Pinning down the evidence for acupuncture for recurrent urinary
tract infection (UTI)
Rufus Cartwright,1 Pawel Miotla2
1) Oxford University Hospitals NHS Foundation Trust,
Oxford, UK
2) Medical University of Lublin,
Lublin, Lubelskie, Poland.
Email: rufus.cartwright@gmail.com
UTI is among the most common bacterial infections, accounting for around
one quarter of all antibiotic prescriptions. At least one quarter of
women who experience a UTI will also go on to have a confirmed
recurrence within six months, thereby meeting the definition for
recurrent UTI [Foxman B. Am J Public Health . 1990;80:331-3].
While antibiotics remain widely effective both for treatment and
prevention of recurrence, we face significant antibiotic resistance,
with high rates of primary resistance in urine cultures, and knock on
effects on bloodstream sepsis, particularly from drug resistant E.
coli . Effective non-antibiotic approaches in recurrent UTI treatment or
prophylaxis would be very attractive both for individual patients and
from the population perspective [Sihra N et al. Nat Rev Urol.2018;15:750-76].
This systematic review [Qin X et al. BJOG 2020
https://doi.org/10.1111/1471-0528.16315] updates earlier reviews of
the topic, including the only two RCTs of acupuncture for prophylaxis of
recurrent UTI, and adding three more recent RCTs that have tested
acupuncture for treatment of upper or lower tract infection. The authors
assert on the basis of two unblinded trials, a GRADE rating of low
certainty in an estimated RR of 0.39 with acupuncture compared to no
treatment for prevention of recurrence over six months. The authors
suggest on the basis of a single partially blinded trial, a GRADE rating
of moderate certainty in an estimated RR of 0.45 for acupuncture
compared to sham acupuncture for prevention of recurrence over six
months. Skeptics might have further rated down the certainty in
estimates, noting few events, wide confidence intervals, high risk of
bias, and uncertainty about selective outcome reporting or publication
bias.
For the issue of treatment of active UTI, among women with a recurrent
UTI, readers may be even more skeptical. The authors identify that while
acupuncture might reduce symptoms of cystitis, it is implausible that it
should treat bacterial cystitis or upper tract infection. On the basis
of three unblinded trials, the authors suggest a GRADE rating of low
certainty in a RR of 1.92 for a composite definition of cure with either
needle acupuncture (one trial) or moxibustion (two trials) compared to
antibiotics. On the basis of one trial, they also suggest very low
certainty in a 2-day reduction in symptom duration. None of these trials
are available in English, and the authors do not specify in the
characteristics of included studies, but these studies may provide only
indirect evidence for the patients seen in gynaecological practice. One
trial is explicitly for chronic pyelonephritis, one is for chronic UTI
(unclear if upper or lower tracts), and the single trial for recurrent
bacterial cystitis demonstrates no benefit in composite cure. All three
trials have extremely low rates of cure with antibiotics (22.9-35.0%).
Again then, we might further rate down the evidence on the basis of
indirectness, as it may not apply for the typical uncomplicated
recurrent bacterial cystitis seen in gynaecology.
Given the lack of biological plausibility, and very low confidence in
the evidence base, it is unsurprising that current guidance does not
recommend use of acupuncture for prevention or treatment of UTI [EAU.
Urological Infections Guidelines.
https://uroweb.org/guideline/urological-infections/ Accessed 27 May
2020]. A change in confidence can only come from adequately blinded,
appropriately powered RCTs, but there will be little appetite from
funders based on the current evidence.
Disclosures: Rufus Cartwright- no conflict of interests; Pawel
Miotla- consultant for Adamed, Angelini, Astellas, Bayer, Bionorica.
Completed disclosure of interest forms are available to view online as
supporting information.