A Clinical Trial of Extended (High) Treatment Dose Antibiotics in Combination With Methenamine Hippurate Compared to the Standard of Care (Either Prophylactic (Low) Dose Antibiotic Treatment or Methenamine Hippurate) in Females With Chronic Urinary Tract Infection

Phase 2RecruitingNCT07202949

University College, London192 enrolled

Overview

Chronic Urinary Tract Infection (UTI) is a type of UTI where symptoms are constant and occur every day, unlike recurrent UTIs, which come and go with symptom-free breaks in between. Current treatment for chronic UTI within the NHS is based on recommended guidelines for recurrent UTI. The standard approach typically includes one of the following treatments: * Long-term, prophylactic (low) dose daily antibiotic (where medication is used at low doses to try to prevent symptoms reoccurring). * Long-term use of a urinary antiseptic (which helps keep your urine bacteria free), called methenamine hippurate. These often do not work for people with chronic UTI, and symptoms can persist. Moreover, standard urine tests may fail to detect infections, making diagnosis and treatment more challenging. The EAT-UP trial will investigate whether longer courses of treatment (higher) dose antibiotics combined with methenamine hippurate (a urinary antiseptic) are a more effective treatment at reducing levels of infection and symptoms than standard of care treatments (as described above).

EAT-UP is a UK multi-centre, randomised, open label, parallel-group, superiority, interventional phase II trial, aiming to recruit 192 female participants. Participants will undergo screening to evaluate their eligibility to participate in the trial. If eligible, participants will be randomly assigned into one of two groups: Group 1 will receive a treatment dose antibiotic in combination with the urinary antiseptic, methenamine hippurate (1 g twice daily). The treating clinician will select one of the following antibiotics based on the individual needs of the participant, such as their medical history, concomitant medications and any known allergies: * Cefalexin (500mg four times daily), or * Nitrofurantoin (100mg twice daily), or * Trimethoprim (200mg twice daily) Group 2 will receive a low-dose prophylactic antibiotic or the urinary antiseptic, methenamine hippurate. The treating clinician will select one of the following treatments based on the individual needs of the participant, such as their medical history, concomitant medications and any known allergies: * Amoxicillin (250mg once daily), or * Cefalexin (125mg once daily), or * Nitrofurantoin (50mg once daily), or * Trimethoprim (100mg once daily), or * Methenamine Hippurate (1g twice daily) Participants will be taking trial medication for 12 weeks and will be required to attend clinic for assessments every 4 weeks. Participant will complete questionnaires and provide blood, urine, and perineal (the area between the vagina and anus) swabs samples.

Study Type

INTERVENTIONAL

Interventions

Treatment dose antibiotic in combination with methenamine hippurateDRUG

Arm A includes treatment with one of three treatment dose antibiotic options, selected by the treating clinician, in combination with methenamine hippurate. Participants allocated to this arm will receive combination therapy, consisting of one of the following antibiotics: * Cefalexin (500mg four times daily), or * Nitrofurantoin (100mg twice daily), or * Trimethoprim (200mg twice daily) in combination with Methenamine Hippurate (1g twice daily) for 12 weeks.

Prophylactic dose antibiotic or methenamine hippurate monotherapyDRUG

Arm B includes treatment with one of four prophylactic dose antibiotics or methenamine hippurate, but not both, selected by the treating clinician. Participants in this arm will receive monotherapy of one of the following: * Amoxicillin (250mg once daily), or * Cefalexin (125mg once daily), or * Nitrofurantoin (50mg once daily), or * Trimethoprim (100mg once daily), or * Methenamine Hippurate (1g twice daily) for 12 weeks.

Eligibility

Sex: FEMALEMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. A diagnosis of chronic UTI, without structural or functional urinary tract abnormality\*, defined as daily persistent symptoms affecting storage (urinary frequency, urgency or urge incontinence) and urinary tract pain symptoms (including bladder pain, urethral pain, or dysuria), for at least 3 months prior to the screening visit, with previously associated transient symptomatic improvement to antibiotic treatment for UTI, which in the opinion of the delegated clinician is secondary to chronic urinary tract infection. 2. A fresh urine microscopy examination showing ≥20 white blood cells/µl of urine at the screening visit. 3. Female\*\* patients. 4. Aged ≥18 years. 5. Screening blood result of eGFR ≥45ml/min/1.73m2. 6. Able and willing to attend trial visits and comply with all study procedures for the duration of the trial. 7. Able and willing to provide informed consent prior to any study related assessments and/or procedures. * A structural or functional abnormality may include kidney reflux, current or long-term catheter use, renal transplant, diversion surgery, renal stones, grade 2 or above utero-vaginal prolapse or incomplete bladder emptying. * For the purposes of this trial, a female will be defined as an individual assigned female at birth who has a female urinary tract. Exclusion Criteria: 1. Inability to take at least one of the following antibiotics: Cefalexin, Nitrofurantoin, or Trimethoprim, at prophylactic and treatment dose according to NICE guidelines, and/or the Summary of Product Characteristics (such as hepatic or renal dysfunction), or any other medical contraindications. 2. Inability to take methenamine hippurate due to medical contraindications. 3. Current use of immune-modulating drugs for the treatment of chronic illnesses such as rheumatoid arthritis, chronic lung disease, any other autoimmune conditions or cancer. 4. Current use of Sodium-Glucose Transport Protein 2 (SGLT2) inhibitors\*. 5. A current diagnosis of bladder cancer. 6. A diagnosis of an active sexually transmitted infection or a recent diagnosis of a sexually transmitted infection within the last 3 months of the screening visit. 7. Previous use of an antibiotic at treatment dose as per NICE guidelines for more than 14 consecutive days for treatment of UTI in the last 3 months prior to the screening visit. 8. Pregnancy (or planned pregnancy during trial participation) and/or breastfeeding. 9. Women of childbearing potential that are unable/unwilling to use an acceptable method of contraception (as described in section 3.4.1) to avoid pregnancy for the duration of the trial and for 1 week after the last dose of trial medication. 10. Current participation in another clinical trial of a device, interventional medicinal product, advanced therapy, or surgical procedure; or previous participation within 6 months of the screening visit. 11. Any medical condition or previous treatment which in the investigator's opinion compromises the potential participant's ability to participate. * Patient's must not have taken a Sodium-Glucose Transport Protein 2 (SGLT2) inhibitor within 24 hours before the screening visits to be eligible for the trial.

Locations (4)

University College London Hospital (UCLH), UCLH NHS Foundation Trust

London, United Kingdom

RECRUITING

Whittington Hospital, Whittington Health NHS Trust

London, United Kingdom

RECRUITING

St Mary's Hospital, Manchester University NHS Foundation Trust

Manchester, United Kingdom

RECRUITING

Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust

Newcastle upon Tyne, United Kingdom

RECRUITING

Outcomes

Primary Outcomes

Change in urinary white blood cell (WBC) count from baseline to Week 12.

Urinary white blood cell (WBC) count, measured using fresh urine microscopy, will be used as the principal biomarker to indicate urinary tract inflammation.

Time frame: Baseline, Week 4, Week 8, Week 12

Secondary Outcomes

Changes in EuroQol EQ-5D 5-Level Health Related Quality of Life Questionnaire (EQ-5D-5L) scores at week 12, adjusted for baseline

The EQ-5D-5L is a participant self-reported questionnaire which evaluates the generic quality of life at the time of completion. It comprises of a 5 item questionnaire (assessing - mobility, self-care, usual activities, pain/discomfort, anxiety/depression) and a visual analogue scale (VAS). Each dimension assessed has 5 response scales to select from: no problems, slight problems, moderate problems, severe problems, and extreme problems

Time frame: Baseline, Week 12

Changes in ICIQ Lower Urinary Tract Symptoms quality of life (ICIQ-LUTSqol)

The ICIQ Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol) is designed to assess the impact of lower urinary tract symptoms (LUTS) on a patient's quality of life. It consists of 19 items that explore various aspects of daily living affected by LUTS, including physical, social, emotional, and psychological domains. Responses are measured using a Likert scale, allowing clinicians and researchers to quantify the burden of symptoms and evaluate changes over time.

Time frame: Baseline, Week 4, Week 8, Week 12

Changes in Whittington 39-point Lower Urinary Tract Symptoms (W-39 LUTS) scores at week 12, adjusted for baseline

The Whittington 39-point Lower Urinary Tract Symptoms (W-39 LUTS) is a questionnaire designed to assess participant's experiences of lower urinary tract symptoms (LUTS). It consists of 39 items that explore the following LUTS symptom groups: Urgency, Pain, Stress Incontinence and Voiding.

Time frame: Baseline, Week 4, Week 8, Week 12

Patient Global Impression of Improvement (PGI-I) scores at week 12.

The Patient Global Impression of Improvement (PGI-I) is used to assess a participant's perception of change in their condition following treatment. It consists of a single-item questionnaire where patients rate their overall improvement on a 7-point Likert scale, ranging from "very much better" to "very much worse."

Time frame: Week 4, Week 8, Week 12

Participant satisfaction with medication using Lübeck Medication Satisfaction (LMS) Questionnaire scores at week 12

The Lübeck Medication Satisfaction (LMS) Questionnaire is designed to assess participant satisfaction with their trial medication. It comprises 18 items that evaluate satisfaction across domains such as effectiveness, side effects, ease of use, and overall contentment.

Time frame: Week 12

Treatment adherence assessed by the MARS-5 questionnaire at weeks 4, 8 and 12.

The Medication Adherence Report Scale (MARS-5) is a self-report questionnaire used to assess medication adherence behaviour in participants with chronic conditions. It includes 5 items that measure both intentional and unintentional non-adherence, such as forgetting to take medication or altering doses. Each item is rated on a 5-point Likert scale, with higher scores indicating better adherence.

Time frame: Week 4, Week 8 and Week 12

Frequency of rescue therapy use for participants requiring further treatment escalation for an acute flare of symptoms at 12

Participants will be prescribed rescue therapies, typically short courses of antibiotics at higher doses than their assigned treatment arm, in response to acute symptom flares. The use and effectiveness of these therapies will be reviewed at each trial visit.

Time frame: Week 4, Week 8 and Week 12

Changes in urine culture species, cfu/ml count, sensitivities and resistance profiles at week 12, adjusted for baseline

Urine samples will be submitted to the central laboratory for testing to evaluate the changes in the type of bacteria found in the urine, the amount of bacteria and how the bacteria is responding to antibiotics (including resistance).

Time frame: Baseline and Week 12

Changes in Perineal swab analyses of E.coli identified, sensitivities and resistance profiles at week 12, adjusted for baseline

A swab will be taken from the area between the vagina and anus (this is called the perineal area) either by the participant (self-swab) or with assistance from the local research team. The swab will be submitted to the central laboratory for testing. The tests will be used to measure any changes in how bacteria in the gut responds to antibiotics (also known as antimicrobial resistance).

Time frame: Baseline and Week 12

Safety and tolerability of the intervention as indicated by changes in pulse (bpm) from baseline to Week 12

Vital signs