Probiotics [LGG-BB12 or RC14-GR1] versus placebo as prophylaxis for urinary tract infection in persons with spinal cord injury [ProSCIUTTU]: a study protocol for a randomised controlled trial
Lee et al. BMC Urology
Probiotics [LGG-BB12 or RC14-GR1] versus placebo as prophylaxis for urinary tract infection in persons with spinal cord injury [ProSCIUTTU]: a study protocol for a randomised controlled trial
Bonsan Bonne Lee 1 2
Swee-Ling Toh 0 1
Suzanne Ryan 2
Judy M. Simpson 0
Kate Clezy 5
Laetitia Bossa 2 4
Scott A. Rice 4
Obaydullah Marial 1 3
Gerard Weber 3
Claire Boswell-Ruys 2
0 School of Public Health, University of Sydney , Sydney , Australia
1 Department of Spinal and Rehabilitation Medicine, Prince of Wales Hospital , Sydney , Australia
2 Neuroscience Research Australia [NeuRA] and the University of New South Wales , Sydney , Australia
3 Royal Rehabilitation
4 Centre for Marine Bio-Innovation, University of New South Wales , Sydney , Australia
5 Department of Infectious Diseases, Prince of Wales Hospital , Sydney , Australia
Background: Urinary tract infections [UTIs] are very common in people with Spinal Cord Injury [SCI]. UTIs are increasingly difficult and expensive to treat as the organisms that cause them become more antibiotic resistant. Among the SCI population, there is a high rate of multi-resistant organism [MRO] colonisation. Non-antibiotic prevention strategies are needed to prevent UTI without increasing resistance. Probiotics have been reported to be beneficial in preventing UTIs in post-menopausal women in several in vivo and in vitro studies. The main aim of this study is to determine whether probiotic therapy with combinations of Lactobacillus reuteri RC-14 + Lactobacillus rhamnosus GR-1 [RC14-GR1] and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 [LGG-BB12] are effective in preventing UTI in people with SCI compared to placebo. Method: This is a multi-site randomised double-blind double-dummy placebo-controlled factorial design study conducted in New South Wales, Australia. All participants have a neurogenic bladder as a result of spinal injury. Recruitment started in April 2011. Participants are randomised to one of four arms, designed for factorial analysis of LGG-BB12 and/or RC14-GR1 v Placebo. This involves 24 weeks of daily oral treatment with RC14-GR1 + LGG-BB12, RC14-GR1 + placebo, LGG-BB12 + placebo or two placebo capsules. Randomisation is stratified by bladder management type and inpatient status. Participants are assessed at baseline, three months and six months for Short Form Health Survey [SF-36], microbiological swabs of rectum, nose and groin; urine culture and urinary catheters for subjects with indwelling catheters. A bowel questionnaire is administered at baseline and three months to assess effect of probiotics on bowel function. The primary outcome is time from randomisation to occurrence of symptomatic UTI. The secondary outcomes are change of MRO status and bowel function, quality of life and cost-effectiveness of probiotics in persons with SCI. The primary outcome will be analysed using survival analysis of factorial groups, with Cox regression modelling to test the effect of each treatment while allowing for the other, assuming no interaction effect. Hazard ratios and Kaplan-Meier survival curves will be used to summarise results. (Continued on next page)
(Continued from previous page)
Discussion: If these probiotics are shown to be effective in preventing UTI and MRO colonisation, they would be a very
attractive alternative for UTI prophylaxis and for combating the increasing rate of antibiotic resistance after SCI.
Trial registration: Australian New Zealand Clinical Trials Registry [ACTRN 12610000512022]. Date of registration:
21 June 2010.
Urinary tract infections [UTIs] are very common in
people with a neurogenic bladder. People with a spinal
cord injury [SCI] and people with the spinal demyelinating
form of Multiple Sclerosis [MS] are highly susceptible to
the development of neurogenic bladder dysfunction.
UTIs have a high societal cost and current prevention
strategies do not work. People with neurogenic bladder
are at significant risk from UTI with approximately two
] UTI episodes per year on average for persons with
]. One of the major clinical challenges for SCI
patients and clinicians is that when patients get a UTI,
simple oral antibiotics frequently are ineffective due
to the high numbers of multi-resistant-organism [s]
[MROs] within SCI populations [about 40–50 % of
SCI people] [
]. This greatly amplifies the health,
societal and economic consequences of disease and
can even lead to life threatening clinical problems
that can spread if not controlled through hospitals
and the community. Health care costs associated with
cross infection are estimated at US$18–30 billion
yearly in the USA and UK combined. Australian costs
are expected to be proportionate . Furthermore,
based on the existing SCI UTI prevention literature,
we have demonstrated that current commonly used
methods of non-antibiotic UTI prevention in SCI do
not work [
]. The prevention of UTI, particularly the
more difficult to treat MRO UTI, is therefore a
clinical imperative for those people with SCI and
neurogenic bladder. Non-antibiotic prevention is needed
to prevent UTI without increasing the antimicrobial
resistance burden [
Probiotics are defined as a preparation containing
viable, defined micro-organisms in sufficient numbers,
which alter the microflora [by implantation or colonization]
in a compartment of the host and thus exert beneficial
health effects in this host [
]. Reid postulated that
probiotics could reduce antibiotic related superinfections, disrupt
bacterial biofilms, and enhance generalised mucosal
immunity in the gastrointestinal and genitourinary
]. In a systematic review conducted by
Falagas et al., it was concluded that several probiotics
tested, e.g. Lactobacillus rhamnosus GR-1 and
Lactobacillus fermentum RC-14, delivered either intravaginally or
orally, were efficacious in restoring vaginal flora and in
preventing recurrent UTIs in women [
]. In another
trial, Manley et al. demonstrated clearance of
vancomycinrelated enterococci in stool after treatment with
Lactobacillus rhamnosus GG [
There are currently no known trials of oral probiotics
and its efficacy in prevention of UTIs in people with
neurogenic bladders. Darouiche and others have
conducted more invasive trials involving inoculating
neurogenic bladders with benign strains of Escherichia coli
and showed this approach was effective at lowering the
rate of UTIs per year [
To test the effectiveness of combination oral probiotic
therapy Lactobacillus reuteri RC-14 + Lactobacillus
rhamnosus GR-1 [RC14-GR1 capsules] and/or
Lactobacillus rhamnosus GG + Bifidobacterium BB-12
[LGG-BB12 capsules] in preventing UTI in people
with SCI compared to placebo.
a) To examine whether probiotics may change or
prevent colonisation or infection with MROs in
persons with SCI.
b) To examine the effects of probiotics on bowel
function in persons with SCI
c) Examination of indwelling and suprapubic catheters
i) How probiotic intervention affects microbial
community composition in the urine and urinary
ii) Differences between microbial communities in
individuals who are symptomatic versus
asymptomatic for UTI.
d) To estimate the cost-effectiveness of probiotics in
persons with SCI
A randomised controlled trial [RCT] was selected as
the design most likely to provide a definitive conclusion
to the primary aim.
This is a prospective multi-site randomised, double-blind,
double-dummy, placebo-controlled factorial design trial
conducted in the state of New South Wales [NSW]
Australia, in order to test the effectiveness of two
probiotic therapies in preventing UTI in people with SCI.
Participants will be recruited from the NSW SCI
community and all the specialist SCI units in NSW hospitals,
including their regional and rural affiliations. These units
are located at the Prince of Wales Hospital [POWH],
Royal Rehabilitation Centre Sydney [RRCS] and Royal
North Shore Hospital [RNSH].
A multi-site ethics approval was obtained from the
Human Research Ethics Committee [HREC] at each of
the three SCI units in NSW, Australia. HREC Protocol
no: 1008-282-CTN-GG [POWH SSA 1008-282 CTN,
RR SSA 11/SSA03, RNSH SSA10/HAWKE/171].
The protocol for catheter sampling and culture
independent technique of bacterial community identification
was categorised as a low-risk study with separate ethics
approval obtained from the HREC at each site [POWH
HREC ref no. 11/036, RNSH HREC/10/HARBR/102 and
The trial was registered with the Australian New
Zealand Clinical Trials Registry [ACTRN 12610000512022]
on 21 June 2010. Informed consent will be provided prior
to recruitment and participation. Participant recruitment
commenced in April 2011.
The trial uses a factorial design which allows the two
probiotics to be compared with placebo simultaneously
without inflating the sample size, on the assumption that
they do not interact with each other. [Refer Table 1].
UTI prevention: In our previous RCT with the same
study population [
], 45 % of participants had a
symptomatic UTI within six months. To have 80 % power
to detect [at 5 % two-sided significance level] a 30 %
reduction in the treatment group requires a total
sample size of 350. Allowing for a 5 % loss to follow-up a
final sample size of 372 is required, 93 participants
being randomly allocated to each of the four study
MRO treatment: It is expected that approximately 40 %
participants will be MRO-positive at enrolment. Assuming
5-10 % become MRO-negative in the control group, a
15–20 % reduction in MRO-positive colonisation rate
with probiotics would be detectable as significant at the
5 % level, with 80 % power, with a sample size of 372.
Randomisation and blinding of assessors
A simple stratified [computer generated] randomisation
protocol is used. JS is responsible for generating the
allocation sequence. Randomisation is stratified by bladder
management types [indwelling/suprapubic vs
intermittent catheters vs condom drainage/reflex voiding] as well
as inpatient/outpatient status. Randomisation occurs
following participant’s compliance check at Day 4. One
central pharmacy is responsible for the assignment and
distribution of the intervention for the entire study. All
four treatment regimens will be indistinguishable by
appearance and taste, and all participants receive the
same quantity of tablets. All clinical staff, researchers
and participants remain blind to treatment allocation
throughout this process. An audit of randomisation,
product allocation and dispensing stock will be performed
at the completion of the study by MT, who is not affiliated
with the final analysis and the clinical management of the
study or study participants.
All participants are to be over 18 years of age and are
required to provide written consent. All participants
with known neurogenic bladder as a result of SCI who
meet inclusion criteria and gave written consent are
enrolled. BL, ST, SR, JK, LB, GW and CBR are
responsible for enrolling participants.
1) Had a known neurogenic bladder;
2) Had a stable SCI or stable multiple sclerosis with a
known spinal demyelinating lesion;
3) Had a stable bladder management technique
[i.e. not receiving bladder management education
for at least 4 weeks] and using a bladder
management technique such as indwelling
catheter, suprapubic catheter, clean intermittent
self-catheterisation or reflex/condom drainage;
4) Agreed to fortnightly telephone consultation for
themselves and their care team during the six
month study period;
5) Agreed not to take any other probiotic in
addition to the allocated intervention during the
course of the study. This includes all oral or
topical preparations of yoghurt and urinary
antiseptics [e.g. methenamine hippurate
(hiprex) or cranberry preparations].
1. Receiving bladder management education within the
last 4 weeks;
2. Being treated for, or symptomatic from a current
infection or long-standing pressure sore;
3. Known to have a complex bladder disturbance
requiring surgical intervention e.g. known
cystoplasty, renal or bladder calculus, significant
hydronephrosis, or current pyelonephritis;
4. Known to have chronic open wound/s or known
long-standing osteomyelitis [greater than 6 weeks];
5. On long-term antibiotic therapy for any indication;
6. Known to have a history of adverse drug reaction to
yoghurt products or a demonstrated intolerance to
the probiotics used. Lactose intolerance was NOT an
7. Known to have severe renal or hepatic failure;
8. Requiring full [invasive] mechanical ventilation;
9. Receiving immunosuppressant medications or
have an underlying immunosuppressive disease
[for example HIV or end-stage/ progressive
diabetes mellitus, multiple sclerosis or
10.Planning to have oral surgery during the
11.Concurrently enrolled in another intervention study
[observational studies or inclusion following
completion of another study was allowed].
Each participant is enrolled for a six month study period,
which includes 24 weeks of treatment [see Fig. 1]. Each
participant randomised is required to take two tablets orally
each day consisting of either RC14-GR1 + LGG-BB12
Fig 1 Participant Study Flow Chart for ProSCIUTTU
or RC14-GR1 + placebo or LGG-BB12 + placebo or 2
1. GR1-RC14. Concentration per capsule is 5.4 × 109
colony forming units.
2. LGG-BB12. Concentration per capsule is 7 × 109
colony forming units.
Participants will be assessed at Day 0, 3 months
and 6 months, supported by fortnightly phone calls
to determine health status and confirm intercurrent
symptomatic UTI status. [Fig. 1] Following witnessed
informed consent, evaluations conducted will be:
Intervention issues and compliance.
Quality of life assessment with the Short Form
Health Survey [SF-36] – baseline and 6 months plus
study endpoint if reached.
Microbiological swabs of rectum, nose and groin,
urine culture and collection of urinary catheters for
participants with indwelling or suprapubic catheters
– baseline, 3 months and 6 months. Urine cultures
also performed if at study endpoint. Specific
instructions for sampling were given by study
co-ordinator to research assistants and community
nurses performing the swabs to ensure consistency.
Bowel questionnaire [
] - baseline and
The indwelling urethral and suprapubic catheter
biofilm is examined as a proxy for the urinary tract
microbial community. Culture-independent techniques
in profiling human microbes will be used to
determine the composition of adherent microbes through
the examination of the bacterial 16S rDNA gene by
Terminal Restriction Fragment Length Polymorphism
] and via next-generation sequencing
Samples are selected irrespective of interventional
Samples are also selected from groups with
recurrent symptomatic UTI compared to no-UTI
symptoms over the study follow-up period. All TRFLP and
sequencing analysis will be conducted blinded by the
use of a participant identification key that de-identifies the
TRFLP is done in collaboration with the Ramaciotti
Centre for Genomics, University of New South Wales
and sequencing through the Singapore Centre for
Environmental Life Sciences Engineering at Nanyang
Technological University, Singapore.
1. The primary outcome measure is the time from
randomisation to occurrence of “symptomatic
UTI” [Fig. 2]. The date of the endpoint is the
date participants develop symptoms consistent
with a “symptomatic UTI” as per the algorithm,
not the date participants start developing any
symptoms. Table 2 outlines the definition of
“symptomatic UTI” as primary endpoint for
ProSCIUTTU. For participants who do not
experience a “symptomatic UTI”, the primary
outcome is at six months. Participants who cease
intervention early are followed up until the end of
the study period.
2. The secondary endpoint is time to change of
MRO colonisation status as determined by two
successive cultures [See guidelines for MRO
change or clearance in Additional file 1].
All analyses of outcomes will be by intention to treat,
apart from safety outcomes which will be according
to actual treatment received. Primary and MRO
outcomes will be analysed using survival analysis. Cox
regression modelling will be performed to test the
effect of each treatment while allowing for the other,
assuming no interaction effect. Hazard ratios and
Kaplan-Meier survival curves will be used to
summarise results. The extremely high prevalence of
MRO in SCI will also allow us to explore whether
probiotics can treat [or prevent] MRO colonisation in
A survey was sent out to selected co-authors for
determining the strength of association of several variables in
regards to UTI in the SCI population [pre hoc review].
Only variables which have strong or moderate
association will be included in the analysis.
Biofilms will be analysed using a combination of RNA
based meta-community sequencing, TRFLP fingerprinting
and culture based methods.
Trial data management
The data will be collected on trial specific case record
forms. OM is responsible for designing and maintaining
the trial database. Following each study visit, a study
team member will ensure data is complete. Databases
will be commissioned within the SCI units and will
contain non-identifiable data. Re-identifiable data will be
available for use only by the study team. Primary
outcome measure endpoint determination will be
verified by BL and ST. The two assessors will be blinded by
each other’s assessment. Discrepancies will be decided
by a third investigator [KC].
Fig 2 Definition of primary endpoint UTI for ProSCIUTTU (need to refer to Table 2)
Feasability, safety, efficacy
The primary study endpoint is symptomatic UTI with
microbiological evidence of infection [refer to Fig. 2 and
Table 2]. However, other secondary measures of interest
Hospital admissions and intensive care unit
admissions related to infection.
A diagnosis of laboratory infection defined by a
positive blood culture.
Clinical adverse events [grade 3–4] regardless of
All causes of mortality.
Use of antibiotics.
Change in of MRO colonisation/infection status as
defined by two consecutive MRO swabs three
Modifications of bladder management.
A cost-effectiveness analysis will be undertaken
using SF-6D utility weights derived from the
SF-36. In addition to antibiotic use, the following
resource data will also be collected during the
– Use of isolation precautions: Single room; Personal
Protective Equipment [PPE];
– Isolation ward;
– Terminal clean
– Infection control auditing
An independent Safety Monitoring Committee [SMC] is
established. Clinicians or investigators responsible for
the clinical care of study participants were not permitted
to be members of the SMC. The SMC will monitor the
trial and review safety data by treatment allocation.
Safety monitoring will be carried out at various intervals
through the trial depending on frequency of adverse
events. The Committee will review laboratory data, Grade
3, Grade 4 and Grade 5 adverse events and serious adverse
events [SAEs] and adverse events leading to cessation of
study therapy [refer Table 3]. A summary of safety data
will be undertaken when all recruited participants have
completed 20 weeks on study.
The SMC Chairman had no formal affiliation with the
trial and coordinated this process.
Project governance and administration support
The chief investigator Dr. Bon San Bonne Lee will be
responsible for overall project management, but is assisted
and advised by a project steering committee comprised of
the collaborating researchers and administrative support
from the administering institution [NeuRA]. The project
steering committee will meet regularly and all agendas
and minutes circulated to all stakeholders.
Grades 1 and 2 Laboratory Abnormality or Clinical Event
Continue intervention at the discretion of the investigator
Grade 3 Laboratory Abnormality or Clinical Event
Grade 3 clinically significant laboratory abnormalities should be confirmed by repeat testing within three to five calendar days of receipt of results and before
discontinuation, unless such a delay is not consistent with good medical practice
For grade 3 clinical events, continue if the event is considered to be unrelated to the intervention. For a grade 3 clinical event, or clinically significant laboratory
abnormality confirmed by repeat testing, that is considered to be related to the intervention, both oral and bodywash interventions should be withheld until the
toxicity returns to ≤ grade 2. When restarting following resolution of the adverse event, both interventions to be restarted simultaneously following discussion
with the study monitor
Grade 4 Laboratory Abnormality or Clinical Event For grade 4 clinical event or clinically significant laboratory abnormality confirmed by repeat testing that is
considered related to the intervention, the intervention should be permanently discontinued and subjects managed according to local practice. The subject
should be followed as clinically indicated until the event resolves to baseline, or is otherwise explained, whichever occurs first. Study interventions may be
continued without modification for non-clinically significant grade 4 laboratory abnormality (e.g. triglyceride elevation that is non-fasting or that can be medically
managed) or clinical event considered unrelated to the study intervention
Additional file 1: Guidelines for MRO change and clearance. (DOC 27 kb)
BB12: bifidobacterium BB-12; GR1: lactobacillus rhamnosus GR-1;
LGG: lactobacillus rhamnosus GG; MRO: multi-resistant organism;
MS: multiple sclerosis; NHMRC: National Health and Medical Research Council
of Australia; PPE: personal protective equipment; RC14: lactobacillus reuteri
RC-14; RNA: ribonucleic acid; SAE: serious adverse event; SF-36: short form
health survey; SCI: spinal cord injury; SMC: safety monitoring committee;
TRFLP: terminal restriction fragment length polymorphism; UTI: urinary
CHR Hansen has been paid commercial rates for providing the intervention
product and placebo. The company had no input into the design of the trial.
BL, JS, SG and JM have received competitive research funding support from
the National Health and Medical Research Council of Australia [NHMRC].
They declare that they have no other financial or non-financial competing
interests. The rest of the authors have no competing financial or
The trial protocol has been developed by all authors over a series of
teleconferences and workshops in Sydney, Australia in late 2009 and early 2010
from an original study design developed by BL and JS. LB and SAR were
responsible for the protocol design and analysis of culture independent
techniques of microbioflora identification. SR is the overall study project
co-ordinator. SR is responsible for the study regulatory processes including
designing the data collection forms, ethics and regulatory submissions as well as
co-ordinating packaging of the investigational products. OM is responsible for
designing and maintaining the trial database. JS is responsible for designing the
biostatistical aspects of the trial and reviewing the statistical analysis. SG is
responsible for designing the health economics aspects of the protocol and
analysing the health economics data. GK is responsible in co-ordinating the
microbiological sample analysis. MT is responsible for auditing the pharmacy
compliance with protocol. BL, JK and GW are site investigators at the respective
three spinal units. Recruitment is undertaken by BL, ST, SR, JK, GW, LB, CBR. Data
collection is conducted by BL, SR, ST, OM, LB and CBR. ST, BL and KC are
responsible for study endpoint determination. BL, SR and ST are responsible for
initial manuscript preparation. All authors reviewed and were involved in writing
up the final version of the manuscript prior to submission.
The authors would like to acknowledge Dr. Marcella Kwan and Ms. Elizabeth
Rose, for their contributions as research assistants for the trial. The authors
would like to thank Professor Ian Cameron for his role as the SMC Chairman.
The authors would also like to thank Ms. Hanan Youssef and Ms. Alysia
Wong for administrative support.
NHMRC is the organisation responsible for funding the supply of probiotics
and matching placebo selected by the researchers for this study and
budgeted within the NHMRC grant.
Centre Sydney, Sydney, Australia. 7Royal North Shore Hospital, Sydney,
Australia. 8Centre for Health Economics Research and Evaluation [CHERE],
University of Technology Sydney, Sydney, Australia. 9The Singapore Centre
for Life Sciences Engineering and the School of Biological Sciences, Nanyang
Technological University, Singapore, Singapore. 10John Walsh Centre for
Rehabilitation Research, Kolling Institute, Northern Sydney Local Health
District, St Leonards, NSW 2065, Australia. 11Sydney Medical School Northern,
University of Sydney, Sydney, Australia.
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