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BJU International Nov 2022To compare recurrent urinary tract infection (rUTI) guidelines from major urological and non-urological organisations internationally and identify areas of consensus and... (Review)
Review
OBJECTIVE
To compare recurrent urinary tract infection (rUTI) guidelines from major urological and non-urological organisations internationally and identify areas of consensus and discrepancy.
METHODS
PubMed, Google Scholar and the official webpages of major urological, gynaecological, infectious diseases and general practice organisations were searched for rUTI guidelines in March 2022. Nine guidelines were included for review: European Association of Urology, National Institute for Health and Care Excellence (NICE), Society of Obstetricians and Gynaecologists of Canada, American Academy of Family Physicians, Mexican College of Gynaecology and Obstetrics Specialists, Swiss Society of Gynaecology and Obstetrics, Spanish Society of Infectious Diseases and Clinical Microbiology, German Association of Scientific Medical Societies, and the combined American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction.
RESULTS
The definition and evaluation of rUTIs, and antibiotic prophylaxis strategies, were mostly consistent across guidelines, and emphasised the importance of obtaining urine cultures and limiting cystoscopy and upper tract imaging in women without risk factors. Variable recommendations were noted for symptomatic treatment, self-initiated antibiotics, and antibiotic-sparing preventative strategies such as cranberry, vaginal oestrogen, immunoactive prophylaxis with OM-89, intravesical glycosaminoglycan instillation, and phytotherapeutics. Recent randomised evidence supports the use of methenamine hippurate. Either continuous or post-coital prophylactic antibiotics were supported by all guidelines. None of the guidelines were tailored to the management recurrent complicated UTI.
CONCLUSION
Multiple rUTI guidelines were identified and mostly limited their recommendations to otherwise healthy non-pregnant women with uncomplicated cystitis. Variation was noted, particularly in antibiotic-sparing preventative strategies. Some conflicting recommendations are due to more recent guidelines including updated evidence. Future guidelines should consider recommendations to assist management of complex patient groups, such as recurrent complicated UTI.
Topics: Pregnancy; Female; Humans; Canada; Urinary Tract Infections; Antibiotic Prophylaxis; Cystitis; Anti-Bacterial Agents
PubMed: 35579121
DOI: 10.1111/bju.15756 -
BMJ (Clinical Research Ed.) Mar 2022To test and compare the efficacy of methenamine hippurate for prevention of recurrent urinary tract infections with the current standard prophylaxis of daily low dose... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To test and compare the efficacy of methenamine hippurate for prevention of recurrent urinary tract infections with the current standard prophylaxis of daily low dose antibiotics.
DESIGN
Multicentre, open label, randomised, non-inferiority trial.
SETTING
Eight centres in the UK, recruiting from June 2016 to June 2018.
PARTICIPANTS
Women aged ≥18 years with recurrent urinary tract infections, requiring prophylactic treatment.
INTERVENTIONS
Random assignment (1:1, using permuted blocks of variable length via a web based system) to receive antibiotic prophylaxis or methenamine hippurate for 12 months. Treatment allocation was not masked and crossover between arms was allowed.
MAIN OUTCOME MEASURE
Absolute difference in incidence of symptomatic, antibiotic treated, urinary tract infections during treatment. A patient and public involvement group predefined the non-inferiority margin as one episode of urinary tract infection per person year. Analyses performed in a modified intention-to-treat population comprised all participants observed for at least six months.
RESULTS
Participants were randomly assigned to antibiotic prophylaxis (n=120) or methenamine hippurate (n=120). The modified intention-to-treat analysis comprised 205 (85%) participants (antibiotics, n=102 (85%); methenamine hippurate, n=103 (86%)). Incidence of antibiotic treated urinary tract infections during the 12 month treatment period was 0.89 episodes per person year (95% confidence interval 0.65 to 1.12) in the antibiotics group and 1.38 (1.05 to 1.72) in the methenamine hippurate group, with an absolute difference of 0.49 (90% confidence interval 0.15 to 0.84) confirming non-inferiority. Adverse reactions were reported by 34/142 (24%) in the antibiotic group and 35/127 (28%) in the methenamine group and most reactions were mild.
CONCLUSION
Non-antibiotic prophylactic treatment with methenamine hippurate might be appropriate for women with a history of recurrent episodes of urinary tract infections, informed by patient preferences and antibiotic stewardship initiatives, given the demonstration of non-inferiority to daily antibiotic prophylaxis seen in this trial.
TRIAL REGISTRATION
ISRCTN70219762.
Topics: Adolescent; Adult; Anti-Bacterial Agents; Antibiotic Prophylaxis; Female; Hippurates; Humans; Methenamine; Middle Aged; Recurrence; Treatment Outcome; Urinary Tract Infections; Young Adult
PubMed: 35264408
DOI: 10.1136/bmj-2021-0068229 -
Current Opinion in Urology Nov 2020Urinary tract infections (UTIs) are one of most common infections in everyday clinical practice. Given the increase in antimicrobial therapy resistance, there has been... (Review)
Review
PURPOSE OF REVIEW
Urinary tract infections (UTIs) are one of most common infections in everyday clinical practice. Given the increase in antimicrobial therapy resistance, there has been an increased interest in nonantibiotic treatment options for common infections.
RECENT FINDINGS
A review of the recent literature including on nonantibiotic options for management of UTIs, symptoms of cystitis and prevention of recurrent UTIs.
SUMMARY
The article provides an overview on alternative therapy to antibiotics in the treatment of cystitis and recurrent UTI prophylaxis, including alkalinization of urine, cranberry products, probiotics, NSAIDS, D-mannose, herbal medicine, methenamine hippurate, oral immunostimulants (immunotherapy), topical oestrogens, vitamins and acupuncture. The last few years of intense research has focused on an effort to find evidence to corroborate potentially efficacious non antibiotic treatments. However, alternative treatments for UTIs have not brought conclusive evidence that antibiotic usage can be replaced completely by nonantibiotic options. The reason for this is largely due to a lack of good-quality randomized controlled trials on this subject.
Topics: Anti-Bacterial Agents; Complementary Therapies; Cystitis; Humans; Hydrogen-Ion Concentration; Phytotherapy; Recurrence; Urinary Tract Infections; Urine
PubMed: 33009152
DOI: 10.1097/MOU.0000000000000821 -
Health Technology Assessment... May 2022Daily, low-dose antibiotic prophylaxis is the current standard care for women with recurrent urinary tract infection. Emerging antimicrobial resistance is a global... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Daily, low-dose antibiotic prophylaxis is the current standard care for women with recurrent urinary tract infection. Emerging antimicrobial resistance is a global health concern, prompting research interest in non-antibiotic agents such as methenamine hippurate, but comparative data on their efficacy and safety are lacking.
OBJECTIVE
To assess the clinical effectiveness and cost-effectiveness of methenamine hippurate (Hiprex; Mylan NV, Canonsburg, PA, USA) compared with current standard care (antibiotic prophylaxis) for recurrent urinary tract infection prevention in adult women.
DESIGN
Multicentre, pragmatic, open-label, randomised, non-inferiority trial of 12 months' treatment with the allocated intervention, including an early, embedded qualitative study and a 6-month post-treatment observation phase. The predefined non-inferiority margin was one urinary tract infection per person-year.
SETTING
Eight UK NHS secondary care sites.
PARTICIPANTS
A total of 240 adult women with recurrent urinary tract infection requiring preventative treatment participated in the trial.
INTERVENTIONS
A central randomisation system allocated participants 1 : 1 to the experimental (methenamine hippurate: 1 g twice daily) or control (once-daily low-dose antibiotics: 50/100 mg of nitrofurantoin, 100 mg of trimethoprim or 250 mg of cefalexin) arm. Crossover between treatment arms was permitted.
MAIN OUTCOME MEASURES
The primary clinical outcome was incidence of symptomatic antibiotic-treated urinary tract infection during the 12-month treatment period. Cost-effectiveness was assessed by incremental cost per quality-adjusted life-year gained, extrapolated over the patient's expected lifetime using a Markov cohort model. Secondary outcomes included post-treatment urinary tract infections, total antibiotic use, microbiologically proven urinary tract infections, antimicrobial resistance, bacteriuria, hospitalisations and treatment satisfaction.
RESULTS
Primary modified intention-to-treat analysis comprised 205 (85%) randomised participants [102/120 (85%) participants in the antibiotics arm and 103/120 (86%) participants in the methenamine hippurate arm] with at least 6 months' data available. During treatment, the incidence rate of symptomatic, antibiotic-treated urinary tract infections decreased substantially in both arms to 1.38 episodes per person-year (95% confidence interval 1.05 to 1.72 episodes per person-year) for methenamine hippurate and 0.89 episodes per person year (95% confidence interval 0.65 to 1.12 episodes per person-year) for antibiotics (absolute difference 0.49; 90% confidence interval 0.15 to 0.84). This absolute difference did not exceed the predefined, strict, non-inferiority limit of one urinary tract infection per person-year. On average, methenamine hippurate was less costly and more effective than antibiotics in terms of quality-adjusted life-years gained; however, this finding was not consistent over the longer term. The urinary tract infection incidence rate 6 months after treatment completion was 1.72 episodes per year in the methenamine hippurate arm and 1.19 in the antibiotics arm. During treatment, 52% of urine samples taken during symptomatic urinary tract infections were microbiologically confirmed and higher proportions of participants taking daily antibiotics (46/64; 72%) demonstrated antibiotic resistance in cultured from perineal swabs than participants in the methenamine hippurate arm (39/70; 56%) (-value = 0.05). Urine cultures revealed that during treatment higher proportions of participants and samples from the antibiotic arm grew resistant to trimethoprim/co-trimoxazole and cephalosporins, respectively. Conversely, post treatment, higher proportions of participants in the methenamine hippurate arm (9/45; 20%) demonstrated multidrug resistance in isolated from perineal swabs than participants in the antibiotic arm (2/39; 5%) ( = 0.06). All other secondary outcomes and adverse events were similar in both arms.
LIMITATIONS
This trial could not define whether or not one particular antibiotic was more beneficial, and progressive data loss hampered economic evaluation.
CONCLUSIONS
This large, randomised, pragmatic trial in a routine NHS setting has clearly shown that methenamine hippurate is not inferior to current standard care (daily low-dose antibiotics) in preventing recurrent urinary tract infections in women. The results suggest that antimicrobial resistance is proportionally higher in women taking prophylactic antibiotics.
RECOMMENDATIONS FOR RESEARCH
Future research should include evaluation of other non-antibiotic preventative treatments in well-defined homogeneous patient groups, preferably with the comparator of daily antibiotics.
TRIAL REGISTRATION
This trial is registered as ISRCTN70219762 and EudraCT 2015-003487-36.
FUNDING
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 26, No. 23. See the NIHR Journals Library website for further project information.
Topics: Adult; Anti-Bacterial Agents; Antibiotic Prophylaxis; Cost-Benefit Analysis; Escherichia coli; Female; Hippurates; Humans; Male; Methenamine; Trimethoprim; Urinary Tract Infections
PubMed: 35535708
DOI: 10.3310/QOIZ6538 -
The American Journal of Dermatopathology Jul 2021Cutaneous reactions surrounding abdominal stoma sites are typically irritant, allergic, infectious, traumatic or pathergic in etiology. Pemphigus, which encompasses a... (Review)
Review
Cutaneous reactions surrounding abdominal stoma sites are typically irritant, allergic, infectious, traumatic or pathergic in etiology. Pemphigus, which encompasses a group of vesiculobullous autoimmune skin disorders, is seldom encountered as a peristomal dermatosis. Direct immunofluorescence (DIF) studies of pemphigus generally show continuous intercellular net-like depositions of IgG. However, punctate or dot-like intercellular deposition of IgG can also be seen in cases of pemphigus. The punctuate pattern is underreported in the literature and little is known about its implication. We describe a case of a 58-year-old Caucasian man with a history of bowel obstruction, status postcolostomy, who presented with a sharply demarcated, erythematous, crusted plaque surrounding his abdominal stoma. The patient endorsed persistent pruritus. A punch biopsy of the lesion was performed for clinical suspicion of fungal infection versus irritant dermatitis. Histopathology revealed a predominantly subcorneal acantholytic dermatitis. Periodic acid-Schiff with diastase and Grocott methenamine silver histochemical stains were negative for fungi. DIF was positive for IgG and C3 detected in a punctate intercellular pattern. In conjunction with the patient's clinical presentation and DIF, a diagnosis of peristomal pemphigus foliaceous was rendered. Herein, we describe a case of punctate pemphigus presenting as a peristomal dermatosis and include a review of the literature to raise awareness of this phenomenon.
Topics: Acantholysis; Aged; Biopsy; Colostomy; Fluorescent Antibody Technique, Direct; Humans; Male; Pemphigus; Skin
PubMed: 33156025
DOI: 10.1097/DAD.0000000000001845 -
Pathology Mar 2022The evolution of the diagnosis of infectious diseases began with the observation of the morphological characteristics of organisms such as ascaris and whipworms,... (Review)
Review
The evolution of the diagnosis of infectious diseases began with the observation of the morphological characteristics of organisms such as ascaris and whipworms, followed by the use of the microscope and haematoxylin and eosin stains, which allowed recognition of microscopic characteristics undetectable with the naked eye, such as the viral cytopathic changes of herpes and the presence of fungi. Patterns of acute and chronic granulomatous inflammation were also observed; these were not specific to the exact aetiology of the disease, which led to the introduction of special methenamine stains for fungi and Ziehl-Neelsen for fungi and mycobacteria. Later, the use of immunohistochemistry was introduced, which acknowledged the use of antibodies to classify microorganisms and detect cases that were either difficult to interpret or in the midst of severe inflammatory processes. Currently, the use of molecular biology has made it possible to reach diagnoses that would have been very difficult to obtain through traditional methods; these techniques show key specific characteristics and facilitate the diagnosis of various infectious pathologies. These new techniques are based on the detection of antigens and nucleic acids of microorganisms, an important advance in the diagnosis of infectious diseases.
Topics: Histocytological Preparation Techniques; Humans; Infections; Microbiological Techniques; Sensitivity and Specificity
PubMed: 35063292
DOI: 10.1016/j.pathol.2021.10.004