Infrastructure (CNKI), VIP and Wan Fang Databases to July 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing treatments using CHM with either an inactive placebo or conventional biomedical treatment. RCTs comparing different CHM strategies and treatments were eligible for inclusion. Quasi-randomised studies were excluded.

DATA COLLECTION AND ANALYSIS

Data extraction was carried out independently by two authors. Where more than one publication of one study existed, these were grouped and the publication with the most complete data was used in the analyses. Where relevant outcomes were only published in earlier versions these data were used. All meta-analyses were performed using relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We included seven RCTs that involved a total of 542 women; of these, five recruited post-menopausal women (aged from 56 to 70 years) (422 women). We assessed all studies to be at high risk of bias. Meta-analyses comparing the overall effectiveness of treatments during acute phases of infection and rates of recurrence were conducted. Analysis of three studies involving 282 women that looked at CHM versus antibiotics suggested that CHM had a higher rate of effectiveness for acute UTI (RR 1.21, 95% CI 1.11 to 33) and reduced recurrent UTI rates (RR 0.28, 95% CI 0.09 to 0.82). Analysis of two studies involving 120 women that compared CHM plus antibiotics versus antibiotics alone found the combined intervention had a higher rate of effectiveness for acute UTI (RR 1.24, 95% CI 1.04 to 1.47) and resulted in lower rates of recurrent infection six months after the study (RR 0.53, 95% CI 0.35 to 0.80).One study comparing different CHM treatments found Er Xian Tang was more effective in treating acute infection in post-menopausal women than San Jin Pian (80 women: RR 1.28, 95% CI 1.03 to 1.57). Analysis showed that active CHM treatments specifically formulated for recurrent UTI were more effective in reducing infection incidence than generic CHM treatments that were more commonly used for acute UTI (RR 0.40, 95% CI 0.21 to 0.77).Only two studies undertook to report adverse events; neither reported the occurrence of any adverse events.

AUTHORS' CONCLUSIONS

Evidence from seven small studies suggested that CHM as an independent intervention or in conjunction with antibiotics may be beneficial for treating recurrent UTIs during the acute phase of infection and may reduce the recurrent UTI incidence for at least six months post-treatment. CHM treatments specifically formulated for recurrent UTI may be more effective than herbal treatments designed to treat acute UTI. However, the small number and poor quality of the included studies meant that it was not possible to formulate robust conclusions on the use of CHM for recurrent UTI in women either alone or as an adjunct to antibiotics.

The challenges of treating women with recurrent urinary tract infections in primary care: a qualitative study of GPs' experiences of conventional management and their attitudes towards possible herbal options

AIM

To explore GPs' experiences of managing recurrent urinary tract infections (RUTIs) and their views on the use of herbal medicines for this condition.

BACKGROUND

RUTIs are an important problem commonly managed in primary care. Antibiotic prophylaxis is an effective treatment for acute infections but growing microbial resistance, adverse effects, and the lack of sustained long-term benefits mean that novel treatments are required. There are a number of promising reports of herbal medicines being used to treat RUTIs.

METHODS

A total of 15 GPs (seven female; aged 34-59 years; in practice from 3 to 31 years) were purposively sampled and took part in semi-structured face-to-face and telephone interviews. Interviews were digitally recorded, transcribed, and analysed using inductive thematic analysis. Data collection and analysis proceeded iteratively to allow emerging themes to inform subsequent interviews.

FINDINGS

Participants were aware of the disabling effect of RUTIs on women's lives. GPs experienced significant challenges in their management of RUTIs with decisions about the provision of antibiotics being particularly complex. While some participants were open to the possibility of herbal treatment options they required more research into effectiveness and safety, better regulation of herbal practitioners, and assurance about herbal quality control and potential herb-drug interactions.

Prevention of recurrent urinary tract infections in women

Around 40-50% of women experience at least one urinary tract infection (UTI) during their lifetime and 20-30% of these have a recurrence within 3-4 months of the initial infection.¹ Recurrent UTI (usually defined as three episodes in the last 12 months or two episodes in the last 6 months) can have a considerable impact on a woman's quality of life. Each episode of acute UTI in young women is typically associated with about 6 days of symptoms, 2.4 days of restricted activities and 0.4 days of bed rest.¹ Antibacterial prophylaxis is effective in preventing recurrent episodes, but at the expense of unwanted effects and a risk of promoting bacterial resistance. Here we assess the efficacy of different antibacterial regimens and non-antibacterial alternatives (cranberry, probiotics, oestrogens, immunostimulation, hyaluronic acid and chondroitin, acupuncture and herbs) in the prevention of recurrent uncomplicated UTIs in women.

Alternative approaches to conventional treatment of acute uncomplicated urinary tract infection in women

The increasing resistance of uropathogens to antibiotics and recognition of the generally self-limiting nature of uncomplicated urinary tract infection (UTI) suggest that it is time to reconsider empirical treatment of UTI using antibiotics. Identifying new and effective strategies to prevent recurrences and alternative treatment strategies are a high priority. We review the recent literature regarding the effects of functional food products, probiotics, vaccines, and alternative treatments on treating and preventing UTI.

Sulfate determines the glucosinolate concentration of horseradish in vitro plants (Armoracia rusticana Gaertn., Mey. & Scherb.)

BACKGROUND

Horseradish plants (Armoracia rusticana) contain high concentrations of glucosinolates. Former studies have revealed that Armoracia plants cultivated in vitro have markedly lower glucosinolate concentrations than those grown in soils. Yet, these studies neglected that the sulfate concentration in the growth medium may have had a strong impact on glucosinolate metabolism. Accordingly, in this study horseradish in vitro plants were cultivated with differing sulfate concentrations and the glucosinolate concentrations were quantified by ion pair HPLC.

RESULTS

Cultivation in 1.7 mmol L(-1) sulfate (as used in the prior studies) resulted in the accumulation of 16.2 µmol g(-1) DW glucosinolates, while the glucosinolate concentration increased to more than 23 µmol g(-1) DW when 23.5 mmol L(-1) sulfate was used in the medium. Correspondingly, the glucosinolate concentration decreased to 1.6 µmol g(-1) DW when sulfate concentration was lowered to 0.2 mmol L(-1).

CONCLUSION

Since the glucosinolate accumulation in relation to the sulfate concentration follows a typical saturation curve, we deduce that the availability of sulfate determines the glucosinolate concentration in horseradish in vitro plants.

Contemporary Management of recurrent UTI in adult females

The management of recurrent UTI is subject to significant variation and patients may fall under the care of a variety of specialties. We review the pathogenesis, investigation and management of this group of patients. Accurate diagnosis of UTI is the cornerstone of successful management, and careful interpretation of MSU results is needed. Although prophylactic antibiotic regimes are often successful, the emergence of antibiotic resistance mandates the cautious use of antibiotics and consideration of other initial therapies where possible.

Efficacy and safety of a combination herbal medicinal product containing Tropaeoli majoris herba and Armoraciae rusticanae radix for the prophylactic treatment of patients with respiratory tract diseases: a randomised, prospective, double-blind, placebo-controlled phase III trial

OBJECTIVE

The aim of this ICH-GCP study was to investigate the efficacy and safety of a prophylactic administration of a combination herbal medicinal product (CHMP) in two dosages compared to placebo with respect to the incidence of new occurring infections of the respiratory tract (RTI). Clinical experience of prophylactic treatment of respiratory tract infections with the marketed CHMP containing horseradish root (Armoraciae rusticanae radix) and nasturtium (Tropaeoli majoris herba) has existed for decades.

METHODS

The study was performed as a phase III, multicentre, randomised, double-blind, double-dummy, placebo-controlled, parallel-group trial. All groups received two film coated tablets three times a day. Group 1 received the CHMP tablets 3 × 2 per day, group 2 the CHMP tablets 2 × 2 and placebo tablets 2 × 1 per day and group 3 received placebo tablets 3 × 2 per day. Maximum duration of treatment was 84 days. The primary efficacy criterion was the comparison of the incidences of new occurring RTIs between the treatment groups during the prophylactic treatment. In addition the character of occurring infections, number of sick days and severity of infections were compared. Further criteria were subjects' well being, the satisfaction of subjects with the respective treatments and severity and incidence of the observed adverse events (AE) and serious adverse events (SAE) during the study period.

TRIAL REGISTRATION

EudraCT No. 2010-023227-26.

RESULTS

From 371 subjects screened, a total of 351 subjects of both sexes from 18 to 75 years were randomly allocated to one of the three groups. In order to achieve scientifically and medically impeccable results it was necessary to address acute infections of the respiratory tract occurring during the normal incubation period. Early infections (≤day 7) were excluded from the data set in a sensitivity analysis. In the intention to treat (ITT) population excluding early infections ≤day 7 (n = 344) the infection rates were 13.3% for CHMP 3 × 2 (n = 113), 18.4% for CHMP 2 × 2 (n = 114) and 25.6% for placebo (n = 117). The statistical trend test showed significant results (p = 0.0171). For the per protocol (PP) population - also excluding infections ≤day 7 (n = 334) - infection rates were: CHMP 3 × 2 (n = 110) 12.7%, CHMP 2 × 2 (n = 113) 18.6% and placebo (n = 111) 24.3% (p = 0.0266). Secondary parameters of infections (infection diagnosis, intensity, duration) showed no relevant differences between the treatment groups. The study medication was well tolerated.

LIMITATIONS

This was the first clinical ICH-GCP study with the CHMP conducted in this indication and with a sufficient number of subjects. The study population comprised subjects from 18 to 75 years and covered different diagnoses of RTIs. The results show a benefit when using 3 × 2 film tablets of CHMP for prophylaxis of RTIs. However, no data are available on use of the CHMP in this indication in children, adolescents and the elderly (over 75 years).

CONCLUSION

This trial demonstrates the efficacy and safety of the combination herbal medicinal product as the treatment of first choice in the prophylactic treatment of episodes of respiratory tract infections. Clinical experience was confirmed in an ICH-GCP study.

Feline bacterial urinary tract infections: An update on an evolving clinical problem

Although feline urine is increasingly submitted for bacterial culture and susceptibility testing as part of a more general diagnostic work-up for a range of presentations in veterinary practice, bacterial urinary tract infections (UTIs) are relatively uncommon due to a variety of physical and immunological barriers to infection. Culture positive urine is most often obtained from older female cats and the clinical history may include hematuria, dysuria and pollakiuria, or the infection may be occult. Urinalysis usually reveals hematuria and pyuria, and Escherichia coli and Gram-positive cocci are cultured most frequently. Most feline UTIs can be successfully treated using oral amoxicillin or amoxicillin/clavulanic acid administered for at least 14days, but the prevalence of antimicrobial resistance amongst infecting bacterial species is a growing concern. There is currently no conclusive information on the safety and efficacy of alternative therapeutic agents for the treatment of feline UTIs.