Rédacteurs : Johan Nguyen, Henri Truong

Recurrent urinary tract infections

Infections urinaires récidivantes : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

1.1. Generic Acupuncture

1.1.1. Qin 2020

Qin X, Coyle ME, Yang L, Liang J, Wang K, Guo X, Zhang AL, Mao W, Lu C, Xue CC, Liu X. Acupuncture for recurrent urinary tract infection in women: A systematic review and meta-analysis. BJOG. 2020. [202654].

Background Increasing antibiotic resistance has motivated interest in non-antibiotic prophylaxis of recurrent urinary tract infections (Ruti).
Objectives To conduct a systematic review of the current state of evidence of acupuncture for uncomplicated Ruti in women.
Methods SEARCH STRATEGY: Nine databases (PubMed, Embase, CENTRAL, CINAHL, AMED, CBM, CNKI, CQVIP, WANFANG) were searched from inception to February 2019. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating the effects of acupuncture and related therapies for prophylaxis or treatment of uncomplicated Ruti in women were included. DATA COLLECTION AND ANALYSIS: Risk of bias was assessed, and the quality and strength of evidence evaluated using the GRADE framework. Results were reported as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).
Main results Five RCTs involving 341 participants were included. Methodological quality of studies and strength of the evidence were low to moderate. The chance of achieving composite cure with acupuncture therapies was greater than that with antibiotics (3 studies, 170 participants, RR 1.92, 95% CI 1.31 to 2.81, I2 =38%). The risk of UTI recurrence was lower with acupuncture compared with no treatment (2 studies, 135 participants, RR 0.39, 95% CI 0.26 to 0.58, I2 =0%) and sham acupuncture (1 study, 53 participants, RR 0.45, 95% CI 0.22 to 0.92).
Conclusions Acupuncture appeared to be beneficial for treatment and prophylaxis of rUTIs, noting the limitations of the current evidence. Given the growing challenge of antibiotic resistance, there is a need for high-quality RCTs of non-pharmacological interventions such as acupuncture.

1.1.2. Beerepoot 2013 ☆

Beerepoot MA, Geerlings SE, Van Haarst EP, Van Charante NM, Ter Riet G. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials. J Urol. 2013. 90(6):1981-9. [170499].

PurposeIncreasing antimicrobial resistance has stimulated interest in nonantibiotic prophylaxis of recurrent urinary tract infections. We assessed the effectiveness, tolerability and safety of nonantibiotic prophylaxis in adults with recurrent urinary tract infections.
Materials and methodsMEDLINE®, EMBASE™, the Cochrane Library and reference lists of relevant reviews were searched to April 2013 for relevant English language citations. Two reviewers selected randomized controlled trials that met the predefined criteria for population, interventions and outcomes. The difference in the proportions of patients with at least 1 urinary tract infection was calculated for individual studies, and pooled risk ratios were calculated using random and fixed effects models. Adverse event rates were also extracted. The Jadad score was used to assess risk of bias (0 to 2-high risk and 3 to 5-low risk).
Results We identified 5,413 records and included 17 studies with data for 2,165 patients. The oral immunostimulant OM-89 decreased the rate of urinary tract infection recurrence (4 trials, sample size 891, median Jadad score 3, RR 0.61, 95% CI 0.48-0.78) and had a good safety profile. The vaginal vaccine Urovac® slightly reduced urinary tract infection recurrence (3 trials, sample size 220, Jadad score 3, RR 0.81, 95% CI 0.68-0.96) and primary immunization followed by booster immunization increased the time to reinfection. Vaginal estrogens showed a trend toward preventing urinary tract infection recurrence (2 trials, sample size 201, Jadad score 2.5, RR 0.42, 95% CI 0.16-1.10) but vaginal irritation occurred in 6% to 20% of women. Cranberries decreased urinary tract infection recurrence (2 trials, sample size 250, Jadad score 4, RR 0.53, 95% CI 0.33-0.83) as did acupuncture (2 open label trials, sample size 165, Jadad score 2, RR 0.48, 95% CI 0.29-0.79). Oral estrogens and lactobacilli prophylaxis did not decrease the rate of urinary tract infection recurrence.
Conclusions The evidence of the effectiveness of the oral immunostimulant OM-89 is promising. Although sometimes statistically significant, pooled findings for the other interventions should be considered tentative until corroborated by more research. Large head-to-head trials should be performed to optimally inform clinical decision making.

1.2. Special Clinical Forms

1.2.1. Recurrent Urinary Tract Infections in Pregnancy

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. Scottish Intercollegiate Guidelines Network (SIGN, Scotland) 2020 ⊕

Management of suspected bacterial lower urinary tract infection in adult women. Scottish Intercollegiate Guidelines Network (SIGN). 2020:68P. [210817]. URL

Acupuncture. Based on two small RCTs, a Canadian guideline recommended that acupuncture may be considered as an alternative intervention in the prevention of recurrent UTI in women who are unresponsive or intolerant to antibiotic prophylaxis. While acupuncture is not routinely used in Scotland for this indication its use could be considered by individual patients.

2.2. Society of Obstetricians and Gynaecologists of Canada ((SOGC, Canada) 2017 ⊕

Epp A, Larochelle A. Recurrent Urinary Tract Infection. J Obstet Gynaecol Can. 2017;39(10):e422-e431. [197220].

10. Acupuncture may be considered as an alternative in the prevention of recurrent urinary tract infections in women who are unresponsive to or intolerant of antibiotic prophylaxis. (I-B).

2.3. Société des Obstétriciens et Gynécologues du Canada (SOGC, Canada) 2010 ⊕

Epp A, Larochelle A. Recurrent Urinary Tract Infection. J Obstet Gynaecol Can. 2010;32(11):1082-90. [165533].

Acupuncture may be considered as an alternative in the prevention of recurrent urinary tract infections in women who are unresponsive to or intolerant of antibiotic prophylaxis. (I-B)

3. Randomized Controlled Trials

3.1. Sources

  1. Qin 2020: Qin X, Coyle ME, Yang L, Liang J, Wang K, Guo X, Zhang AL, Mao W, Lu C, Xue CC, Liu X. Acupuncture for recurrent urinary tract infection in women: A systematic review and meta-analysis. BJOG. 2020. [202654].
  2. Beerepoot 2013: Beerepoot MA, Geerlings SE, Van Haarst EP, Van Charante NM, Ter Riet G. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials. J Urol. 2013. 90(6):1981-9. [170499].

3.2. List

2018Liu JL, Luo Q, Liu XH, Lin L. [Observation on the clinical effect of external treatment of strong renal moxibustion on recurrent urinary tract infection], China Modern Doctor. 2018;56(29):116-8. [202983].Qin 2020
2013Hong JY, Li F, Liang XQ, Hou Z. [Efficacy observation on female chronic pyelonephritis treated with abdominal cluster-needling therapy]. Chinese Acupuncture and Moxibustion. 2013;33(4):303-5. [162588]. Qin 2020
2010Yu Siming, Guo Dandan. [Treatment of 30 cases of chronic urinary tract infection in adult women with moxibustion and antibiotics]. Shandong Journal of TCM. 2010;29(9):621-2. [160480]. Qin 2020
2002Alraek T, Soedal LI, Fagerheim SU, Digranes A, Baerheim A. Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women. Am J Public Health. 2002;92(10):1609-11. [107367].
Alraek T, Baerheim A. The effect of prophylactic acupuncture treatment in women with recurrent cystitis: Kidney patients fare better. Journal of Alternative and Complementary Medicine. 2003;9(5):651-8.. [117504].
Qin 2020, Beerepoot 2013
1998Aune A, Alraek T, LiHua H, Baerheim A. Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women. Scandinavian Journal of Primary Health Care. 1998;16(1):37-39. [58390]. Qin 2020, Beerepoot 2013