Management Of Recurrent Urinary Tract Infections Research Articles

Recurrent urinary tract infection management and prevention techniques among a population-based cohort of women.

Recurrent urinary tract infection (rUTI), defined as three or more UTIs in 12 months, has psychological, physical, and financial burden. Many women with rUTI are not satisfied with care and report only starting preventative measures after several infections. The goal of this study is to elucidate current UTI management trends and the implementation of UTI prevention strategies. A web-based study was sent to a national sample of adult women enrolled in ResearchMatch.org. Women were recruited to participate if they had a self-reported UTI in the past 12 months. Of the 755 subjects, nearly 30% reported rUTI. Among women with rUTI, more than 50% reported being peri- or postmenopausal, and two-thirds reported vaginal symptoms. 15.8% of women with rUTI reported dissatisfaction with care versus 7.9% of women without rUTI. Most women see their primary care physician for UTI management and only 26% of women with rUTI follow with a urologist. More than 65% of women increase their fluid intake, wipe from front to back, and urinate after sexual activity to prevent UTIs. Significantly more women with rUTI use transvaginal estrogen, cranberry extract, and low-dose prophylactic antibiotics. These interventions appear to be driven by urologists. Most women who have had a UTI in the last 12 months implement lifestyle changes to prevent future infections. Most women see their PCP for UTI management and women with rUTI are twice as likely to report dissatisfaction with care. Despite urologists optimizing medical rUTI prevention, they appear to be underutilized.

Will Probiotics Be a Game Changer in the Treatment of Recurrent UTI? – a Short Review

The most frequent condition primary care doctorsaddress is recurrent urinary tract infections (RUTI) inboth men and women. RUTI is defined as occurring atleast three times in the past year or twice in the pastsix months. This is a serious health hazard for women.Even though there is a wide range of antibioticsavailable for the treatment of bacterial urinary tractinfections (UTIs), due to the development of antibioticresistance, chronic UTIs are now the subject of debate.This review focuses on the connection between probioticuse and the management of recurrent UTIs and offersrecommendations for using probiotics as a substitute tolessen the likelihood of adverse medication reactions.After reviewing a number of studies, it was determinedthat probiotics might be a better choice than antibioticsgiven their advantages over disadvantages.

Novel Insights on Plant Extracts to Prevent and Treat Recurrent Urinary Tract Infections

Urinary tract infections (UTI) represent one of the most widespread infections, and frequent recurrent episodes, induced mostly by uropathogenic Escherichia coli, make them increasingly difficult to treat. Long-term antibiotic therapy is an effective approach to treat recurrent UTI but generates adverse effects, including the emergence of pathogenic strains resistant to the vast majority of antibiotics. These drawbacks have enhanced the interest toward new alternatives based on plant extracts to prevent and treat recurrent UTI, especially in a synergistic antibiotic approach. Therefore, this review highlights the potential of some medicinal plants to be used in the management of recurrent UTI, including plants that have been approved for the treatment of urinary infections and promising, but less studied, plant candidates with proven anti-uropathogenic activity. Pomegranate (Punica granatum L.), black chokeberry (Aronia melanocarpa Michx.), and cornelian cherry (Cornus mas L.) have great potential to be used for prevention or in a combined antibiotic therapy to cure UTI, but more studies and clinical trials in specific population groups are required. Further progress in developing plant-based products to cure rUTI will be supported by advances in UTI pathogenesis and human-based models for a better understanding of their pharmacological activities.

Analysis of recurrent urinary tract infection management in women seen in outpatient settings reveals opportunities for antibiotic stewardship interventions.

We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim-sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or β-lactam prescribing, or longer duration of therapy. This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis. Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and β-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a β-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58-15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07-4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15-1.44) were associated with longer antibiotic duration. We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.

Probiotic Use in Recurrent Urinary Tract Infection Management: Collective Information on Commercially Available Products

Probiotic Use in Recurrent Urinary Tract Infection Management: Collective Information on Commercially Available Products

Рецидивирующие инфекции мочевой системы: доказательная база и дискутабельные вопросы мероприятий неантибактериальной профилактики

Рецидивирующая инфекция мочевой системы (ИМС) является распространенным, дорогим и обременительным состоянием, которое касается женщин всех возрастных категорий, рас и этнических групп без учета социально-экономического статуса или образовательного уровня. Современные стратегии, направленные на профилактику рецидивирующих ИМС, как и раньше, не являются оптимальными, о чем свидетельствует относительно высокая распространенность данной нозологии у женщин. Цель данной статьи заключалась в освещении и обсуждении как доказательной базы, так и ряда нерешенных вопросов менеджмента рецидивирующих ИМС. Рассмотрены темы, вызывающие клинический интерес: диагностика, возрастные ассоциации, постоянная и интермиттирующая антимикробная профилактика, эффективность современных мероприятий неантимикробной профилактики, потенциальная роль форинала (комплекс D-маннозы и экстракта плодов клюквы) в профилактике рецидивирующих ИМС.

Anthocran® Phytosome®: Prevention of Recurring Urinary Infections and Symptoms after Catheterization

In this preliminary pilot registry study, we investigated the effects of the oral supplementation of a standardized cranberry extract (Anthocran® Phytosome®, Indena) delivered by a lecithin-based system, for the prophylactic management of recurrent-urinary tract infections (R-UTIs). We included 64 otherwise healthy subjects who underwent a surgical procedure and required post-surgical urinary catheterization for high-risk UTIs or a previous history of R-UTIs. Patients were given supplementation with the standardized cranberry extract at the dose of either 120 mg/day (n = 12) or 240 mg/day (n = 12) or assigned to a control group consisting of standard management (SM; n = 18) or nitrofurantoin administration (n = 22) for 4 weeks. After 4 weeks, patients receiving the standardized cranberry supplementation reported to have a more effective reduction in UTI symptoms, as assessed on the visual analogue scale, compared with patients in the SM or nitrofurantoin groups. The occurrence of hematuria and urine bacterial contamination were decreased among patients treated with the supplement compared with controls (p < 0.05). The cranberry extract was also superior to the control management in terms of recurrence of signs/symptoms, with none of the patients in this group suffering from a R-UTI in the 3 months following the study end (p < 0.05). The supplementation showed an optimal safety profile, with no significant adverse events and no drop-outs in the supplement group. This registry shows that this cranberry extract is effective as a supplementary, preventive management in preventing post-operative, post-catheter UTIs; the product has a good tolerability profile.

Fosfomycin Prevents Intravenous Antibiotic Therapy in Women With Recurrent Urinary Tract Infections: A Retrospective Review.

The aim of this study was to evaluate the role of oral fosfomycin to prevent the use of intravenous (IV) antibiotic therapy in women with recurrent urinary tract infection (RUTI) complicated by antibiotic allergies and/or multidrug-resistant organisms. After institutional review board approval, a retrospective review of women prescribed fosfomycin for RUTI at our institution was performed. Excluded were patients who did not take fosfomycin. Data collected included demographics, baseline voiding function/urological anatomic abnormalities, need for IV antibiotic therapy for RUTI, RUTI-related surgery, antibiotic allergies, and urine culture results before and after taking fosfomycin. Success was defined as no subsequent IV antibiotic use for RUTI management after fosfomycin within the study follow-up. Secondary outcomes included time to next UTI after fosfomycin, time to next extended-spectrum beta-lactamase UTI, factors predicting failure, urine culture results after fosfomycin, and need for surgical intervention. Between 2013 and 2019, 105 women met study criteria. At a median follow-up (including phone interviews) of 1.7 years (interquartile range, 0.3-5.8) after fosfomycin, the success rate was 74%. Twenty-seven patients had documented sterile urine cultures immediately after fosfomycin. Prior history of hospitalization for UTI and infection with resistant organisms were predictive of failure. After fosfomycin, 25 women underwent bladder electrofulguration, and 3 required cystectomy. Fosfomycin reduced the rate of IV antibiotic therapy in the management of RUTI in women with multidrug-resistant organisms and/or antibiotic allergies. Fosfomycin was less effective in those with prior hospitalization for UTI or infection with resistant organisms.

Analysis of Recurrent Urinary Tract Infection Management in Outpatient Settings Reveals Opportunities for Antibiotic Stewards

Background: Studies of antibiotic prescribing choice and duration have typically excluded women with recurrent UTI (rUTI), yet the Infectious Disease Society of America (IDSA) UTI treatment guidelines are applicable to recurrent and sporadic cystitis. We sought to better understand prescribing practices among uncomplicated rUTI patients in terms of choice of drug, duration of therapy, and the risk factors for receiving guideline-discordant therapy. Methods: We performed a retrospective database study by extracting electronic health record data from adults seen at academic primary care, internal medicine, or urology practices between November 2016 and December 2018. Inclusion criteria included having ≥2 or ≥3 International Classification of Diseases Tenth Edition (ICD-10) cystitis codes recorded within a 6- or 12-month period, respectively. We excluded patients with ICD-10 codes indicating any structural or functional genitourinary comorbidities, interstitial cystitis, vaginosis, compromised immune systems, or pregnancy in the prior year. Patients were also excluded if they had signs or symptoms of pyelonephritis at presentation. Results: Overall, 232 patients presented for 597 outpatient visits. Most were married (52.2%), non-Hispanic white (62.9%), and female (92.2%), with a median age of 58 years (IQR, 41–68). Only 21% of visits with an antibiotic prescribed for treatment consisted of a first-line therapy agent prescribed for the recommended duration. In terms of antibiotic choice, these agents were prescribed in 58.4% of scenarios, which primarily included nitrofurantoin (37.8%) and trimethoprim-sulfamethoxazole (TMP-SMX) (20.3%). Guideline-discordant choices of fluoroquinolones (28.8%), and β-lactams (11.2%) were the second and third most commonly prescribed drug categories, respectively. Multinomial logistic regression identified age (OR, 1.02; 95% CI, 1.002–1.04) or having a telephone visit (OR, 3.17; 95% CI, 1.54–6.52) as independent risk factors for receiving a β-lactam. The duration exceeded the 3-day guideline recommendation in 87.6% of fluoroquinolones and 73% of TMP-SMX (73%) prescriptions, and 61% of nitrofurantoin prescriptions exceeded the recommended 5-day duration. Multiple logistic regression analysis revealed that seeking care at a urology clinic (OR, 2.81; 95% CI, 1.59–5.17) served as an independent factor for therapy duration exceeding guideline recommendations. Conclusions: This retrospective study revealed shortcomings in prescribing practices in the type and duration of therapy for rUTI. rUTI as well as sporadic UTI are important targets for outpatient antibiotic stewardship interventions.Funding: This investigator-initiated research study was funded by Rebiotix Inc, a Ferring Company.Disclosures: None

Role of D-Mannose in the Prevention of Recurrent Uncomplicated Cystitis: State of the Art and Future Perspectives.

Background: Urinary tract infections (UTI) are highly frequent in women, with a significant impact on healthcare resources. Although antibiotics still represent the standard treatment to manage recurrent UTI (rUTI), D-mannose, an inert monosaccharide that is metabolized and excreted in urine and acts by inhibiting bacterial adhesion to the urothelium, represents a promising nonantibiotic prevention strategy. The aim of this narrative review is to critically analyze clinical studies reporting data concerning the efficacy and safety of D-mannose in the management of rUTIs. Methods: A non-systematic literature search, using the Pubmed, EMBASE, Scopus, Web of science, Cochrane Central Register of Controlled Trials, and Cochrane Central Database of Systematic Reviews databases, was performed for relevant articles published between January 2010 and January 2021. The following Medical Subjects Heading were used: “female/woman”, “urinary tract infection”, and “D-mannose”. Only clinical studies, systematic reviews, and meta-analyses reporting efficacy or safety data on D-mannose versus placebo or other competitors were selected for the present review. Evidence was limited to human data. The selected studies were organized in two categories according to the presence or not of a competitor to D-mannose. Results: After exclusion of non-pertinent studies/articles, 13 studies were analyzed. In detail, six were randomized controlled trials (RCTs), one a randomized cross-over trial, five prospective cohort studies, and one a retrospective analysis. Seven studies compared D-mannose to placebo or others drugs/dietary supplements. Six studies evaluated the efficacy of D-mannose comparing follow-up data with the baseline. D-mannose is well tolerated, with few reported adverse events (diarrhea was reported in about 8% of patients receiving 2 g of D-mannose for at least 6 months). Most of the studies also showed D-mannose can play a role in the prevention or rUTI or urodynamics-associated UTI and can overlap antibiotic treatments in some cases. The possibility to combine D-mannose with polyphenols or Lactobacillus seems another important option for UTI prophylaxis. However, the quality of the collected studies was very low, generating, consequently, a weak grade of recommendations as suggested by international guidelines. Data on D-mannose dose, frequency, and duration of treatment are still lacking. Conclusion: D-mannose alone or in combination with several dietary supplements or Lactobacillus has a potential role in the non antimicrobial prophylaxis or recurrent UTI in women. Despite its frequent prescription in real-life practice, we believe that further well-designed studies are urgently needed to definitively support the role of D-mannose in the management of recurrent UTIs in women.

MP23-09 PRACTICE PATTERNS ACROSS SPECIALTIES IN THE TREATMENT OF WOMEN WITH RECURRENT UTIS IN AN ACADEMIC HEALTHCARE SYSTEM

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Kidney & Bladder II1 Apr 2017MP23-09 PRACTICE PATTERNS ACROSS SPECIALTIES IN THE TREATMENT OF WOMEN WITH RECURRENT UTIS IN AN ACADEMIC HEALTHCARE SYSTEM Matthew Sterling, Eliza Lamin, Alexander Skokan, Alan Wein, and Ariana Smith Matthew SterlingMatthew Sterling More articles by this author , Eliza LaminEliza Lamin More articles by this author , Alexander SkokanAlexander Skokan More articles by this author , Alan WeinAlan Wein More articles by this author , and Ariana SmithAriana Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.737AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrent urinary tract infections (UTIs) are a common problem managed by a variety of medical specialties. Several treatment strategies exist and no evidence-based pathway of care has been established. The objective of this investigation is to better understand the practice patterns for managing patients with recurrent UTIs in a tertiary care healthcare system. METHODS A 17-question electronic survey regarding the management of recurrent UTIs in women was distributed to 210 providers in the Internal Medicine (IM), Family Medicine (FM), Ob-Gyn (OBG), and Urology departments. Recurrent UTIs was defined as =3 in 1 year. RESULTS A total of 68 (32.3%) providers completed the survey. Sixty percent (39/65) of providers report treating patients with recurrent UTIs with an extended course of antibiotics. Additionally, 35% (23/65) of providers treat despite lack of symptoms and 37% (24/65) of providers utilize suppressive antibiotics. OBG and Urologists utilize suppressive antibiotics more than IM and FM at 50%. Of those providing suppressive antibiotics, 79% (19/24) chose nitrofurantoin. Providers refer to specialists after trying a median of 3 courses of antibiotics (IQR 3-4). Referral to Urologists was most common for concomitant stones (88%, 51/58) or hydronephrosis (78%, 45/58), whereas referral to Infectious Disease (ID) was most common for bacterial resistance (75%, 51/68) or multiple patient allergies (48.5%, 33/68). Overall, 91.2% (62/68) of providers felt a protocol for evaluating and managing recurrent UTIs would be useful. CONCLUSIONS Practice patterns for managing recurrent UTIs in female patients vary across and within specialties within the same healthcare system. There is limited data to suggest extended courses of antibiotics are effective for recurrent UTIs and may potentially contribute to increasing susceptibility to infection, yet this strategy is commonly employed in our healthcare system. Although referral patterns differ between Urologists and ID specialists, multiple antibiotics are employed prior to referral. The majority of providers believe a written protocol would improve patient care, reducing variability and improving quality. © 2017FiguresReferencesRelatedDetailsCited bySmith A, Brown J, Wyman J, Berry A, Newman D and Stapleton A (2018) Treatment and Prevention of Recurrent Lower Urinary Tract Infections in Women: A Rapid Review with Practice RecommendationsJournal of Urology, VOL. 200, NO. 6, (1174-1191), Online publication date: 1-Dec-2018. Volume 197Issue 4SApril 2017Page: e296 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Matthew Sterling More articles by this author Eliza Lamin More articles by this author Alexander Skokan More articles by this author Alan Wein More articles by this author Ariana Smith More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Chinese herbal medicine for treating recurrent urinary tract infections in women.

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. 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. 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. 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 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). 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. 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.

Subinhibitory antibiotic therapy alters recurrent urinary tract infection pathogenesis through modulation of bacterial virulence and host immunity.

ABSTRACTThe capacity of subinhibitory levels of antibiotics to modulate bacterial virulence in vitro has recently been brought to light, raising concerns over the appropriateness of low-dose therapies, including antibiotic prophylaxis for recurrent urinary tract infection management. However, the mechanisms involved and their relevance in influencing pathogenesis have not been investigated. We characterized the ability of antibiotics to modulate virulence in the uropathogens Staphylococcus saprophyticus and Escherichia coli. Several antibiotics were able to induce the expression of adhesins critical to urothelial colonization, resulting in increased biofilm formation, colonization of murine bladders and kidneys, and promotion of intracellular niche formation. Mice receiving subinhibitory ciprofloxacin treatment were also more susceptible to severe infections and frequent recurrences. A ciprofloxacin prophylaxis model revealed this strategy to be ineffective in reducing recurrences and worsened infection by creating larger intracellular reservoirs at higher frequencies. Our study indicates that certain agents used for antibiotic prophylaxis have the potential to complicate infections.

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.

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

21 * MANAGEMENT OF RECURRENT URINARY TRACT INFECTIONS IN ELDERLY INPATIENTS

Evidence base: SIGN guidelines and Cochrane 2008 advise that women with recurrent urinary tract infections (UTIs) consider using cranberry products. Evidence shows that they significantly reduce UTI incidence at 12 months (relative risk, 0.65). The only reported adverse event was an interaction with warfarin. Cochrane 2004 showed that antibiotic prophylaxis for 6 to 12 months reduced the incidence of UTIs compared to controls; however, with more adverse events. This suggests that cranberry juice is preferable to prophylactic antibiotics. SIGN also recommends that men with recurrent UTIs should be referred to urology. Change strategies: We worked with our urology colleagues to develop a care of the elderly, departmental guide, into the management of recurrent UTIs. This included investigations and the use of cranberry products and prophylactic antibiotics. This was presented, together with first loop audit results in a departmental meeting. The guide was emailed to all medical staff and included in induction material. Change effects: Pre-intervention, 16% [32/200] of our elderly, inpatient population had recurrent, symptomatic, UTIs, post-intervention, 13% [26/200]. The use of cranberry products increased from 0% to 12% [3/26], in the female population. The use of prophylactic antibiotics fell from 3% to 0%, perhaps because people were appropriately tried on cranberry products first. The referral rate of males to urology increased from 6% to 11%. Conclusion: We have shown that the incidence and management of recurrent UTIs are a significant problem amongst our elderly, inpatient, population. The reluctance to prescribe prophylactic antibiotics is understandable due to their adverse effects. Our change strategy did improve both the use of cranberry products and referral rate to urology but there is still scope for improvement. Improving the identification of patients with recurrent UTIs, developing clear guidelines on the delivery of cranberry products and improving its availability should also improve compliance with guidelines.

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

Aim: To assess the efficacy and safety of intravesical hyaluronic acid (HA) in the management of female patients with recurrent urinary tract infections (UTIs) in our hospital. Also to perform a literature review about the use of Glycosaminoglycan (GAGs) such as hyaluronic acid (HA) and chondroitin sulphate (CS) in the management of female recurrent UTI and compare our findings to the published evidence available. Method: We performed a literature review of studies using HA or CS for the management of recurrent UTIs. We retrospectively reviewed the outcome of 22 female patients who were treated at our district general hospital for recurrent UTIs refractory to first line management and compared our experience of using this treatment to the recently published literature. Results: Literature review showed growing evidence for the use of intravesical HA and HA-CS for the prevention of female recurrent UTIs including three recently published prospective randomised controlled trials (RCTs). These studies show a reduction in UTIs by over 70% in comparison to placebo and that intravesical treatment is more effective than low dose antibiotic prophylaxis. In our experience, intravesical HA was an effective second line treatment for females with recurrent UTIs. Of 22 patients with recurrent UTIs (aged 17 - 72 years), 64% (14 patients) remained recurrence free one year after treatment. In our experience, this treatment was tolerated well by the patients with minimal side effects. Conclusion: HA offers an effective management option for female patients with recurrent UTIs. It is a safe and effective second line treatment for female patients with recurrent urinary tract infections that may be refractory to first line management strategies.

Antimicrobial Prescribing in Nursing Homes in Northern Ireland

In 2005, the European Commission recommended that all member states should establish or strengthen surveillance systems for monitoring the use of antimicrobial agents. There is no evidence in the literature of any surveillance studies having been specifically conducted in nursing homes (NHs) in Northern Ireland (NI). The aim of this study was to determine the prevalence of antimicrobial prescribing and its relationship with certain factors (e.g. indwelling urinary catheterization, urinary incontinence, disorientation, etc.) in NH residents in NI. This project was carried out in NI as part of a wider European study under the protocols of the European Surveillance of Antimicrobial Consumption group. Two point-prevalence surveys (PPSs) were conducted in 30 NHs in April and November 2009. Data were obtained from nursing notes, medication administration records and staff in relation to antimicrobial prescribing, facility and resident characteristics and were analysed descriptively. The point prevalence of antimicrobial prescribing was 13.2% in April 2009 and 10.7% in November 2009, with a 10-fold difference existing between the NHs with the highest and lowest antimicrobial prescribing prevalence during both PPSs. The same NH had the highest rate of antimicrobial prescribing during both April (30.6%) and November (26.0%). The group of antimicrobials most commonly prescribed was the penicillins (April 28.6%, November 27.5%) whilst the most prevalent individual antimicrobial prescribed was trimethoprim (April 21.3%, November 24.3%). The majority of antimicrobials were prescribed for the purpose of preventing urinary tract infections (UTIs) in both April (37.8%) and in November (46.7%), with 5% of all participating residents being prescribed an antimicrobial for this reason. Some (20%) antimicrobials were prescribed at inappropriate doses, particularly those which were used for the purpose of preventing UTIs. Indwelling urinary catheterization and wounds were significant risk factors for antimicrobial use in April [odds ratio {OR} (95% CI) 2.0 (1.1, 3.5) and 1.8 (1.1, 3.0), respectively] but not in November 2009 [OR (95% CI) 1.6 (0.8, 3.2) and 1.2 (0.7, 2.2), respectively]. Other resident factors, e.g. disorientation, immobility and incontinence, were not associated with antimicrobial use. Furthermore, none of the NH characteristics investigated (e.g. number of beds, hospitalization episodes, number of general practitioners, etc.) were found to be associated with antimicrobial use in either April or November 2009. This study has identified a high overall rate of antimicrobial use in NHs in NI, with variability evident both within and between homes. More research is needed to understand which factors influence antimicrobial use and to determine the appropriateness of antimicrobial prescribing in this population in general and more specifically in the management of recurrent UTIs.

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

Recurrent urinary tract infections (UTIs) are very common, particularly among women in their reproductive years. Alternatives to antibacterial prophylaxis are needed, particularly measures to increase host defences. Various bacterial lysates have been proposed with this indication. The objective of this review and meta-analysis was to assess the efficacy and safety of bacterial lysates in the management of recurrent UTIs. Electronic databases identified 11 studies with the descriptors ‘urinary tract infection’, ‘immunotherapy’ or ‘vaccines’ and ‘double blind’. Seven of the studies dealt with an oral immunostimulant (OM-89), of which about five (1000 adult patients) were retained for analysis with an observation period of 6–12 months. The mean number of UTIs was significantly lower in OM-89-treated patients in all the trials analysed (mean 39%), as was the use of antibacterials. Four of the studies dealt with a vaginal vaccine, of which three small studies were retained for analysis (220 adult patients). The results suggest that this vaginal vaccine is effective when administered with a booster cycle (no recurrent UTI in 50% vs. 14% with placebo). No blind controlled studies could be identified with other bacterial lysates claiming the same indication. In conclusion, among the various immunotherapeutic products, studies were published only for one product (OM-89) that are in accordance with current standards. This product was shown to be effective under conditions of daily practice. The second product (vaginal vaccine) also appears to be effective but adequate phase III studies are necessary.

Recurrent urinary tract infection in women

Recurrent urinary tract infections (UTI) are common among young healthy women even though they generally have anatomically and physiologically normal urinary tracts. Women with recurrent UTI have an increased susceptibility to vaginal colonization with uropathogens, which is due to a greater propensity for uropathogenic coliforms to adhere to uroepithelial cells. Risk factors for recurrent UTI include sexual intercourse, use of spermicidal products, having a first UTI at an early age, and having a maternal history of UTIs. Inherited factors may be important in some women with recurrent UTI. Many factors thought to predispose to recurrent UTI in women, such as pre- and post-coital voiding patterns, frequency of urination, wiping patterns, and douching have not been proven to be risk factors for UTI. In contrast to the predominantly behavioral risk factors for young women, mechanical and/or physiological factors that affect bladder emptying are most strongly associated with recurrent UTI in healthy postmenopausal women. The management of recurrent UTI is the same as that for sporadic UTI except that the likelihood of infection with an antibiotic resistant uropathogen is higher in women who have received recent antimicrobials. Strategies to prevent recurrent UTI in young women should include education about the association of recurrent UTI with frequency of sexual intercourse and the usage of spermicide-containing products. Continuous or post-coital prophylaxis with low-dose antimicrobials or intermittent self-treatment with antimicrobials have all been demonstrated to be effective in managing recurrent uncomplicated UTIs in women. Estrogen use is very effective in preventing recurrent UTI in post-menopausal women. Exciting new approaches to prevent recurrent UTI include the use of probiotics and vaccines. Further understanding of the pathogenesis of UTI will lead to more effective and safer methods to prevent these frequent infections.

Probiotic Therapy and Functional Foods for Prevention of Urinary Tract Infections: State of the Art and Science.

In the past year, interest has heightened in the potential for probiotics to prevent urinary tract infection (UTI). Mainly, this has been due to concerns about antibiotic resistance and recognition of the scientific efficacy of probiotics. The critical factors in any successful application of probiotics to patient care are the scientific basis for selecting probiotic strains and clinical verification that they are effective against the recurrence of UTI. Three strains--Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum B-54 and RC-14--have been shown to colonize the vagina and act as a barrier to the ascension of uropathogens into the bladder. Their ability to produce growth and adhesion antagonists against urogenital pathogens is clinically important, because these appear to be important mechanisms of action. Probiotic therapy has been shown to be safe, but too few reliable products are on the market, and none are yet available for use against UTI. Given the right strains and delivery system, probiotic therapy could provide the first new UTI-prevention system in 40 years, and may help in the management of recurrent UTI.