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LETTER |
Correspondence: Requests for reprints should be sent to Alan R. Katz, MD, MPH, Department of Public Health Sciences and Epidemiology, John A. Burns School of Medicine, University of Hawaii, 1960 East-West Rd, Biomedical Sciences Bldg, Room D104K, Honolulu, HI 96822 (e-mail: katz{at}hawaii.edu).
I read with interest the article by Alraek and colleagues describing a study in which women with a history of uncomplicated recurrent urinary tract infections (UTIs) were randomly assigned to receive acupuncture or no treatment to assess the efficacy of acupuncture on the incidence of recurrent UTIs.1 The use of a randomized clinical trial with well-defined objective endpoints lends strength to this study; however, before acupuncture is recommended as an effective method of prophylaxis for UTIs, additional information is needed.
No mention is made of how (or even whether) recurrent UTIs occurring during the follow-up period were treated. While asymptomatic bacteriuria in healthy nonpregnant women may not warrant therapeutic interventions,2 antimicrobials are indicated for symptomatic UTIs with bacteriuria ( 
105 colony-forming units per milliliter uropathogens), especially in young women.3 Information regarding possible differences in either the antibiotics dispensed or duration of treatment in the women experiencing recurrent UTIs during the follow-up period would be important in interpreting the study’s findings.
Biological plausibility of the findings is a key issue.4 Although no attempt was made to directly address how acupuncture reduces the risk of UTI, data are given demonstrating a decrease in residual urine in the acupuncture group. However, this point would have greater support if, in addition to the notreatment group, the residual urine levels were also shown to remain unchanged in a "sham-acupuncture" group (information also missing from the authors’ earlier study5). Further urodynamic or bladder imaging studies (e.g., ultrasonography or magnetic resonance imaging) to explain and validate these findings are clearly in order.
One potential concern with the study was that some women were of reproductive age. The consequences of an untreated UTI, whether symptomatic or asymptomatic, are significantly greater for pregnant women.3 Although pregnancy was noted as an exclusionary criterion for study entry, there was no mention by the authors of whether pregnancy status was reevaluated at the time that recurrent UTIs were documented. If these infections were left untreated, this is somewhat worrisome.
It is important and necessary to subject complementary and alternative methods to rigorous and sound epidemiological study evaluations before they are offered as effective. In addition, alternative explanations for unexpected or unexplained findings should be explored, and additional confirmatory information provided before one embraces any new therapeutic or prophylactic modality.
References
1. Alraek T, Soedal LIF, 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;92:1609–1611.
2. Nicolle LE. Asymptomatic bacteriuria—important or not? N Engl J Med.2000;343:1037–1039.
3. Schaeffer AJ. Infections of the urinary tract. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: WB Saunders Co; 2002:515–602.
4. Rothman KJ, Greenland S. Causation and causal inference. In: Rothman KJ, Greenland S. Modern Epidemiology. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998:7–28.
5. Aune A, Alraek T, LiHua H, Baerheim A. Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women. Scand J Prim Health Care.1998;16:37–39.[Medline]
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