Evaluation of long term antibiotic therapy for UTIs: a systematic review

Practice context:
Antibiotic therapy for preventing urinary tract infections
Urinary tract infections occur due to the action of microbes, specifically bacteria and few
fungi and are one of the most common infections that affects humans. This infection primarily
affects the lower portions of the urinary tract and is also referred to as bladder infection or cystitis
(Foxman 2013). The most common cause for UTI is Escherichia coli, and certain risk factors such as,
obesity, diabetes, female anatomy, family history, and sexual intercourse. According to Foxman
(2014) some of the common symptoms of UTI include burning sensation with urination, bloody
urine, cloudy urine, pelvic pain, increased urgency, and rectal pain. Most uncomplicated cases of
UTIs are provided treatment with short course of antibiotics namely,
trimethoprim/sulfamethoxazole or nitrofurantoin (Flores-Mireles et al. 2015). Resistance to the
antibiotics that are commonly administered for treating this condition is increasing at an alarming
rate.
Under circumstances when the patient suffers from complicated UTI incidence, intravenous
or longer course of antibiotic administration is often required. Administration of
phenazopyridine often helps with the management of symptoms (Rowe and Juthani-Mehta 2014).
Older women and men are commonly prescribed antibiotics for preventing recurrent urinary tract
infections. Use of antibiotics have been recognised as the principle driver of antibiotic resistance.
Thus, use of long term antibiotics must be backed with adequate evidence, where the potential
benefits outweigh the risks (Edlin et al. 2013).
Project title:
Evaluation of available evidence for determining the effectiveness of long term antibiotic
therapy for the treatment of urinary tract infections (UTIs): a systematic review.
Evidence based practice/research question:
“Are long-term antibiotics more beneficial, to effectively manage urinary tract infections and
inform the clinicians and patients during decision making?”
Focused question model employed:
The PICO framework was used for formulating this question, in relation to evidence based
practice. This framework facilitated the framing and development of the clinical research question
and effectively assisted in adopting certain literature search strategies (Hastings and Fisher 2014).
The acronym for the research question are given below:
P- Patients with urinary tract infection
I- Long term antibiotic therapy
C- None
O- Enhanced health outcomes and reduced symptoms
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6NU995 Project proposal template july 2016

Aims & objectives:
Research aim- To explore available evidence regarding the administration of long term
antibiotic therapy, in people who have been clinically diagnosed with UTI.
Research objectives-
 To explore the impact of long term antibiotic therapy on symptoms of UTI
 To determine the effect of long term antibiotic therapy on frailty and multimorbidity
 To explore the effect of long term antibiotic therapy on patient satisfaction and user
experience
 Make recommendations for changes in UTI treatment
Rationale for the project:
Urinary tract infections and subsequently recurrent UTIs, are over diagnosed in the elderly.
Thus, antibiotic prophylaxis might essentially be approved for indications that characterise bladder
dysfunction or restricted vaginal signs, in place of exact UTI, and therefore might not be able to exert
the intended benefits. Infirmity, multimorbidity, and poly-pharmacy are quite prevalent in elder
individuals and are influential factors for probable damages, such as, those associated to drug
interactions (Martín-Gutiérrez et al. 2015). In addition, older adults who have been prescribed with
trimethoprim-containing antibiotics and renin–angiotensin system inhibitors have been found to
stay at an increased likelihood of the onset of hyperkalaemia, associated hospitalisation rates, and
sudden death (Fralick et al. 2014).
The bacteria that are responsible for UTI are found to enter the urinary bladder through the
urethra. However, these infections also occur due to lymph and blood. There is mounting evidence
for the fact that females are placed at a greater risk for developing UTI due to their anatomy
(Foxman 2013). Antibiotic resistance refers to the capability of microbes to resist the impacts of
certain medication that has the potential to successfully kill the microbe. Resistant microbes are
often difficult to treat, and thus require high dosage of antimicrobial and/or alternative medications
(Niranjan and Malini 2014). These approaches are often more expensive and have toxic impacts on
the body of the UTI patients. The resistance to antibiotics often arise due to three different
mechanisms namely, genetic mechanisms, natural resistance, or acquiring it from others (Bryce et al.
2016). Thus, microbes that are resistant to several antimicrobials are referred to as multidrug
resistant (MDR).
Overview of methods:
A scoping search strategy of several academic databases that are associated with life science
and medicine including MEDLINE, CINAHL, and PubMed was conducted. These electronic search
engines and databases were fed with key phrases and search terms that were relevant to the
phenomenon being investigated (Aveyard 2014). The search was conducted in order to extract
relevant evidences from already existing scholarly literature, in order to draw significant conclusions
to the research question. The search terms comprised of medical subject headings and keywords
that contained information on urinary tract infection and long term antibiotic use.
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6NU995 Project proposal template july 2016

Publications that combined obtainable evidences in a methodical way, all research designs
and confirmation syntheses such as, reviews with overt search procedure that were published
internationally, were encompassed in the review. Nonetheless, articles that were published in
foreign languages and not English were barred. Also omitted were scholarly literature that establish
the grade of 4 (Schünemann et al. 2016). Hence, research that were inconsistent in their findings,
and failed to provide detailed beneficial evidence were eliminated from the review. Articles
discussed in certain systematic reviews were not involved autonomously in this assessment.
However, systematic reviews were contained within this assessment.
Number Search terms
2 urinary tract Infection AND antibiotics
4 UTI AND antibiotics
5 UTI AND anti-bacterial agent
6 urinary tract infection AND anit-bacterial agent
Table 1- Search strategy
Following input of the search terms, a total of 56 articles were extracted. The duplicates
were removed from the databases. This was followed by exclusion of articles after screening their
abstracts and titles. The potentially relevant articles were later on identified for assessing their full
text eligibility. This led to exclusion of several articles and ultimately resulted in five articles. The
inclusion and exclusion criteria for selection of the articles are mentioned below:
Criteria Population Intervention Impact
Inclusion Humans  Antibiotic therapy
for prolonged
period of time
 Antibiotic therapy
for bacteriuria
 Anti-bacterial
treatment for UTI
 Health
improvement
 Health outcome
 Satisfaction
 Experience
 Reduced
hospitalisation
 Reduced frailty
Exclusion  Animal models
 Clinical guidelines
-  No measures of
healthy outcome
 No improvement
Table 2- Inclusion and exclusion criteria
Key milestones:
Milestone Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8
Draft chapter
1
(Introduction)
Draft chapter
2 (Methods)
Evidence
search
Critical
appraisal
Draft chapter
3 (Results)
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6NU995 Project proposal template july 2016