#05 Click here to see the previous editions September 23, 2023
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Welcome to UTI News! In this newsletter, we will cover the most important hot topics in the field of urinary tract infections every two months. Stay tuned for updates and insights on this important topic.

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Hello urologists, gynaecologists, primary care doctors and all of you who have to deal with urinary tract infections. Urinary tract infection management and prevention is one of the activities on a routine basis for all caregivers.

This Newsletter intends to review the last recommendation for managing and preventing urinary infections. Our focus is reducing the number of infections, avoiding antibiotic use when not indicated to prevent resistance and reviewing the evidence about non-antibiotic measures to prevent infections. Scientific support of the evidence and practice guidelines recommendations will be the key to all the information in the Newsletter.

The focus of this issue is the revision of three articles. First of all, the effect of urine pH on the activity of different antibiotics against the main uropathogens Secondly, we review the non-antibiotic treatment of uncomplicated urinary tract infections. It is a controversial topic and the article by Vik et al review the evidence. Finally, the research by Tommaso Cai is a comparative research comparing the efficacy of short-term antibiotic treatment and L-methionine plus phytotherapy in the management of uncomplicated urinary tract infections

img The influence of urinary pH on antibiotic efficacy against bacterial uropathogens.
Yang L, Wang K, Li H, Denstedt JD, Cadieux. Urology. 2014 Sep;84(3):731.e1-7
img 2'
https://pubmed.ncbi.nlm.nih.gov/25168568/ img

The focus of the study is to understand the role of urine pH in the effect of antibiotic treatment for urinary tract infections. As urine pH may be changed with oral drugs is useful if that may affect the selection of antibiotics or pH changes may prevent urinary tract infections. The research was carried out evaluating the inhibitory activity of 24 antimicrobial agents against Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis, Staphylococcus saprophyticus, and Staphylococcus epidermidis using different range of urine pH from 5 to 8. The fluoroquinolones, co-trimoxazole, aminoglycosides, and macrolides all functioned optimally at alkaline pH, whereas the tetracyclines, nitrofurantoin, and many of the β-lactams tested exhibited their highest activity under more acidic conditions. Sulfamethoxazole, oxacillin, amoxicillin and clavulanic acid, vancomycin, imipenem, and clindamycin were largely unaffected by pH.

Therefore, the selection of antibiotics and manipulation of urine pH is of paramount importance in patients with risk factors for urinary tract infections and recurrent urinary tract infections. Moreover, the authors conclude that future clinical investigations examining urinary pH and antibiotic efficacy may result in the application of decreased antibiotic dosages and regimen durations, potentially reducing antibiotic resistance development.

img Predicting the use of antibiotics after initial symptomatic treatment of an uncomplicated urinary tract infection: analyses performed after a randomised controlled trial.
Vik I, Mdala I, Bollestad M, Cordoba GC, Bjerrum L, Neumark T, Damsgaard E, Bærheim A, Grude N, Lindbaek M. BMJ Open. BMJ Open. 2020;10(8):e035074.
img 2'
https://pubmed.ncbi.nlm.nih.gov/32868350/ img

Uncomplicated urinary tract infections are one of the main reasons for seeking medical care in women. The diagnosis of urinary tract infections rely on symptoms and antibiotic is usually prescribed. However, there is a worrisome about the increase of antibiotic resistance and many uncomplicated urinary tract infections may cure without antibiotics. Several articles have reviewed the outcomes and complications related to the treatment of uncomplicated urinary tract infections with ibuprofen in comparison with Fosfomycin or Pivmecillinam. It is seemed that antibiotic is more effective to achieve clinical and bacteriological cure. However, 53% of women without antibiotics recover from the infection. The present study includes 153 patients with the focus of predicting which patients' antibiotics may be avoided. It is reported that the number of days with symptoms before inclusion (<3 days) and feeling unwell (≥4 on a scale of 0–6) were significant predictors for the subsequent use of antibiotic treatment.

However, no antibiotic prescription may be associated with the development of febrile urinary tract infection or upper urinary tract infection. Therefore, currently, urinary tract infections must be managed with antibiotics. Symptomatic relief to patients who are willing to delay taking antibiotics, with a backup prescription at hand should be discussed with selected patients.

img L-Methionine associated with Hibiscus sabdariffa and Boswellia serrata extracts are not inferior to antibiotic treatment for symptoms relief in patients affected by recurrent uncomplicated urinary tract infections: Focus on antibiotic-sparing approach.
Cai T, Cocci A, Tiscione D, Puglisi M, Di Maida F, Malossini G, Verze P, Palmieri A, Mirone V, Bjerklund Johansen TE. Arch Ital Urol Androl. 2018 Jun 30;90(2):97-100.
img 2'
https://pubmed.ncbi.nlm.nih.gov/29974725/ img

This is a randomised phase 3 study of women suffering from uncomplicated urinary tract infections. The treatment groups are 46 women receiving the combination of methionine with herbal medicine based on Hibiscus sabdariffa and Boswellia serrata for 7 days compared to 47 women receiving a short course of antibiotic therapy. The study evaluates the results of urine cultures and reported quality of life. In both groups an improvement in quality of life is observed with 95% of the patients in the group treated with methiothin and phytotherapy improving their quality of life. No side effects were observed in the group with methiothin and phytotherapy, while 14% of patients on antibiotic treatment did not complete it due to side effects. In the group treated without antibiotic therapy, a higher percentage of patients (26%) had asymptomatic bacteriuria.

The authors postulate, based on previous publications, that the existence of asymptomatic bacteriuria may prevent symptomatic recurrence in patients with recurrent infections. L-methionine acts by creating less favourable conditions for bacterial growth through its effect on urinary pH. Thus, the use of therapies that act by lowering urinary pH may reduce the use of antibiotic therapy and reduce recurrences of recurrent urinary tract infections.

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