Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT

Robert Pickard, Thomas Chadwick, Yemi Oluboyede, Catherine Brennand, Alexander von Wilamowitz-Moellendorff, Doreen McClurg, Jennifer Wilkinson, Laura Ternent, Holly Fisher, Katherine Walton, Elaine McColl, Luke Vale, Ruth Wood, Mohamed Abdel-Fattah, Paul Hilton, Mandy Fader, Simon Harrison, James Larcombe, Paul Little, Anthony TimoneyJames N’Dow, Heather Armstrong, Nicola Morris, Kerry Walker, Nikesh Thiruchelvam

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Abstract

Background: People carrying out clean intermittent self-catheterisation (CISC) to empty their bladder often suffer repeated urinary tract infections (UTIs). Continuous once-daily, low-dose antibiotic treatment (antibiotic prophylaxis) is commonly advised but knowledge of its effectiveness is lacking.
Objective: To assess the benefit, harms and cost-effectiveness of antibiotic prophylaxis to prevent UTIs in people who perform CISC.
Design: Parallel-group, open-label, patient-randomised 12-month trial of allocated intervention with 3-monthly follow-up. Outcome assessors were blind to allocation.
Setting: UK NHS, with recruitment of patients from 51 sites.
DOI: 10.3310/hta22240 HEALTH TECHNOLOGY ASSESSMENT 2018 VOL. 22 NO. 24
© Queen’s Printer and Controller of HMSO 2018. This work was produced by Pickard et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
vii
Participants: Four hundred and four adults performing CISC and predicted to continue for = 12 months who had suffered at least two UTIs in the previous year or had been hospitalised for a UTI in the previous year.
Interventions: A central randomisation system using random block allocation set by an independent statistician allocated participants to the experimental group [once-daily oral antibiotic prophylaxis using either 50mg of nitrofurantoin, 100mg of trimethoprim (Kent Pharmaceuticals, Ashford, UK) or 250mg of cefalexin (Sandoz Ltd, Holzkirchen, Germany); n=203] or the control group of no prophylaxis (n=201), both for 12 months.
Main outcome measures: The primary clinical outcome was relative frequency of symptomatic, antibiotic-treated UTI. Cost-effectiveness was assessed by cost per UTI avoided. The secondary measures were microbiologically proven UTI, antimicrobial resistance, health status and participants’ attitudes to antibiotic use.
Results: The frequency of symptomatic antibiotic-treated UTI was reduced by 48% using prophylaxis [incidence rate ratio (IRR) 0.52, 95% confidence interval (CI) 0.44 to 0.61; n=361]. Reduction in microbiologically proven UTI was similar (IRR 0.49, 95% CI 0.39 to 0.60; n=361). Absolute reduction in UTI episodes over 12 months was from a median (interquartile range) of 2 (1–4) in the no-prophylaxis group (n=180) to 1 (0–2) in the prophylaxis group (n=181). The results were unchanged by adjustment for days at risk of UTI and the presence of factors giving higher risk of UTI. Development of antimicrobial resistance was seen more frequently in pathogens isolated from urine and Escherichia coli from perianal swabs in participants allocated to antibiotic prophylaxis. The use of prophylaxis incurred an extra cost of £99 to prevent one UTI (not including costs related to increased antimicrobial resistance). The emotional and practical burden of CISC and UTI influenced well-being, but health status measured over 12 months was similar between groups and did not deteriorate significantly during UTI. Participants were generally unconcerned about using antibiotics, including the possible development of antimicrobial resistance.
Limitations: Lack of blinding may have led participants in each group to use different thresholds to trigger reporting and treatment-seeking for UTI.
Conclusions: The results of this large randomised trial, conducted in accordance with best practice, demonstrate clear benefit for antibiotic prophylaxis in terms of reducing the frequency of UTI for people carrying out CISC. Antibiotic prophylaxis use appears safe for individuals over 12 months, but the emergence of resistant urinary pathogens may prejudice longer-term management of recurrent UTI and is a public health concern. Future work includes longer-term studies of antimicrobial resistance and studies of non-antibiotic preventative strategies.
Trial registration: Current Controlled Trials ISRCTN67145101 and EudraCT 2013-002556-32. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 22, No. 24. See the NIHR Journals Library website for further project information.
Original languageEnglish
JournalHealth Technology Assessment
Volume22
Issue number24
DOIs
Publication statusPublished - 31 May 2018

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Intermittent Urethral Catheterization
Antibiotic Prophylaxis
Urinary Tract Infections
Biomedical Technology Assessment
Anti-Bacterial Agents
Cost-Benefit Analysis
National Institutes of Health (U.S.)
Random Allocation
Costs and Cost Analysis
Health Status
Libraries
Reproduction
Research
Confidence Intervals
Cephalexin
Nitrofurantoin

Keywords

  • antibiotic
  • urinary tract infection
  • clean intermittent self-catheterisation

Cite this

Pickard, Robert ; Chadwick, Thomas ; Oluboyede, Yemi ; Brennand, Catherine ; von Wilamowitz-Moellendorff, Alexander ; McClurg, Doreen ; Wilkinson, Jennifer ; Ternent, Laura ; Fisher, Holly ; Walton, Katherine ; McColl, Elaine ; Vale, Luke ; Wood, Ruth ; Abdel-Fattah, Mohamed ; Hilton, Paul ; Fader, Mandy ; Harrison, Simon ; Larcombe, James ; Little, Paul ; Timoney, Anthony ; N’Dow, James ; Armstrong, Heather ; Morris, Nicola ; Walker, Kerry ; Thiruchelvam, Nikesh. / Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT. In: Health Technology Assessment. 2018 ; Vol. 22, No. 24.
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title = "Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT",
abstract = "Background: People carrying out clean intermittent self-catheterisation (CISC) to empty their bladder often suffer repeated urinary tract infections (UTIs). Continuous once-daily, low-dose antibiotic treatment (antibiotic prophylaxis) is commonly advised but knowledge of its effectiveness is lacking.Objective: To assess the benefit, harms and cost-effectiveness of antibiotic prophylaxis to prevent UTIs in people who perform CISC.Design: Parallel-group, open-label, patient-randomised 12-month trial of allocated intervention with 3-monthly follow-up. Outcome assessors were blind to allocation.Setting: UK NHS, with recruitment of patients from 51 sites.DOI: 10.3310/hta22240 HEALTH TECHNOLOGY ASSESSMENT 2018 VOL. 22 NO. 24{\circledC} Queen’s Printer and Controller of HMSO 2018. This work was produced by Pickard et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.viiParticipants: Four hundred and four adults performing CISC and predicted to continue for = 12 months who had suffered at least two UTIs in the previous year or had been hospitalised for a UTI in the previous year.Interventions: A central randomisation system using random block allocation set by an independent statistician allocated participants to the experimental group [once-daily oral antibiotic prophylaxis using either 50mg of nitrofurantoin, 100mg of trimethoprim (Kent Pharmaceuticals, Ashford, UK) or 250mg of cefalexin (Sandoz Ltd, Holzkirchen, Germany); n=203] or the control group of no prophylaxis (n=201), both for 12 months.Main outcome measures: The primary clinical outcome was relative frequency of symptomatic, antibiotic-treated UTI. Cost-effectiveness was assessed by cost per UTI avoided. The secondary measures were microbiologically proven UTI, antimicrobial resistance, health status and participants’ attitudes to antibiotic use.Results: The frequency of symptomatic antibiotic-treated UTI was reduced by 48{\%} using prophylaxis [incidence rate ratio (IRR) 0.52, 95{\%} confidence interval (CI) 0.44 to 0.61; n=361]. Reduction in microbiologically proven UTI was similar (IRR 0.49, 95{\%} CI 0.39 to 0.60; n=361). Absolute reduction in UTI episodes over 12 months was from a median (interquartile range) of 2 (1–4) in the no-prophylaxis group (n=180) to 1 (0–2) in the prophylaxis group (n=181). The results were unchanged by adjustment for days at risk of UTI and the presence of factors giving higher risk of UTI. Development of antimicrobial resistance was seen more frequently in pathogens isolated from urine and Escherichia coli from perianal swabs in participants allocated to antibiotic prophylaxis. The use of prophylaxis incurred an extra cost of £99 to prevent one UTI (not including costs related to increased antimicrobial resistance). The emotional and practical burden of CISC and UTI influenced well-being, but health status measured over 12 months was similar between groups and did not deteriorate significantly during UTI. Participants were generally unconcerned about using antibiotics, including the possible development of antimicrobial resistance.Limitations: Lack of blinding may have led participants in each group to use different thresholds to trigger reporting and treatment-seeking for UTI.Conclusions: The results of this large randomised trial, conducted in accordance with best practice, demonstrate clear benefit for antibiotic prophylaxis in terms of reducing the frequency of UTI for people carrying out CISC. Antibiotic prophylaxis use appears safe for individuals over 12 months, but the emergence of resistant urinary pathogens may prejudice longer-term management of recurrent UTI and is a public health concern. Future work includes longer-term studies of antimicrobial resistance and studies of non-antibiotic preventative strategies.Trial registration: Current Controlled Trials ISRCTN67145101 and EudraCT 2013-002556-32. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 22, No. 24. See the NIHR Journals Library website for further project information.",
keywords = "antibiotic, urinary tract infection, clean intermittent self-catheterisation",
author = "Robert Pickard and Thomas Chadwick and Yemi Oluboyede and Catherine Brennand and {von Wilamowitz-Moellendorff}, Alexander and Doreen McClurg and Jennifer Wilkinson and Laura Ternent and Holly Fisher and Katherine Walton and Elaine McColl and Luke Vale and Ruth Wood and Mohamed Abdel-Fattah and Paul Hilton and Mandy Fader and Simon Harrison and James Larcombe and Paul Little and Anthony Timoney and James N’Dow and Heather Armstrong and Nicola Morris and Kerry Walker and Nikesh Thiruchelvam",
note = "Acceptance from PDF VoR permitted by journal",
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Pickard, R, Chadwick, T, Oluboyede, Y, Brennand, C, von Wilamowitz-Moellendorff, A, McClurg, D, Wilkinson, J, Ternent, L, Fisher, H, Walton, K, McColl, E, Vale, L, Wood, R, Abdel-Fattah, M, Hilton, P, Fader, M, Harrison, S, Larcombe, J, Little, P, Timoney, A, N’Dow, J, Armstrong, H, Morris, N, Walker, K & Thiruchelvam, N 2018, 'Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT', Health Technology Assessment, vol. 22, no. 24. https://doi.org/10.3310/hta22240

Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT. / Pickard, Robert; Chadwick, Thomas ; Oluboyede, Yemi ; Brennand, Catherine; von Wilamowitz-Moellendorff, Alexander; McClurg, Doreen; Wilkinson, Jennifer; Ternent, Laura; Fisher, Holly; Walton, Katherine ; McColl, Elaine; Vale, Luke; Wood, Ruth; Abdel-Fattah, Mohamed ; Hilton, Paul ; Fader, Mandy; Harrison, Simon ; Larcombe, James; Little, Paul; Timoney, Anthony ; N’Dow, James; Armstrong, Heather; Morris, Nicola ; Walker, Kerry; Thiruchelvam, Nikesh.

In: Health Technology Assessment, Vol. 22, No. 24, 31.05.2018.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT

AU - Pickard, Robert

AU - Chadwick, Thomas

AU - Oluboyede, Yemi

AU - Brennand, Catherine

AU - von Wilamowitz-Moellendorff, Alexander

AU - McClurg, Doreen

AU - Wilkinson, Jennifer

AU - Ternent, Laura

AU - Fisher, Holly

AU - Walton, Katherine

AU - McColl, Elaine

AU - Vale, Luke

AU - Wood, Ruth

AU - Abdel-Fattah, Mohamed

AU - Hilton, Paul

AU - Fader, Mandy

AU - Harrison, Simon

AU - Larcombe, James

AU - Little, Paul

AU - Timoney, Anthony

AU - N’Dow, James

AU - Armstrong, Heather

AU - Morris, Nicola

AU - Walker, Kerry

AU - Thiruchelvam, Nikesh

N1 - Acceptance from PDF VoR permitted by journal

PY - 2018/5/31

Y1 - 2018/5/31

N2 - Background: People carrying out clean intermittent self-catheterisation (CISC) to empty their bladder often suffer repeated urinary tract infections (UTIs). Continuous once-daily, low-dose antibiotic treatment (antibiotic prophylaxis) is commonly advised but knowledge of its effectiveness is lacking.Objective: To assess the benefit, harms and cost-effectiveness of antibiotic prophylaxis to prevent UTIs in people who perform CISC.Design: Parallel-group, open-label, patient-randomised 12-month trial of allocated intervention with 3-monthly follow-up. Outcome assessors were blind to allocation.Setting: UK NHS, with recruitment of patients from 51 sites.DOI: 10.3310/hta22240 HEALTH TECHNOLOGY ASSESSMENT 2018 VOL. 22 NO. 24© Queen’s Printer and Controller of HMSO 2018. This work was produced by Pickard et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.viiParticipants: Four hundred and four adults performing CISC and predicted to continue for = 12 months who had suffered at least two UTIs in the previous year or had been hospitalised for a UTI in the previous year.Interventions: A central randomisation system using random block allocation set by an independent statistician allocated participants to the experimental group [once-daily oral antibiotic prophylaxis using either 50mg of nitrofurantoin, 100mg of trimethoprim (Kent Pharmaceuticals, Ashford, UK) or 250mg of cefalexin (Sandoz Ltd, Holzkirchen, Germany); n=203] or the control group of no prophylaxis (n=201), both for 12 months.Main outcome measures: The primary clinical outcome was relative frequency of symptomatic, antibiotic-treated UTI. Cost-effectiveness was assessed by cost per UTI avoided. The secondary measures were microbiologically proven UTI, antimicrobial resistance, health status and participants’ attitudes to antibiotic use.Results: The frequency of symptomatic antibiotic-treated UTI was reduced by 48% using prophylaxis [incidence rate ratio (IRR) 0.52, 95% confidence interval (CI) 0.44 to 0.61; n=361]. Reduction in microbiologically proven UTI was similar (IRR 0.49, 95% CI 0.39 to 0.60; n=361). Absolute reduction in UTI episodes over 12 months was from a median (interquartile range) of 2 (1–4) in the no-prophylaxis group (n=180) to 1 (0–2) in the prophylaxis group (n=181). The results were unchanged by adjustment for days at risk of UTI and the presence of factors giving higher risk of UTI. Development of antimicrobial resistance was seen more frequently in pathogens isolated from urine and Escherichia coli from perianal swabs in participants allocated to antibiotic prophylaxis. The use of prophylaxis incurred an extra cost of £99 to prevent one UTI (not including costs related to increased antimicrobial resistance). The emotional and practical burden of CISC and UTI influenced well-being, but health status measured over 12 months was similar between groups and did not deteriorate significantly during UTI. Participants were generally unconcerned about using antibiotics, including the possible development of antimicrobial resistance.Limitations: Lack of blinding may have led participants in each group to use different thresholds to trigger reporting and treatment-seeking for UTI.Conclusions: The results of this large randomised trial, conducted in accordance with best practice, demonstrate clear benefit for antibiotic prophylaxis in terms of reducing the frequency of UTI for people carrying out CISC. Antibiotic prophylaxis use appears safe for individuals over 12 months, but the emergence of resistant urinary pathogens may prejudice longer-term management of recurrent UTI and is a public health concern. Future work includes longer-term studies of antimicrobial resistance and studies of non-antibiotic preventative strategies.Trial registration: Current Controlled Trials ISRCTN67145101 and EudraCT 2013-002556-32. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 22, No. 24. See the NIHR Journals Library website for further project information.

AB - Background: People carrying out clean intermittent self-catheterisation (CISC) to empty their bladder often suffer repeated urinary tract infections (UTIs). Continuous once-daily, low-dose antibiotic treatment (antibiotic prophylaxis) is commonly advised but knowledge of its effectiveness is lacking.Objective: To assess the benefit, harms and cost-effectiveness of antibiotic prophylaxis to prevent UTIs in people who perform CISC.Design: Parallel-group, open-label, patient-randomised 12-month trial of allocated intervention with 3-monthly follow-up. Outcome assessors were blind to allocation.Setting: UK NHS, with recruitment of patients from 51 sites.DOI: 10.3310/hta22240 HEALTH TECHNOLOGY ASSESSMENT 2018 VOL. 22 NO. 24© Queen’s Printer and Controller of HMSO 2018. This work was produced by Pickard et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.viiParticipants: Four hundred and four adults performing CISC and predicted to continue for = 12 months who had suffered at least two UTIs in the previous year or had been hospitalised for a UTI in the previous year.Interventions: A central randomisation system using random block allocation set by an independent statistician allocated participants to the experimental group [once-daily oral antibiotic prophylaxis using either 50mg of nitrofurantoin, 100mg of trimethoprim (Kent Pharmaceuticals, Ashford, UK) or 250mg of cefalexin (Sandoz Ltd, Holzkirchen, Germany); n=203] or the control group of no prophylaxis (n=201), both for 12 months.Main outcome measures: The primary clinical outcome was relative frequency of symptomatic, antibiotic-treated UTI. Cost-effectiveness was assessed by cost per UTI avoided. The secondary measures were microbiologically proven UTI, antimicrobial resistance, health status and participants’ attitudes to antibiotic use.Results: The frequency of symptomatic antibiotic-treated UTI was reduced by 48% using prophylaxis [incidence rate ratio (IRR) 0.52, 95% confidence interval (CI) 0.44 to 0.61; n=361]. Reduction in microbiologically proven UTI was similar (IRR 0.49, 95% CI 0.39 to 0.60; n=361). Absolute reduction in UTI episodes over 12 months was from a median (interquartile range) of 2 (1–4) in the no-prophylaxis group (n=180) to 1 (0–2) in the prophylaxis group (n=181). The results were unchanged by adjustment for days at risk of UTI and the presence of factors giving higher risk of UTI. Development of antimicrobial resistance was seen more frequently in pathogens isolated from urine and Escherichia coli from perianal swabs in participants allocated to antibiotic prophylaxis. The use of prophylaxis incurred an extra cost of £99 to prevent one UTI (not including costs related to increased antimicrobial resistance). The emotional and practical burden of CISC and UTI influenced well-being, but health status measured over 12 months was similar between groups and did not deteriorate significantly during UTI. Participants were generally unconcerned about using antibiotics, including the possible development of antimicrobial resistance.Limitations: Lack of blinding may have led participants in each group to use different thresholds to trigger reporting and treatment-seeking for UTI.Conclusions: The results of this large randomised trial, conducted in accordance with best practice, demonstrate clear benefit for antibiotic prophylaxis in terms of reducing the frequency of UTI for people carrying out CISC. Antibiotic prophylaxis use appears safe for individuals over 12 months, but the emergence of resistant urinary pathogens may prejudice longer-term management of recurrent UTI and is a public health concern. Future work includes longer-term studies of antimicrobial resistance and studies of non-antibiotic preventative strategies.Trial registration: Current Controlled Trials ISRCTN67145101 and EudraCT 2013-002556-32. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 22, No. 24. See the NIHR Journals Library website for further project information.

KW - antibiotic

KW - urinary tract infection

KW - clean intermittent self-catheterisation

U2 - 10.3310/hta22240

DO - 10.3310/hta22240

M3 - Article

VL - 22

JO - Health Technology Assessment

JF - Health Technology Assessment

SN - 1366-5278

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