All evidence statements for UTIs are level Ia.
Prevention of UTI- Five SRs were identified which assessed interventions for the prevention of UTI.308-311 A review of five studies looking at the effects of cranberry extract in elderly patients, patients needing intermittent catheterisation, and women with recurrent UTI, found no reliable evidence of the effectiveness of cranberry juice and other cranberry products.309 A review of eight RCTs comparing the effectiveness of indwelling silver coated urinary catheters and uncoated indwelling urinary catheters found that silver alloy catheters were significantly more effective in preventing UTIs as measured by the presence of bacteriuria than uncoated catheters but these studies were confined to relatively short-term use of catheters (2-10 days).311 The results from three of the eight trials indicated that women benefited from the silver-coated urinary catheters more than men. The third review looked at risk factors for UTI and the effects of antibiotic prophylaxis in patients with neurogenic bladder due to spinal cord dysfunction.310 This review found that indwelling catheterisation was associated with more frequent infections than intermittent catheterisation, which in turn is associated with more frequent infection than methods not involving a catheter. The literature did not support firm conclusions regarding most other risk factors. It also reported that antibiotic prophylaxis significantly reduces bacteriuria among acute spinal cord injury patients. However, antibiotic prophylaxis was not associated with a reduced number of symptomatic infections in the populations studied. Antibiotic prophylaxis resulted in a twofold increase in the occurrence of antibiotic-resistant bacteria. A second review assessing the effectiveness of antibiotic prophylaxis reported similar findings. However, this review only found reduced bacteriuria among patients with acute spinal cord injury, not in those with non-acute spinal cord injury.308 A final review of 11 studies assessed the efficacy of methenamine hippurate in patients at risk of developing a UTI. Four of the trials studied symptomatic bacteriuria and six studied bacteriuria as an outcome measure. The direction of six of the seven pooled trials was towards a favourable treatment effect for methenamine hippurate. However, due to heterogeneity interpretation of the pooled estimates could not be undertaken.312
Health economic analysis of interventions to reduce the risk of UTIs - Only one economic study was identified with any relevance to the population of people with MS.313 This was a decision analytic model to compare the cost-effectiveness of silver alloy-coated urinary catheters with standard (uncoated) catheters. Coated catheters are more expensive (per unit) than uncoated catheters but are more effective; hence the relevant decision is whether the improved efficacy is worth the additional per unit cost?
The base case simulation showed silver-coated catheters to be a dominant strategy, ie more effective and less costly, due to savings in costs of treating symptomatic UTIs and bacteraemia. One-way sensitivity analysis revealed that the strategy remained dominant throughout the ranges evaluated. In the multivariate sensitivity analysis the strategy provided clinical benefits over standard catheters in all cases and cost savings in 84% of cases.
Interventions to treat UTI - Two reviews which assessed the effectiveness of interventions for the treatment of UTI met inclusion criteria. The first review assessed the effectiveness of cranberry juice or cranberry products for the treatment of UTI, but did not find any RCTs which met inclusion criteria and so was unable to draw any conclusions.314 The second review compared the effectiveness of single dose and multi-dose antibiotic treatment in female adult patients with UTI.315 This review found no significant differences between women treated with single dose and multi-dose antibiotic therapy (1a). One further RCT comparing cranberry concentrate supplements to placebo found no significant difference between the groups in terms of the number of patients developing a UTI316 (1b).
Areas where evidence was not found - No evidence was found to allow recommendations on several important clinical issues including altering fluid intake, the frequency of changing long-term catheters, the use of bladder wash-outs, the appropriate use of suprapubic catheters, and the best policy concerning routine monitoring of renal tract structure and function.
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