Scientific Advances in Understanding the Pathogenesis, Diagnosis, and Prevention of Urinary Tract Infection in the Past 10 Years

Urinary tract infection (UTI) is a very common disease that is accompanied by various complications in the affected person. UTI triggers diverse inflammatory reactions locally in the infected urinary bladder and kidney, causing tissue destruction and organ failure. Moreover, systemic responses in the entire body carry the risk of urosepsis with far-reaching consequences. Understanding the cell-, organ-, and systemic mechanisms in UTI are crucial for prevention, early intervention, and current therapeutic approaches. This review summarizes the scientific advances over the last 10 years concerning pathogenesis, prevention, rapid diagnosis, and new treatment approaches. We also highlight the impact of the immune system and potential new therapies to reduce progressive and recurrent UTI.

The diagnostic yield of the Meares & Stamey test can be significantly improved by symptom-based patient selection and the experience of the test performer

BACKGROUND

Even if Meares-Stamey 4-glass (M&S) test is regarded a decisive tool for diagnosing prostatitis its use is only rarely performed in everyday clinical practice. Here, we analyze if the diagnostic yield of the M&S test could be improved by a pre-test categorization of patients due to undergo a M&S test.

METHODS

All clinical and microbiological data of patients who underwent M&S test in two urological centers from January 2004 to December 2021 were analyzed in this retrospective cohort study. One center has a dedicated staff member for the study of prostatitis (Cohort I), while the other center is a general urological unit (Cohort II). All patients were divided into 3 groups on the basis of the assembled data: patients with symptoms related to prostatitis only (Group I), patients with symptoms related to both prostatitis and BPH (Group II), patients with symptoms related to BPH only (Group III). The rates of positive microbiological results in each group were compared.

RESULTS

In the whole period, 9347 patients were analyzed and categorized as follows: Group I, 1884; Group II, 5151; Group III, 2312. Three-thousand and eight-hundred twenty-three patients showed positive culture results (40.9%). The most common isolated species was Escherichia coli (49.7%), followed by Enteroccus spp. (31.8%). The rates of positive M&S tests in the different symptom groups were: Group I, 1532 (81.4%); Group II, 1494 (29.0%); Group III, 797 (34.4%). The overall rate of positive M&S tests in each urology center showed that the center with a staff member who is dedicated to prostatitis studies (Cohort I) had a significantly higher rate of positive M&S tests than the general urological department (Cohort II) (64.3% vs 31.4%; p < 0.001).

CONCLUSIONS

Symptom-based patient selection and dedicated staff members will increase the diagnostic yield of the M&S test and reduce the number of unnecessary tests.

[Urinary tract infections including pyelonephritis]

Urinary tract infections (UTIs) are among the most common bacterial infections. The clinical phenotypes of UTIs are heterogeneous, ranging from rather benign uncomplicated infections to complicated UTIs and pyelonephritis to severe urosepsis. There has been a sharp increase in the incidence of severe UTIs, whilst the incidence of sepsis in general is declining. The classifications of UTIs partially differ between clinical and regulatory claims. Experience has also been gained over the last few years to define the appropriate endpoints that are used in clinical studies. Above all, patient-centered evaluation strategies of the endpoints were developed, in order to be able to identify the advantages of new antibiotics compared to traditional antibiotics. The development of new antibiotics for UTIs is essential, since multidrug-resistant enterobacteria, which belong to the typical bacterial spectrum of UTIs, are frequently associated with mortality from infections. In recent years, several new antibiotics/combinations that are particularly effective against multi-resistant gram-negative pathogens have been investigated for the treatment of UTIs.

[New antibiotics for the treatment of urinary tract infections]

Urinary tract infections (UTIs) are among the most common bacterial infections. The clinical phenotypes of UTIs are heterogeneous, ranging from rather benign uncomplicated infections to complicated UTIs and pyelonephritis to severe urosepsis. Antibiotics have become indispensable in modern medicine, but the development of resistance is threatening clinical effectiveness. Antimicrobial resistance rates are locally high in UTIs, however can vary significantly depending on the population studied and the type of study. In addition, between 1990 and 2010, there was a discovery void in the development of new antibiotics that is still having an impact today. In recent years, UTIs have emerged as an infection model for research into novel antibiotics. In the last 10 years, novel gram-negative active drugs have been explored in these groups. On the one hand, novel beta-lactam/beta-lactamase inhibitor combinations were investigated, and there has also been further development of cephalosporins and aminoglycosides.

[Chronic prostatitis/chronic pelvic pain syndrome]

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is defined as chronic pain or discomfort in the pelvic region for at least 3 of the past 6 months. It is variably associated with lower urinary tract symptoms, psychosocial consequences, and sexual dysfunction. Specific test systems or biomarkers for a definitive diagnosis are still not available. The purposes of the basic diagnostic assessment are to determine the individual spectrum of symptoms and to rule out differential diagnoses of pelvic pain. Patient-reported outcome measures (PROMs) like the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) are valuable instruments for the initial diagnostic assessment and to evaluate treatment response. Classification systems like UPOINTS (urinary, psychosocial, organ specific, infection, neurologic/systemic, tenderness of skeletal muscles, sexual dysfunction) are valuable tools to determine the individual spectrum of symptoms, to guide the adapted diagnostic assessment, and to identify relevant targets for a multimodal and tailored treatment. Close urological monitoring of CP/CPPS patients is usually necessary, especially to minimize the unwarranted use of antibiotics in the case of undulating complaints.

Polish version of the Acute Cystitis Symptom Score for patients with acute uncomplicated cystitis

Introduction

The Acute Cystitis Symptom Score (ACSS) is a self-reporting questionnaire to evaluate the symptoms and quality of life in women with uncomplicated acute cystitis (AC). The aim of the current study was the additional cognitive and clinical validation of the Polish version.

Material and methods

Professional forward and backward translations from original Russian to Polish were performed by Mapi SAS. For cognitive assessment, women with different ages and educational levels were asked to comment on each item of the Polish ACSS to establish the final study version. The clinical validation was performed as a prospective, non-interventional cohort study. Women with AC (Patients) and those without (Controls) filled in the Polish ACSS during their visits to a physician's office and at a follow-up visit. Statistical analysis included ordinary descriptive values, calculation of reliability, validity, discriminative ability, responsiveness (sensitivity, specificity), and comparative analysis.

Results

The cognitive assessment was performed in 60 women with a median (range) age of 44.5 (21-88) years and different educational levels: grade school (n = 8), high school (n = 25), college (n = 22), and postgraduate education (n = 5). Forty-three patients were recruited for the clinical validation study along with 34 controls. Statistical analyses resulted in excellent values of internal consistency, discriminative ability, and validity for diagnosis of AC. At a summary score of 6 and higher in the ´Typical´ domain, positive and negative predictive values were 97% and 79%, and sensitivity and specificity were 79% and 97%, respectively.

Conclusions

The Polish version of the ACSS has demonstrated benefits for diagnosis and patient-reported outcome assessment. It is objective, fast, and cost-effective, and it may help to easily confirm the accurate diagnosis of AC. The Polish ASCSS can now be recommended for use in clinical and epidemiological studies, in clinical practice, or for self-diagnosis and patient-reported outcome in women with symptoms of AC.

Artificial Intelligence Can Guide Antibiotic Choice in Recurrent UTIs and Become an Important Aid to Improve Antimicrobial Stewardship

BACKGROUND

A correct approach to recurrent urinary tract infections (rUTIs) is an important pillar of antimicrobial stewardship. We aim to define an Artificial Neural Network (ANN) for predicting the clinical efficacy of the empiric antimicrobial treatment in women with rUTIs.

METHODS

We extracted clinical and microbiological data from 1043 women. We trained an ANN on 725 patients and validated it on 318.

RESULTS

The ANN showed a sensitivity of 87.8% and specificity of 97.3% in predicting the clinical efficacy of empirical therapy. The previous use of fluoroquinolones (HR = 4.23; p = 0.008) and cephalosporins (HR = 2.81; p = 0.003) as well as the presence of Escherichia coli with resistance against cotrimoxazole (HR = 3.54; p = 0.001) have been identified as the most important variables affecting the ANN output decision predicting the fluoroquinolones-based therapy failure. A previous isolation of Escherichia coli with resistance against fosfomycin (HR = 2.67; p = 0.001) and amoxicillin-clavulanic acid (HR = 1.94; p = 0.001) seems to be the most influential variable affecting the output decision predicting the cephalosporins- and cotrimoxazole-based therapy failure. The previously mentioned Escherichia coli with resistance against cotrimoxazole (HR = 2.35; p < 0.001) and amoxicillin-clavulanic acid (HR = 3.41; p = 0.007) seems to be the most influential variable affecting the output decision predicting the fosfomycin-based therapy failure.

CONCLUSIONS

ANNs seem to be an interesting tool to guide the antimicrobial choice in the management of rUTIs at the point of care.

[What is the proportion of infectiology in the specialization urology? : A pilot study to underline the significance of Antibiotic Stewardship in urology]

BACKGROUND

Urinary tract infections account for one of the most bacterial infectious diseases worldwide.

OBJECTIVES

The primary aim of this pilot project was to identify the relative percentage of antibiotic use in comparison to all patients in a university medical center for the better establishment of antibiotic stewardship (ABS) programs.

MATERIAL AND METHODS

This is an epidemiological pilot project. In the time period of three months it was evaluated which relative percentage of the patients was treated with antibiotics for bacterial urinary tract infection in comparison to all patients.

RESULTS

In summary, about 40% of all urological patients received an antibiotic treatment against urinary tract infections or as perioperative prophylaxis against bacterial infection in the operating room (OR). The antibiotic use at the urological ward is highest in comparison to ambulance or OR.

CONCLUSION

Infectious diseases, especially bacterial infections, account for a significant part of urology. This knowledge is essential to establish ABS programs and to tackle the progression of antibiotic resistance. Detailed studies are necessary to understand antibiotic prescription practice in urology to develop targeted ABS interventions.

Management of Recurrent Cystitis in Women: When Prompt Identification of Risk Factors Might Make a Difference

BACKGROUND

Management of recurrent urinary tract infection (rUTI) is still challenging. A better understanding of the natural history of rUTI could help us reduce antibiotic use and improve antibiotic stewardship.

OBJECTIVE

To describe the effect of risk identification, stratification, and counseling on the natural course of the disease in women with rUTI.

DESIGN, SETTING, AND PARTICIPANTS

A total of 373 women affected by recurrent cystitis were enrolled in this longitudinal cohort study between December 2014 and December 2019. A systematic and standardized identification of risk factors was performed.

INTERVENTION

As intervention, risk factors were treated or removed where possible. Patients with nonremovable risk factors were included in the control group. All patients were scheduled for follow-up visits every 6 mo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The main outcome measures were the rate of symptomatic recurrences and improvement in questionnaire results from baseline to the end of the follow-up period. Reduction of antibiotic usage was regarded as a secondary outcome measure.

RESULTS AND LIMITATIONS

Finally, 353 women were analyzed: 196 in the study group and 157 in the control group. At the end of the follow-up period, a statistically significant reduction in the symptomatic recurrence rate was found between the two groups (0.9 ± 0.2 and 2.6 ± 0.5; p < 0.001), as well as in quality of life and anxiety according to mean questionnaire results: quality of life (0.88 ± 0.06 and 0.63 ± 0.09; p < 0.001) and Spielberger State-Trait Anxiety Inventory-Form Y (32.7 ± 9.3 and 47.5 ± 14.3; p < 0.001). The use of antibiotics was significantly lower in the study group: 4410 versus 9821 (p < 0.001). A limitation to consider is the lack of a randomized design for the active approach in the high-risk group.

CONCLUSIONS

Identification, counseling, and removal of risk factors, where possible, are able to change the natural history of rUTI, by reducing the number of symptomatic episodes and antibiotic use and improving quality of life.

PATIENT SUMMARY

In this report, we analyzed a large cohort of women affected by recurrent urinary tract infections and followed for a long time period. We found that risk factor identification and counseling may change the natural history of recurrent urinary tract infections, concluding that this approach is able to reduce the number of symptomatic episodes, reduce antibiotic usage, and improve patients' quality of life.

[Urinary diversion for acute epididymitis : Transurethral or suprapubic catheter?]

Acute infective epididymitis is the most common cause for scrotal pain in adults. The severe course of the disease requires immediate antimicrobial management, comprised antibiotic treatment and supportive measures. Patients with chronic indwelling catheters and developing epididymitis show a more severe clinical course compared to patients without a catheter. Although it is common clinical practice to place a catheter for the treatment of a systemic infectious condition of the genitourinary tract, there is only limited evidence of support due to the absence of clinical trials.

Psychosocial burden of recurrent uncomplicated urinary tract infections

Introduction: Urinary tract infections (UTI) are a leading cause of bacterial infections in women. Despite acute treatment, 30-50% of women who have a UTI will experience a recurrence within 6-12 months. In this review, the focus will be on the personal psychosocial impacts of recurrent UTI. Methods: A PubMed/MEDLINE literature search was carried out from 2000 to 2020 in order to identify any recent high-quality meta-analyses or systematic reviews on these topics. Results: One systematic review was found appropriate for this manuscript. Concerning impact on quality of life (QoL) and daily activities, a reduced quality of both intimate and social relationships, self-esteem, and capacity for work was found due to recurrent UTI. Social function was substantially more reduced than physical function. In one study, the greatest reduction overall was in mental role functioning, whereas in another study, mental health reductions were not substantially greater than those of physical health. About one third of women suffered from UTI very often or often after sexual intercourse, and more than half of the patients stated that sexual relations were negatively influenced by UTI. Data from the GESPRIT study suggest that prophylaxis for recurrent UTI is underutilized, because less than 40% of the study population were offered prophylaxis after experiencing three UTI per year, despite all surveyed participants being willing to undertake at least one of the prophylactic measures listed in the survey. Conclusions: Little data on the psychosocial impact of recurrent UTI are available. Therefore, future studies must also incorporate QoL assessments as key outcome measures.

Translation and validation of the Korean version of acute cystitis symptom score

Purpose

Acute Cystitis Symptom Score (ACSS) is a simple self-reporting questionnaire initially developed in Uzbek language to help diagnose acute uncomplicated cystitis (AUC). The purpose of this study was to translate the ACSS to Korean and validate the Korean version of ACSS using Korean-speaking women.

Materials and Methods

The original version of ACSS in Uzbek was translated into the target (Korean) version according to internationally accepted guidelines for the translation and cultural adaptation. Cognitive interviews were then conducted for five women with symptoms of AUC and five women without AUC who were native speakers of the Korean language to investigate the clarity, understandability, and acceptability of the translation. The final Korean version of the ACSS was tested in 50 women (31 AUC patients and 19 controls) for clinical validation.

Results

Reliability test for 9 questions (6 questions about typical symptoms of AUC, and 3 questions on quality of life) showed high values (Cronbach’s alpha=0.853). The sum score of typical symptoms showed the highest balance for diagnostic sensitivity and specificity (area under the ROC curve=0.935). Sensitivity and specificity to predict AUC were 90.3% and 89.5% at cut-off score 6 of the typical domain.

Conclusions

The Korean version of the ACSS showed high levels of reliability and validity, similar to other validated versions in different languages. It will play an important role in practice and/or clinical research for diagnosis and treatment efficacy monitoring of Korean-speaking women suffering from AUC.

Clinical Validation of the Greek Version of the Acute Cystitis Symptom Score (ACSS)-Part II

The Acute Cystitis Symptom Score (ACSS) is a patient self-reporting questionnaire for the clinical diagnosis and patient-reported outcome (PRO) in women with acute uncomplicated cystitis (AC). The aim of the current study (part II) is the clinical validation of the Greek ACSS questionnaire. After linguistic validation according to internationally accepted guidelines and cognitive assessment (part I), the clinical validation was performed by using the Greek ACSS study version in 92 evaluable female participants including 53 patients with symptoms suspicious of AC and 39 controls. The clinical outcome using the ACSS questionnaire at different points in time after the start of treatment was demonstrated as well. The age (mean ± SD) of the 53 patients (44.7 ± 17.0 years) and 39 controls (49.3 ± 15.9 years) and their additional conditions at baseline visits, such as menstruation, premenstrual syndrome, pregnancy, menopause, diabetes mellitus, were comparable. There was, however, a significant difference (p < 0.001) between patients and controls at baseline visit regarding sum score of the ACSS domains, such as typical symptoms and quality of life. The clinical outcome of up to 7 days showed a fast reduction of the symptom scores and improvement of quality of life. The optimal thresholds for the patient-reported outcome of successful therapy could be established. The linguistically and clinically validated Greek ACSS questionnaire can now be used for clinical or epidemiological studies and also for patients' self-diagnosis of AC and as a PRO measure tool.

Linguistic and clinical validation of the acute cystitis symptom score in German-speaking Swiss women with acute cystitis

INTRODUCTION AND HYPOTHESIS

The Global Prevalence Study of Infections in Urinary tract in Community Setting (GPIU.COM) includes epidemiological aspects of acute cystitis (AC) in women in Germany and Switzerland. The primary study relates to the German version of the Acute Cystitis Symptom Score (ACSS), a self-reporting questionnaire for self-diagnosis and monitoring the symptomatic course of AC in women. The current study aimed to analyze the validity and reliability of the German ACSS in German-speaking female patients with AC in Switzerland.

METHODS

Anonymized patient data were collected and analyzed from women with AC at the first visit (diagnosis) and follow-up visits as baseline and controls, respectively. Data from 97 patients with a median age of 41 years underwent analysis. Psychometric and diagnostic characteristics of the ACSS were measured and statistically analyzed.

RESULTS

Average internal consistency of the ACSS resulted in a Cronbach's alpha (95% CI) of 0.86 (0.83; 0.89) and did not differ significantly between the Swiss and German cohorts. Diagnostic values of the ACSS for the Swiss cohort were relatively lower than for the German cohort, possible due to discrepancies between definitions of UTI in national guidelines.

CONCLUSIONS

The analysis showed that the German version of the ACSS is also suitable for use in the German-speaking female population of Switzerland. Minor differences in definitions of AC between German and Swiss guidelines explain the observed discrepancies in diagnostic values of the ACSS between cohorts.

Anti-Biofilm Effect of Octenidine and Polyhexanide on Uropathogenic Biofilm-Producing Bacteria

BACKGROUND

A catheter allowing a release of antibacterial substances such as antiseptics into the bladder could be a new way of preventing biofilm formation and subsequent catheter-associated urinary tract infections.

METHODS

Minimal inhibitory and bactericidal concentration (MIC/MBC) determinations in cation-adjusted Mueller-Hinton broth and artificial urine were performed for 4 antiseptics against 3 uropathogenic biofilm producers, Escherichia coli, Pseudomonas aeruginosa, and Proteus mirabilis. Furthermore, effects of octenidine and polyhexanide against catheter biofilm formation were determined by quantification of biofilm-producing bacteria.

RESULTS

Sodium hypochlorite showed MIC/MBC values between 200 and 800 mg/L for all strains tested. Triclosan was efficient against E. coli and P. mirabilis (MIC ≤2.98 mg/L) but ineffective against P. aeruginosa. Octenidine and polyhexanide showed antibacterial activity against all 3 species tested (MIC 1.95-7.8 and 3.9-31.25 mg/L). Both octenidine and polyhexanide were able to prevent biofilm formation on catheter segments in a concentration dependent manner. Furthermore, adding 250 mg/L of each biocide disrupted biofilms formed by E. coli and P. mirabilis, whereas even 500 mg/L was not sufficient to completely destroy P. aeruginosa biofilms.

CONCLUSION

Octenidine- and polyhexanide-containing antiseptics showed a broad effect against typical uropathogenic biofilm producers even in high dilutions. This study provides a basis for further investigation of the potential of octenidine and polyhexanide as prophylaxis or treatment of catheter biofilms.

[Complicated urinary tract infections]

Urinary tract infections (UTIs) are among the most common bacterial infections in Germany, both in outpatient and inpatient settings. The clinical spectrum is heterogeneous and ranges from benign, often self-limiting, uncomplicated infections to complicated urinary tract infections (cUTIs) with life-threatening courses. Complicated urinary tract infections have a higher risk of chronicity, recurrence and/or progression than uncomplicated infections and may be associated with severe disease progression. Stratification of patients with urinary tract infections is, therefore, of utmost importance. Host factors rather than pathogen attributes determine the pathophysiology and therapy of complicated urinary tract infections and pyelonephritis. Complicated UTIs and pyelonephritis are also associated with high rates of antimicrobial resistance in the causative pathogens, so they should be given particular emphasis.

Hyperbaric Oxygenation in the Treatment of Fournier's Gangrene: A Systematic Review

INTRODUCTION

Fournier's gangrene (FG) is a sporadic, life-threatening, necrotizing infection affecting the perineum, perineal region, and genitals. Hyperbaric oxygenation (HBO) improves tissue perfusion and promotes angiogenesis and collagen synthesis. Despite these positive effects of HBO, the indication and the effects on outcome as adjunct therapy in FG remain controversial. Consequently, we decided to perform a systematic review to compare the treatment of FG with or without the use of HBO as an adjunct therapy.

MATERIALS AND METHODS

We performed a systematic review following the recommendations provided in the Cochrane Handbook of systematic Reviews and the PRISMA reporting guidelines. Due to the paucity of data and a suspected lack of randomized controlled trials, we considered all the available information for this systematic review.

RESULTS

The literature search for primary studies yielded 79 results. Finally, 13 studies were considered, which included a total of 376 patients with FG, of whom 202 received HBO therapy. Five of these studies had a retrospective case-control design. However, these 5 studies included a total of 319 patients; 145 of these patients were treated with adjunct HBO therapy. Overall, this leads to a mortality rate of 16.6% in the HBO group and 25.9% in the non-HBO group. Overall, risk of bias was assessed as moderate to high.

CONCLUSIONS

We conclude that despite the risk of bias, HBO has potential as an adjunct in FG treatment, but it is challenging to carry out further studies, mainly due to the rareness of FG and availability of HBO.

Escherichia coli Resistance to Fluoroquinolones in Community-Acquired Uncomplicated Urinary Tract Infection in Women: a Systematic Review

Antibiotic resistance is a threat to public health, and uncomplicated urinary tract infections (uUTIs) are an example of this concern. This systematic review (International Prospective Register of Systematic Reviews [PROSPERO] ID: CRD42020156674) is the first to determine the prevalence of Escherichia coli resistance to fluoroquinolones in women with community-acquired uUTI. PubMed and Embase searches were conducted; 38 studies fulfilled eligibility criteria and were included in the systematic review. Within Europe, ciprofloxacin resistance in E. coli isolates varied between countries and increased in some from 2006 to 2008 and 2014 to 2016, specifically in the United Kingdom (0.5% to 15.3%), Germany (8.7% to 15.1%), and Spain (22.9% to 30.8%), although methodologies and settings were often not comparable. In Asia, there was a substantial increase in ciprofloxacin resistance during 2008 to 2014 from 25% to more than 40%. In North America, resistance to ciprofloxacin also increased between 2008 and 2017, from 4% to 12%. Data exploring different age groups did not show a consistent relationship with resistance, whereas two studies found that fluoroquinolone resistance was higher in postmenopausal women than premenopausal women. One study indicated a link between fluoroquinolone resistance and uUTI recurrence. These findings may have implications for the empirical treatment of uUTI with fluoroquinolones globally, but more data are needed to fully understand regional situations and impact patient management.

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

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

Effect of Different Media on the Bactericidal Activity of Colistin and on the Synergistic Combination With Azidothymidine Against mcr-1-Positive Colistin-Resistant Escherichia coli

Antimicrobial susceptibility testing (AST) performed according to defined guidelines is important to identify resistance and to predict the clinical success or failure of specific antibiotic therapy. However, these guidelines do not cover all physiological conditions that can have a tremendous impact on in vivo resistance. In this study, we tested the susceptibility of thirteen mcr-1-positive Escherichia coli strains against colistin, one of the last resort antibiotics for treating multi-drug resistant pathogens, in media recommended for ASTs as well as – physiologically more relevant – in human serum and artificial urine (AU). Minimal inhibitory concentration (MIC) values in heat-inactivated human serum were similar to those in cation-adjusted Mueller-Hinton broth (CAMHB), but reduced in native serum for almost all strains that could grow in this media. In AU MIC values for mcr-1 positive E. coli were increased significantly up to 16-fold compared to that in CAMBH, which did not apply to the colistin-susceptible E. coli strains tested. Although different growth media could affect the MIC of colistin alone, their impact on the synergistic effect of the combination with the antiviral drug azidothymidine was minimal. The higher divalent cation concentration combined with acidic pH values is most likely responsible for the increased MIC values of the mcr-1 harboring E. coli strains tested against colistin in AU compared to that in CAMHB. Antimicrobial susceptibility screening procedures for colistin using CAMHB only could lead to an underestimation of resistance under different physiological conditions. Therefore, not only pharmacokinetic but also pharmacodynamic studies in urine are as important as in serum or plasma.

Once-Daily Plazomicin for Complicated Urinary Tract Infections

BACKGROUND

The increasing multidrug resistance among gram-negative uropathogens necessitates new treatments for serious infections. Plazomicin is an aminoglycoside with bactericidal activity against multidrug-resistant (including carbapenem-resistant) Enterobacteriaceae.

METHODS

We randomly assigned 609 patients with complicated urinary tract infections (UTIs), including acute pyelonephritis, in a 1:1 ratio to receive intravenous plazomicin (15 mg per kilogram of body weight once daily) or meropenem (1 g every 8 hours), with optional oral step-down therapy after at least 4 days of intravenous therapy, for a total of 7 to 10 days of therapy. The primary objective was to show the noninferiority of plazomicin to meropenem in the treatment of complicated UTIs, including acute pyelonephritis, with a noninferiority margin of 15 percentage points. The primary end points were composite cure (clinical cure and microbiologic eradication) at day 5 and at the test-of-cure visit (15 to 19 days after initiation of therapy) in the microbiologic modified intention-to-treat population.

RESULTS

Plazomicin was noninferior to meropenem with respect to the primary efficacy end points. At day 5, composite cure was observed in 88.0% of the patients (168 of 191 patients) in the plazomicin group and in 91.4% (180 of 197 patients) in the meropenem group (difference, -3.4 percentage points; 95% confidence interval [CI], -10.0 to 3.1). At the test-of-cure visit, composite cure was observed in 81.7% (156 of 191 patients) and 70.1% (138 of 197 patients), respectively (difference, 11.6 percentage points; 95% CI, 2.7 to 20.3). At the test-of-cure visit, a higher percentage of patients in the plazomicin group than in the meropenem group were found to have microbiologic eradication, including eradication of Enterobacteriaceae that were not susceptible to aminoglycosides (78.8% vs. 68.6%) and Enterobacteriaceae that produce extended-spectrum β-lactamases (82.4% vs. 75.0%). At late follow-up (24 to 32 days after initiation of therapy), fewer patients in the plazomicin group than in the meropenem group had microbiologic recurrence (3.7% vs. 8.1%) or clinical relapse (1.6% vs. 7.1%). Increases in serum creatinine levels of 0.5 mg or more per deciliter (≥40 μmol per liter) above baseline occurred in 7.0% of patients in the plazomicin group and in 4.0% in the meropenem group.

CONCLUSIONS

Once-daily plazomicin was noninferior to meropenem for the treatment of complicated UTIs and acute pyelonephritis caused by Enterobacteriaceae, including multidrug-resistant strains. (Funded by Achaogen and the Biomedical Advanced Research and Development Authority; EPIC ClinicalTrials.gov number, NCT02486627.).

Multidisciplinary approach to prostatitis

The modern clinical research on prostatitis started with the work of Stamey and coworkers who developed the basic principles we are still using. They established the segmented culture technique for localizing the infections in the males to the urethra, the bladder, or the prostate and to differentiate the main categories of prostatitis. Such categories with slight modifications are still used according to the NIH classification: acute bacterial prostatitis, chronic bacterial prostatitis, Chronic Pelvic Pain Syndrome (CPPS) and asymptomatic prostatitis. Prostatic inflammation is considered an important factor in influencing both prostatic growth and progression of symptoms of benign prostatic hyperplasia and prostatitis. Chronic inflammation/neuroinflammation is a result of a deregulated acute phase response of the innate immune system affecting surrounding neural tissue at molecular, structural and functional levels. Clinical observations suggest that chronic inflammation correlates with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and benign prostatic hyperplasia (BPH) and an history of clinical chronic prostatitis significantly increases the odds for prostate cancer. The NIHNIDDK classification based on the use of the microbiological 4- glasses localization test or simplified 2-glasses test, is currently accepted worldwide. The UPOINT system identifies groups of clinicians with homogeneous clinical presentation and is used to recognize phenotypes to be submitted to specific treatments. The UPOINTS algorithm implemented the original UPOINT adding to the urinary domains (U), psycho-social (P), organspecific (O), infection (I), neurological (N), muscle tension and tenderness (T) a further domain related to sexuality (S). In fact sexual dysfunction (erectile, ejaculatory, libido loss) has been described in 46-92% of cases with a high impact on the quality of life of patients with CP/CPPS. Prostatic ultrasound represents the most popular imaging test in the work-up of either acute and chronic prostatitis although no specific hypo-hyperechoic pattern has been clearly associated with chronic bacterial prostatitis and CPPS. Use of a digital-processing software to calculate the extension of prostatic calcification area at ultrasound demonstrated a higher percentage of prostatic calcification in patients with chronic bacterial prostatitis. Multiparametric Magnetic Resonance Imaging (mpMRI) is the current state-of-the art imaging modality in the assessment of patients with prostate cancer although a variety of benign conditions, including inflammation, may mimic prostate cancer and act as confounding factors in the discrimination between neoplastic and non-neoplastic lesions. Bacteria can infect prostate gland by: ascending the urethra, reflux of urine into the prostatic ducts, direct inoculation of bacteria through inserted biopsy needles or hematogenous seeding. Enterobacteriaceae are the predominant pathogens in acute and chronic bacterial prostatitis, but an increasing role of Enterococci has been reported. Many strains of these uropathogens exhibit the ability to form biofilm and multidrug- resistance. Sexually Transmitted Infections (STI) agents, in particular Chlamydia trachomatis and Mycoplasma genitalium, have been also considered as causative pathogens of chronic bacterial prostatitis. On the contrary the effective role in genital diseases of other "genital mycoplasmas" is still a much debated issue. Sexually Transmitted Infections agents should be investigated by molecular methods in both patient and sexual partner. "Next generation" investigations, such as cytokine analysis, cytological typing of immune cells could help stratifying the immune response. Epigenetic dysregulation of inflammatory factors should be investigated according to systemic and compartment-specific signals. The search for biomarkers should also include evaluation of hormonal pathways, as measurement of estrogen levels in semen. Antimicrobials are the first line agents for the treatment of bacterial prostatitis. The success of antimicrobial treatment depends on the antibacterial activity and the pharmacokinetic characteristics of the drug which must reach high concentrations in prostate secretion and prostate tissue. Acute bacterial prostatitis can be a serious infection with a potential risk for urosepsis For iInitial treatment of severely ill patients, intravenous administration of high doses of bactericidal antimicrobials, such as broad-spectrum penicillins, third-generation cephalosporins or fluoroquinolones, is recommended in combination with an aminoglycoside. Use of piperacillin-tazobactam and meropenem is justified in presence of multiresistant gramnegative pathogens. The antibiotic treatment of chronic prostatitis is currently based on the use of fluoroquinolones that, given for 2 to 4 weeks, cured about 70% of men with chronic bacterial prostatitis. For the treatment of Chlamydial prostatitis macrolides were shown to be more effective than fluoroquinolones, whereas no differences were observed in microbiological and clinical efficacy between macrolides and tetracyclines for the treatment of infections caused by intracellular pathogens. Aminoglycosides and fosfomycin could be considered as a therapeutic alternative for the treatment of quinolone resistant prostatitis. Use of alpha-blockers in CP/CPPS patients with urinary symptoms and analgesics +/- non steroidal anti-inflammatory drugs (NSAID), in presence of pain demonstrated a reduction of symptoms reduction and an improvement of quality of life, although long term use of NSAID is limited by side effect profile. However, the multimodal therapeutic regimen by contemporary use of alphablockers, antibiotics and anti-inflammatory showed a better control of prostatitis symptoms than single drug treatment. Novel therapeutic substances for the treatment of pain, such as the cannabinoid anandamide would be highly interesting to test. An alternative for the treatment of chronic prostatitis/chronic pelvic pain syndrome is phytotherapy, as primary therapy or in association with other drugs. Quercetin, pollen extract, extract of Serenoa repens and other mixtures of herbal extracts showed a positive effect on symptoms and quality of life without side effects. The association of CP/CPPS with alterations of intestinal function has been described. Diet has its effects on inflammation by regulation of the composition of intestinal flora and direct action on the intestinal cells (sterile inflammation). Intestinal bacteria (microbiota) interacts with food influencing the metabolic, immune and inflammatory response of the organism. The intestinal microbiota has protective function against pathogenic bacteria, metabolic function by synthesis of vitamins, decomposition of bile acids and production of trophic factors (butyrate), and modulation of the intestinal immune system. The alteration of the microbiota is called "dysbiosis" causing invasive intestinal diseases pathologies (leaky gut syndrome and food intolerances, irritable bowel syndrome or chronic inflammatory bowel diseases) and correlating with numerous systemic diseases including acute and chronic prostatitis. Administration of live probiotics bacteria can be used to regulate the balance if intestinal flora. Sessions of hydrocolontherapy can represent an integration to this therapeutic approach. Finally, microbiological examination of sexual partners can offer supplementary information for treatment.

Management of Urethritis: Is It Still the Time for Empirical Antibiotic Treatments?

CONTEXT

Urethritis prevalence in Europe changed in the last years due to both the increase of migratory streams from North Africa and the more frequent exposition of males to relevant risk factors. Owing to these reasons, urethritis treatment should be optimized by accurate microbiological investigations to avoid the risk of persistence, recurrence, or reinfection.

OBJECTIVE

The aim of this systematic review is to optimize the treatments for urethritis and investigate the applicability of nucleic acid amplification test (NAAT) as the primary microbiological investigation.

EVIDENCE ACQUISITION

A literature search in Medline, Cochrane, and Google Scholar databases was conducted up to June 2018. Subject headings were selected as follows: Urethritis OR gonococcal urethritis OR non-gonococcal urethritis AND Antibiotics OR Recurrence. A total of 528 abstracts were identified and selected. Finally, 12 full-text articles were selected for a qualitative synthesis. The Preferred Reported Items for Systematic Reviews and Meta-Analyses statement was used to perform an accurate research checklist and report.

EVIDENCE SYNTHESIS

Empirical treatments are no more recommended, although a broad spectrum of antibiotic therapy may be initiated while awaiting the results from pathogens' microbiological characterization. First-line treatment for gonococcal urethritis consists of a single dose of ceftriaxone/azithromycin combined therapy. Specific therapies should be initiated for nongonococcal urethritis according to each single pathogen involved in the infection process. Owing to this reason, NAAT is mandatory in the clinical approach to the disease, although the Gram stain of urethral discharge or smear remains applicable for some less frequent nongonococcal urethritis. Moreover, the urethritis "modern view" also includes noninfectious etiologies that occurred after traumas or injection of irritating compounds. Sexual abstinence of at least 7 d should be observed from the start of treatment to avoid reinfection, while sexual partners should evenly be treated.

CONCLUSIONS

The treatment of urethritis implies accurate determination of pathogens involved in the infection process by NAAT with subsequent appropriate antibiotic therapy, thus avoiding the risk of antibiotic resistance and overuse of antibiotics indicated for empirical treatments. The population exposed to relevant risk factors should be adequately informed about the increased risk of developing infections and motivated toward the intensive use of condoms during sexual intercourses.

PATIENT SUMMARY

Urethritis is a sexually transmitted disease generally characterized by urethral discharge or other symptoms such as itching, tingling, and apparent difficulties in having a regular urinary flow. Microbiological investigations are mandatory to obtain satisfactory results from the treatment. Multiple antibiotic treatments are often necessary due to the high risk of multiple pathogens responsible for the disease. Similarly, sexual partners should be investigated and treated in the same way. Several risk factors such as immunodeficiency, multiple sexual partners, homo- and bisexuality, and alcohol abuse may be related to the disease. In these cases, the use of condom is strongly recommended.

Comparison of fosfomycin against fluoroquinolones for transrectal prostate biopsy prophylaxis: an individual patient-data meta-analysis

PURPOSE

To systematically review and meta-analyse available evidence comparing fosfomycin trometamol (FT) to fluoroquinolone (FQ) prophylaxis to prevent transrectal ultrasound-guided prostate biopsy (TRUSPB) related infectious complications.

METHODS

Electronic databases were queried for studies comparing FT to FQ-based TRUSPB prophylaxis. Studies were assessed for comparable outcomes and methodological quality (ROBINS-I modification). The primary outcome measure was the relative odds of overall infectious complications following TRUSPB according to FT/FQ treatment, which was evaluated with meta-analysis. Safety and tolerability were also assessed. The relative odds of infections of different severity [Grade 1, bacteriuria and afebrile urinary tract infection (UTI); Grade 2, bacteraemia, febrile UTI, and urosepsis] according to FT/FQ treatment were also estimated.

RESULTS

Five studies, being three prospective randomised trials and two retrospective cohort studies, representing 3112 patients, were included. The relative odds of an infectious complication (OR 0.22, 95% CI 0.09-0.54) or of a more severe (Grade 2) infection (OR 0.13, 95% CI 0.07-0.26) were significantly lower in those receiving FT compared to FQ prophylaxis. A low incidence of medication-related side effects was observed. There were less observed infections due to FQ-resistant pathogens in those receiving FT prophylaxis.

CONCLUSIONS

Patients who received FT prophylaxis were less likely than those who received FQ prophylaxis to develop infections overall, as well as severe and resistant infections after TRUSPB. Assessing the performance of FT in other geographic locations or in comparison to targeted prophylaxis based on risk assessment or rectal cultures is desired.

The role of nutraceuticals and phytotherapy in the management of urinary tract infections: What we need to know?

Urinary Tract Infections (UTIs) are amongst the most common infectious diseases and carry a significant impact on patient quality of life and health care costs. Despite that, there is no well-established recommendation for a "standard" prophylactic antibiotic management to prevent UTI recurrences. The majority of patients undergoes long-term antibiotic treatment that severely impairs the normal microbiota and increases the risk of development of multidrugresistant microorganisms. In this scenario, the use of phytotherapy to both alleviate symptoms related to UTI and decrease the rate of symptomatic recurrences is an attractive alternative. Several recently published papers report conflicting findings and cannot give confident recommendations for the everyday clinical practice. A new approach to the management of patients with recurrent UTI might be to use nutraceuticals or phytotherapy after an accurate assessment of the patient`s risk factors. No single compound or mixture has been identified so far as the best preventive approach in patients with recurrent UTI. We reviewed our non-antibiotic approach to the management of recurrent UTI patients in order to clarify the evidence-base for the commonly used substances, understand their pharmacokinetics and pharmacodynamics in order to tailor the best way to improve patient's quality of life and reduce the rate of antibiotic resistance. Lack of a gold-standard recommendation and the risk of increasing antibiotic resistance is the reason why we need alternatives to antibiotics in the management of urinary tract infections (UTIs). A tailored approach according to bacterial characteristics and the patient risk factors profile is a promising option.

The role of the Acute Cystitis Symptom Score questionnaire for research and antimicrobial stewardship. Validation of the Hungarian version

Introduction

The Acute Cystitis Symptom Score (ACSS) is a new self-reporting tool to evaluate the symptoms of uncomplicated acute cystitis (AC) in women. The linguistic and clinical validation process of the Hungarian version used in this study may serve as a guide for the validation of the ACSS in other languages.

Material and methods

In this prospective cohort study, women with AC (Patients) and those without (Controls) filled in the Hungarian ACSS version, during their visits to physician's office. Statistical analysis included ordinary descriptive values, calculation of reliability, validity, discriminative ability, responsiveness (sensitivity, specificity) and comparative analysis.

Results

Thirty-one patients were recruited for validation along with 37 controls. Statistical analyses resulted in excellent values of internal consistency, discriminative ability and validity for diagnosis of AC. At the cut-off at a score of 6 in the 'typical' domain, positive and negative predictive values were 97% and 92%, sensitivity and specificity were 90% and 97%, respectively.

Conclusions

The ACSS has demonstrated benefits for diagnosis and patient-reported outcome assessment. It is objective, fast, and cost-effective, and may help to easily confirm the accurate diagnosis of AC. Therefore, it may be especially important for clinical and epidemiological studies on AC in women.

Is Preoperative Assessment and Treatment of Asymptomatic Bacteriuria Necessary for Reducing the Risk of Postoperative Symptomatic Urinary Tract Infections After Urologic Surgical Procedures?

OBJECTIVE

To evaluate whether it is always necessary to test for the presence of asymptomatic bacteriuria (AB) in patients undergoing urologic surgical procedures, and if present, whether to treat AB with antimicrobial prophylaxis.

MATERIALS AND METHODS

All patients who underwent urologic surgical procedures from December 2008 to October 2013 in a tertiary referral urologic center were considered for this study. All patients received antimicrobial prophylaxis in line with European Association of Urology guidelines on urologic infections. AB was diagnosed if ≥10⁵ colony-forming units/mL were cultured. The population was subdivided into 2 groups: group A, patients with preoperative AB, and group B, patients without AB. Data on postoperative symptomatic urinary tract infections (UTIs) were compared for the 2 groups.

RESULTS

A total of 2201 patients were considered eligible for this study and were analyzed; 668 (30.4%) patients were found to harbor AB (group A), and 1533 (69.6%) patients did not have AB (group B). Microbiologically verified symptomatic postoperative UTIs occurred in 198 patients (8.9%). No difference in terms of overall rate of postoperative symptomatic UTI was found between the 2 groups (group A: 70 [10.4%] and group B: 128 [8.3%]; OR: 1.28 95%CI 0.94-1.74; P = .12), as well as in terms of urosepsis (group A: 2 [0.30%] and group B: 4 [0.26%]; P = 1.0).

CONCLUSION

In patients undergoing urologic surgical procedures who are receiving antimicrobial prophylaxis in accordance with European Association of Urology guidelines, the preoperative presence of AB in this study was not associated with a higher incidence of postoperative symptomatic UTI.

Chronic Prostatitis Affects Male Reproductive Health and Is Associated with Systemic and Local Epigenetic Inactivation of C-X-C Motif Chemokine 12 Receptor C-X-C Chemokine Receptor Type 4

Background/Aims/Objectives: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has detrimental effects on the quality of life including the aspect of sexual dysfunction. The aim of the study was to identify if there was an adverse effect on the male genital compartment and if there are systemic or compartment-specific local signals for epigenetic dysregulation of inflammatory factors in CP/CPPS patients.

METHODS

One hundred five NIH IIIb CP/CPPS patients and 41 healthy men were recruited and underwent investigations of urines, semen and blood. Promoter methylation and expression of the chemokine C-X-C motif chemokine 12 and its receptor C-X-C chemokine receptor type 4 (CXCR4) (involved in the recruitment of mast cells) were analyzed in prostate epithelial cell lines and in healthy volunteers' and patients' blood, ejaculate cell pellets, and separated ejaculate fractions (sperm and seminal somatic cells).

RESULTS

Independently from age, CP/CPPS NIH IIIb was associated with significant impairment of sperm motility, morphology and semen pH (p < 0.001). Patients older than 33 years showed significantly increased seminal interleukin-8 and serum prostate specific antigen values. In patients, the CXCR4 mRNA-expression was significantly decreased in whole blood and ejaculate cell pellets due to promoter hypermethylation. Analyses on separated fractions of sperm and seminal somatic cells revealed that sperm DNA was unaffected, whereas somatic cell DNA was differentially methylated.

CONCLUSIONS

NIH IIIb CP/CPPS has negative effects on surrogate parameters of male fertility and is associated significantly with systemic and local epigenetic inactivation of CXCR4.

The Acute Cystitis Symptom Score for Patient-Reported Outcome Assessment

OBJECTIVES

The Acute Cystitis Symptom Score (ACSS) was developed as a self-reporting questionnaire for clinical diagnosis of acute uncomplicated cystitis (AUC) and symptomatic changes in female patients. The aim of the present study was to assess the utility of the different domains of ACSS including the 'dynamics' domain after therapy. The applicability of these domains in assessing changes in symptoms, as a function of time, in this population was investigated.

MATERIALS AND METHODS

During the validation process of the ACSS in Uzbek and Russian languages, a subgroup of patients (n = 63) returned after therapy and filled in part B of ACSS. Descriptive statistics were used, where suitable.

RESULTS

The reduction of typical symptoms and quality of life (QoL) assessment between first and follow-up visit correlated significantly with answers in the 'dynamics' domain. Success/cure and non-success/failure could be clearly differentiated by the scores obtained in 'typical' and 'QoL' domains.

CONCLUSION

The ACSS has proven to be a useful instrument to clinically diagnose AUC in women. It is also a suitable instrument for patient-reported outcome assessment, with applicability in both daily practice and in clinical studies. Slight modifications in the 'dynamics' domain will even increase the applicability.

Antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy: fosfomycin trometamol, an attractive alternative

OBJECTIVE

To compare fosfomycin trometamol (FT) and ciprofloxacin (CIP) for antibiotic prophylaxis in transrectal prostate biopsy (TR-PB).

PATIENTS AND METHODS

Data for 1109 patients (mean age 66.7 ± 8.45) who underwent TR-PB between March to September 2015 in seven Italian urological institutions were retrospectively reviewed, of which 632 received FT (Group 1) and 477 received CIP (Group 2) for prophylaxis. We reviewed all urine culture results obtained after the procedure, all adverse drug reactions (ADRs) related to the drug and all febrile and/or symptomatic urinary tract infections (UTIs) occurring within 1 month after TR-PB. The rate of symptomatic UTIs and the rate of ADRs were considered the main outcome measures.

RESULTS

In the total study population, 72/1109 (6.5 %) patients experienced symptomatic UTIs and among these 11 (0.9 % of total) had urosepsis. Out of 72, 53 (73.6 %) symptomatic UTIs were caused by fluoroquinolone-resistant strains. Out of 632, 10 (1.6 %) patients in Group 1 and 62/477 (12.9 %) patients in Group 2 had symptomatic UTIs (p < 0.001); in particular, 2/632 (0.3 %) patients in Group 1 and 9/477 (1.8 %) patients in Group 2 had urosepsis (p < 0.001). No differences were reported in terms of adverse events (0.6 vs 0.4 %; p = 0.70). A Charlson comorbidity index ≤1 and type of antimicrobial prophylaxis (FT) were found to be associated with a lower probability of symptomatic UTIs in the multivariate model.

CONCLUSIONS

Antibiotic prophylaxis with FT for TR-PB had a lower rate of adverse events and a lower rate of symptomatic UTIs as compared with CIP. Fosfomycin trometamol appears as an attractive alternative prophylactic regimen in prostate biopsies.

How to Use Antimicrobial Prophylaxis in Urological Procedures

A revision of clinical practice in terms of antimicrobial prophylaxis is urgently needed starting from: (1) obtaining information about local pathogen profiles and antimicrobial resistance, (2) evaluating all patient-related risk factors for the development of infectious complications, (3) and prescribing antimicrobials according to the principles of the European Association of Urology guidelines.

[Urinary tract infections in the elderly]

Urinary tract infections (UTIs) and asymptomatic bacteriuria are frequent in elderly patients. Distinguishing UTI from asymptomatic bacteriuria in older adults, particularly those living in long-term care facilities, might be a challenge for physicians due to the presence of confounding factors, such as an overactive bladder, prostate enlargement, and an indwelling bladder catheter. The absence of standards in the definition and treatment of UTI in the elderly frequently leads to overtreatment. Consequently, antibiotic selection pressure increases and as a result multidrug-resistant organisms might arise. On the other hand, insufficient treatment can result in prolonged and complicated courses of infections or increased morbidity. This review covers the definition, prevalence, diagnosis and management of UTI in older adults.

Contemporary Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome

CONTEXT

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common condition that causes severe symptoms, bother, and quality-of-life impact in the 8.2% of men who are believed to be affected. Research suggests a complex pathophysiology underlying this syndrome that is mirrored by its heterogeneous clinical presentation. Management of patients diagnosed with CP/CPPS has always been a formidable task in clinical practice. Due to its enigmatic etiology, a plethora of clinical trials failed to identify an efficient monotherapy.

OBJECTIVE

A comprehensive review of published randomized controlled trials (RCTs) on the treatment of CP/CPPS and practical best evidence recommendations for management.

EVIDENCE ACQUISITION

Medline and the Cochrane database were screened for RCTs on the treatment of CP/CPPS from 1998 to December 2014, using the National Institutes of Health Chronic Prostatitis Symptom Index as an objective outcome measure. Published data in concert with expert opinion were used to formulate a practical best evidence statement for the management of CP/CPPS.

EVIDENCE SYNTHESIS

Twenty-eight RCTs identified were eligible for this review and presented. Trials evaluating antibiotics, α-blockers, anti-inflammatory and immune-modulating substances, hormonal agents, phytotherapeutics, neuromodulatory drugs, agents that modify bladder function, and physical treatment options failed to reveal a clear therapeutic benefit. With its multifactorial pathophysiology and its various clinical presentations, the management of CP/CPPS demands a phenotypic-directed approach addressing the individual clinical profile of each patient. Different categorization algorithms have been proposed. First studies applying the UPOINTs classification system provided promising results. Introducing three index patients with CP/CPPS, we present practical best evidence recommendations for management.

CONCLUSIONS

Our current understanding of the pathophysiology underlying CP/CPPS resulting in this highly variable syndrome does not speak in favor of a monotherapy for management. No efficient monotherapeutic option is available. The best evidence-based management of CP/CPPS strongly suggests a multimodal therapeutic approach addressing the individual clinical phenotypic profile.

PATIENT SUMMARY

Chronic prostatitis/chronic pelvic pain syndrome presents a variable syndrome. Successful management of this condition is challenging. It appears that a tailored treatment strategy addressing individual patient characteristics is more effective than one single therapy.

A Randomized, Double-Blind, Parallel-Group, Multicenter Clinical Study of Escherichia coli-Lyophilized Lysate for the Prophylaxis of Recurrent Uncomplicated Urinary Tract Infections

BACKGROUND

One strategy for managing recurrent uncomplicated urinary tract infections (UTIs) is prevention. This study tested OM-89S, a lyophilized lysate of 18 Escherichia coli strains manufactured using a modified lytic process.

METHODS

This was a randomized, double-blind trial in 451 female subjects with recurrent uncomplicated UTIs. Period 1 of the study tested 6 mg of OM-89S versus placebo (3 months), plus a 3-month observation. Period 2 of the study was a 3-month treatment period (each monthly cycle consisted of 6 mg of OM-89S daily for 10 days and placebo for 20 days, vs. 50 mg nitrofurantoin daily for 30 days), plus a 3-month observation.

RESULTS

There was no difference in the mean rate of UTI episodes between the OM-89S (0.66 ± 0.93) and placebo groups (0.63 ± 0.86; p = 0.95) in period 1. Similar findings were obtained for period 2. OM-89S was well-tolerated.

CONCLUSIONS

Our results did not demonstrate a preventive effect of OM-89S compared to placebo. This may be due to the low number of UTIs that occurred during the study, the high number of protocol violations, and/or the modified manufacturing process used for OM-89S.

Multimodal therapy for category III chronic prostatitis/chronic pelvic pain syndrome in UPOINTS phenotyped patients

The complex network of etiological factors, signals and tissue responses involved in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) cannot be successfully targeted by a single therapeutic agent. Multimodal approaches to the therapy of CP/CPPS have been and are currently being tested, as in the frame of complex diagnostic-therapeutic phenotypic approaches such as the urinary, psychosocial, organ-specific, infection, neurological and muscle tenderness (UPOINTS) system. In this study, the effect of combination therapy on 914 patients diagnosed, phenotyped and treated in a single specialized prostatitis clinic was analyzed. Patients received α-blockers, Serenoa repens (S. repens) extracts combined or not with supplements (lycopene and selenium) and, in the presence of documented or highly suspected infection, antibacterial agents. Combination treatment induced marked and significant improvements of National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) prostatitis symptom scores, International Index of Erectile Function (IIEF) sexual dysfunction scores, urinary peak flow rates and bladder voiding efficiency. These improvements, assessed after a 6-month course of therapy, were sustained throughout a follow-up period of 18 months. A clinically appreciable reduction of ≥6 points of the total NIH-CPSI score was achieved in 77.5% of patients subjected to combination therapy for a period of 6 months. When the patients were divided in two cohorts, depending on the diagnosis of CP/CPPS [inflammatory (IIIa) vs. non-inflammatory (IIIb) subtypes], significant improvements of all signs and symptoms of the syndrome were observed in both cohorts at the end of therapy. Intergroup comparison showed that patients affected by the IIIa sub-category of CP/CPPS showed more severe signs and symptoms (NIH-CPSI total, pain and quality of life impact scores, and Qmax) at baseline when compared with IIIb patients. However, the improvement of symptoms after therapy was significantly more pronounced in IIIa patients when compared with IIIb patients. In contrast to current opinion, the evidence emerging from the present investigation suggests that the inflammatory and non-inflammatory sub-categories of CP/CPPS may represent two distinct pathological conditions or, alternatively, two different stages of the same condition. In conclusion, a simple protocol based on α-blockers, S. repens extracts and supplements and antibacterial agents, targeting the urinary, organ specific and infection domains of UPOINTS, may induce a clinically appreciable improvement of the signs and symptoms of CP/CPPS in a considerable percentage of patients. In patients not responding sufficiently to such therapy, second-line agents (antidepressants, anxiolytics, muscle relaxants, 5-phosphodiesterase inhibitors and others) may be administered in order to achieve a satisfactory therapeutic response.

Pollen extract in association with vitamins provides early pain relief in patients affected by chronic prostatitis/chronic pelvic pain syndrome

The therapeutic efficacy for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is currently unsatisfactory. The aim of the present study was to assess the safety and efficacy of pollen extract in association with vitamins (DEPROX 500^®) in males with CP/CPPS. All patients with a diagnosis of CP/CPPS attending the same urologic centre between March and October 2012 were enrolled in this randomised controlled phase III study. Participants were randomised to receive oral capsules of DEPROX 500^® (two capsules every 24 h) or ibuprofen (600 mg, one tablet three times a day) for four weeks. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), International Prostate Symptom Score and Quality of Well-Being (QoL) questionnaires were used. In the intention-to-treat analysis, 87 males (25 class IIIa and 62 class IIIb) with a mean age of 33.6±5.9 years were randomly allocated to the DEPROX 500^® (n=41) or ibuprofen (n=46) treatment groups. At the follow-up examination (following one month of treatment), in the DEPROX 500^® group, 31/41 patients (75.6%) reported an improvement in quality of life, defined as a reduction of the NIH-CPSI total score by ≥25%, compared with 19/46 (41.3%) in the control group (P=0.002). The greater improvement in the DEPROX 500^® group compared with the ibuprofen group was statistically significant (treatment difference in the NIH-CPSI pain domain, −2.14±0.51, P<0.001; QoL scores, P=0.002). All patients were negative at the Meares-Stamey test evaluation. Adverse events were less frequent in the DEPROX 500^® group than in the ibuprofen group. The DEPROX 500^® treatment significantly improved total symptoms, pain and quality of life compared with ibuprofen in patients with CP/CPPS, without severe side-effects.