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Prospective study-antibiosis vs the association of N-acetylcysteine, D-mannose and Morinda

Prospective study to compare antibiosis versus the

association of N-acetylcysteine, D-mannose and Morinda

citrifolia fruit extract in preventing urinary tract infections

in patients submitted to urodynamic investigation.

Giovanni Palleschi 1, Antonio Carbone 1, Pier Paolo Zanello 2, Rita Mele 3, Antonino Leto 1,

Andrea Fuschi 1, Yazan Al Salhi 1, Gennaro Velotti 1, Samer Al Rawashdah 4, Gianluca Coppola 1,

Angela Maurizi 1, Serena Maruccia 5, Antonio L. Pastore 1

1 Unit of Urology, Department of Sciences and Medico Surgical Biotechnologies, Sapienza, University of Rome, Latina, Italy,

Uroresearch Association;

2 Researcher in Microbiology and Virology, Deakos Consultant,

3 Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy;

4 Urology Unit, Special Surgery Department, Faculty of Medicine, Mutah University, Karak, Jordan;

5 Unit of Urology, IRCCS Policlinico San Donato Milanese, Milano, Italy.

Background: The abuse of antimicrobical

drugs has increased the resistance of

microorganisms to treatments, thus to make urinary tract

infections (UTIs) more difficult to eradicate. Among natural

substances used to prevent UTI, literature has provided

preliminary data of the beneficial effects of D-mannose,

N-acetylcysteine, and Morinda citrifolia fruit extract, due to

their complementary mechanism of action which contributes

respectively to limit bacteria adhesion to the urothelium, to

destroy bacterial pathogenic biofilm, and to the anti-inflammatory

and analgesic activity. The purpose of this study was

to compare the administration of an association of

D-mannose, N-acetylcysteine (NAC) and Morinda citrifolia

extract versus antibiotic therapy in the prophylaxis of UTIs

potentially associated with urological mini-invasive

diagnostics procedures, in clinical model of the urodynamic


Methods: 80 patients eligible for urodynamic examination,

42 men and 38 women, have been prospectively enrolled in

the study and randomised in two groups (A and B) of 40

individuals. Patients of group A followed antibiotic therapy

with Prulifloxacine, by mouth 400 mg/day for 5 days, while

patients of the group B followed the association of mannose

and NAC therapy, two vials/day for 7 days. Ten days after

the urodynamic study, the patients were submitted to urine

examination and urine culture.

Results: The follow up assessment didn't show statistical

significant difference between the two groups regarding the

incidence of UTI.

Conclusions: The association of mannose and NAC therapy

resulted similar to the antibiotic therapy in preventing UTIs

in patients submitted to urodynamic examination.

This result leads to consider the possible use of these

nutraceutical agents as a good alternative in the prophylaxis

of the UTI afterwards urological procedures in urodynamics.

KEY WORDS: Urinary Tract Infection (UTI); D-mannose -

N-acetylcysteine (NAC); Urodynamic; Biofilm.

Submitted 24 July 2016; Accepted 24 December 2016


Competing interests

Zanello PierPaolo: Consultant: Deakos.

The other CoAuthors have no financial or non-financial competing interests to declare.


Urinary tract infections (UTIs) are defined as the presence

and the proliferation of bacteria which are pathogens in

one or more parts of the urinary tract with subsequent

invasion of tissue and the onset of symptoms. UTIs represent

a great problem for the public health systems,

because they are responsible for high morbility and are

also one of the main causes of antibiotic prescriptions

associated to an increased resistance to them (1).

In Europe UTIs represent the second cause of bacterial

infection, after the respiratory, and are the most frequent

form of nosocomial infections, associated mostly to the

bladder catheterism (2, 3). Furthermore, the high volume

of antibiotics used to face UTIs determines high costs for

the sanitary systems and their abuse has significantly contributed

to the development of resistance mechanisms of

the germs to these drugs (4). Females are usually more

exposed to this pathologic condition due to anatomical

factors. However, after the age of 50, the risk of UTI

increases also for men because of obstructive problems

due to the benign prostatic hypertrophy (Table 1).

Some other factors may contribute to increase the risk of

developing UTI, and they should not be underestimated,

such as intrauterine contraceptives (spiral), pregnancy

(because it causes urinary stasis), menopausal status,

anatomical and endocrine disrupters, constipation, wrong

behavioural habits, various types of urinary catheterisms

(ureteral stent, nephrostomy, intermittent or indwelling

bladder catheterization). The Annual Epidemiological report

of the European Centre for Disease Prevention and Control

(ECDC) published in April 2015, reported that pathogenic

agent which is responsible of most UTIs (about 70%) is

Escherichia coli, a bacteria of faecal origin which belongs to

the gram-negative (5). E. coli is an emerging problem also

regarding community acquired UTI either in pediatric

population either in the adult and elderly subjects (4).

Particularly, subjects with severe chronic urinary dysfunc-

DOI: 10.4081/aiua.2017.1.45

Archivio Italiano di Urologia e Andrologia 2017; 89, 1

G. Palleschi, A. Carbone, P.P. Zanello, et al.


tions secondary to neuropathies and people recovered in

intensive care units are exposed to UTIs (6, 7).

For these reasons, a better understanding of mechanisms

which induce the germs’ resistance to antibiotics is needed,

such as improvement of the strategies to prevent

infections and their recurrences, with the aim to limit use

of antibiosis in the clinical practice.

In the urinary tract, the interaction between pathogen

bacteria and the epithelium is mediated by various factors

located on the bacteria cell or secreted by the same.

In fact, adhesion of bacteria is a complex process,

depending on the presence of certain fimbrial/pili structures

that allow a specific interaction of the microbe with

certain host cell receptors (8). These structures are represented

by proteins, called adhesins, that allow the specific

and selective bacterial adhesion. Specifically, two

different types of pili are distinguished: 1) mannose -

sensitive, pili or fimbria type I; 2) mannose - resistant,

pili or fimbria type II.

The type I are the main responsible factor for the colonization

and invasion of the lower urinary tract due to

the adhesion at urothelium cells level (8). However,

another feature of the pathogen bacteria is the ability to

produce, under favourable conditions, a large quantity of

a particular capsular material: the biofilm (9, 10).

Pathogenic biofilms represent the still neglected etiology

of recurrences. Biofilms are polimicrobial structured

communities, composed by 15% of bacteria and/or fungi

and 85% of a self-produced mucopolysaccharides polymeric

matrix. On biological surface, biofilms can be

intra- or extracellular, in the bladder or on mucous surface

respectively, but they can also adhere to an inert

structure, such as catether or other medical device.

Pathogens live in a quiescent state in the deep layers of

biofilm as “persister cells”, phenotypically resistant to

antibiotics and host defences and ready to re-attack the

host. Biofilm has an important role in UTIs pathogenesis,

especially when intracellular, established inside bladder

cells, because it doesn’t allow to pharmacological treatments

and to the autoimmune system to reach bacteria

efficiently. Furthermore, biofilm have a complex and

ingenious architecture that mimics a primitive circulatory

system, with particular structures called "water channels"

and "pore", allow both the distribution of nutrient,

signalling molecule, for the removal of toxic substances

too (10). It also allows the transition of genes, thanks to

the physical proximity of bacterial cells, contributing to

resistant infections and drugs- resistance (11).

Particularly considering the risk to induce drugs resistance

by germs, the possible side effects, such as intestinal

dysbiosis, the use of antibiotics should be very careful.

Aim of this research is to find an alternative natural

approach instead of antibiotics prophylaxis to prevent

UTIs, such as in mini-invasive diagnostic urodynamics

procedures. In fact, a large use of antibiotics is applied to

prevent infections, especially in men, potentially related to

various diagnostic invasive urological examinations.

Considering the pathophysiologic mechanisms that mostly

contribute to the bacteria adhesion, to prevent the

attachment and pathologic growth of bacteria and to promote

the degradation of biofilm, must be considered as

one of the main strategies to reduce the risk of UTIs.

An alternative to the antibiotic prophylaxis, in the prevention

of UTIs which can arise after urological procedures,

could be the use of natural substances, especially when

the microbial load is still low. One of these substances is

D-mannose, an inert monosaccharide which is physiologically

present in the human body (12-14). After assumption,

D-mannose is sparely metabolized, and mostly

removed through the urine. The mechanism of action is

represented by the inhibition of bacterial adhesion to the

urothelium, interfering with fimbrial adhesins type I -

Mannose - sensitive.

D-mannose plays an important role also in other functions

such as the ability to regenerate glycosaminoglycans

(GAGs) of bladder and mucosal surface, after

injury, and to detach bacteria already linked at the

urothelium (12-14). Its beneficial effects in reducing UTI

and complementary and integrative therapy for lower

urinary tract inflammatory diseases have been shown by

various studies (15-17). However, D-mannose is ineffective

against the pathogens inside biofilm thus to induce

the need of further action to better prevent the persistence

and recurrence of UTI, and the bacterial resistance.

Some evidence has already been provided about the ability

of N-acetylcysteine on reducing bacterial biofilm either

in vitro and in vivo studies (18, 19). These investigations

showed a clinical benefit due to an high ability to dis-

Table 1.

Risk factors and prevalence of UTIs according to the age and sex.

Women Men

Age Prevalence (%) Risk factors Prevalence (%) Risk factors

< 1 1 Functional or anatomic alterations of the urinary tract; 1 Functional or anatomic alterations of the urinary tract;

Incomplete immune system Incomplete immune system

1-5 4-5 Vesicoureteral reflux; congenital alterations 0.5 Congenital alterations

6-15 4-5 Vesiureteral reflux 0.5 No

16-35 20 Sexual relations; Diaphragm/spiral and spermicide; 0.5 Sexual relations


36-65 35 Estrogens deficit (post-menopausal); 20 Vesicoureteral reflux;

gynaecological surgery; neurological disorders; benign prostatic hyperplasia; stenosis;

vesicoureteral reflux; vaginal prolapse; neurological disorders; surgery;

instrumentations; dismetabolic disease; lithiasis instrumentations; dismetabolic disease; lithiasis

> 65 30 Idem + incontinence, bladder catheterism; 35 Idem + incontinence, bladder catheterism;

antimicrobical therapy antimicrobical therapy

solve the ripe biofilm matrix. Therefore, it has already

been reported that N-acetylcysteine could be useful in the

treatment of UTI, also caused by E. coli, due to its

inhibitory effect on both bacterial growth and biofilm

formation (20).

In recent years, the growing interest in phytotherapic

remedies has focused a particular interest also to Morinda

citrifolia fruit, a native plant of South - East Asia, Polynesia

and Hawaii. The demonstrated range of therapeutic

effects of Morinda citrifolia fruit is attributable to the richness

of its chemical components: Xeronine, Proxeronine,

Scopoletin, Octoanoic acid, potassium, vitamin C, terpenoids,

alkaloids, anthraquinones, linoleic acid, Alizarin, amino

acids, Acubine, L-asperuloside, caprylic acid, ursolic acid,

rutin, carotene, vitamin A (21). The dry fruit extract is

commonly used in various nutritional supplements

products for its antibacterial, anti-inflammatory, analgesic

and immunomodulatory activity, suggesting a great

role also in recurrent UTIs prevention.

For all the overmentioned considerations, it appeared of

interest to design a study to evaluate the efficacy of a

combination of D-mannose, N-acetylcysteine and Morinda

citrifolia extract on UTIs after urodynamic procedures.

Aim of this clinical study was to compare assumption

of a phytoterapic product composed by D-mannose,

N-acetylcysteine and Morinda citrifolia extract (registered

as Ausilium NAC® by Deakos s.r.l. Corso Nazionale, 169 -

La Spezia), versus the antibiotic prophylaxis with fluorochinolones,

in preventing UTIs potentially related to

mini-invasive urological diagnostic procedures. To

achieve this goal, the urodynamic examination represented

the experimental clinical model.


The clinical study has been conducted at the University of

Rome, La Sapienza, Unit of Urology, ICOT Hospital, Latina.

From February to September 2015, 80 patients have

been subjected to the urodynamic examination. Patients

have been chosen random in a cohort study including 42

men and 38 women. At the preliminary urologic consultation,

all patients were submitted to history, physical

examination including digital rectal examination in men

and vaginal exploration in women. The day for the urodynamic

investigation was planned and all the subjects

were invited to present urine examination and urine culture

7 days before the test. Patients with pathological

findings at urine examination (presence of nitrites and

pathological number of leukocytes in the urine sediment)

and/or with positive urine culture suggestive for

UTI (defined by > 105 colony-forming units/Ml) were

invited to assume antibiotics basing on antibiogram and

were excluded from this protocol. All the other patients

with negative urine examination and negative urine culture

were considered and accepted to be screened for the

study, after they have signed an informed consent.

Inclusion criteria were considered: legal age (18 years in

Italy) and ability to understand and sign the informed


Exclusion criteria were represented by: history of recent

hematuria (within 3 months), presence of indwelling

catheter or nephrostomy or suprapubic catheter or

ureteral stent, recent urological, gynaecological or pelvic

surgery (within 3 months), neoplastic disease, evidence

or suspicious of fistula, diagnosis of interstitial cystitis,

pathological findings at physical examination (e.g., digital

rectal exploration suspicious for prostate cancer or

suggestive for prostatitis). All patients satisfying inclusion

criteria were then enrolled. Therefore, the 80

patients considered for the protocol came from a preliminary

population of 134 individuals attending our outpatient

office. Following those criteria, a randomized procedure

was used for the random allocation of the

enrolled patients into two groups of 40 in equal proportions

to ensure a uniform allocation ratio (1:1). A specific

protocol has been developed for each group:

Group A: traditional treatment with antibiotics

Prulifloxacine by mouth, 400 mg/day, for 5 days starting

from the day before the procedure. Prulifloxacine is the

antibiotic suggested by the service for the prevention and

treatment of the infective diseases of the hospital; thus it

represents the recommended antibiotic for urological practice

in our institution.

Group B: oral administration of two vials/day of Ausilium

NAC® for 7 days starting from the day of the examination.

Each vial contain D-mannose 500 mg, N-acetylcysteine

100 mg and Morinda citrifolia fruit extract 300 mg,

an anti-inflammatory, immunostimulant and analgesic

phytoteraphic remedy.

After 10 days from urodynamic test, a second laboratory

assessment based on urine examination and urine culture

was performed in all patients. Results were observed

and submitted to statistical analysis, which was performed

using the S-PSS 20.0 software. At beginning, a

careful analysis was conduct to evaluated the statistical

homogeneity among the two groups (either plurifloxacine,

or Ausilium NAC®) according to the demographic

data and comorbidities. Then, patients were

compared according to their group allocation and analysis

of variance was used to find the significance of study

parameters among the groups of patients. Fisher’s exact

test, Mann-Whitney, and 95% confidence intervals were

used as appropriate. Two-tailed p value of less than 0.05

was considered as statistically significant. The local

Ethical Committee, as prescribed by law, was informed

of this observational investigation before starting the

protocol. Schematic overview of experimental design is

represented in Figure 1.


The results obtained from the anamnestic assessments

between the two groups did not show significant difference

in relation to the age, sex, body mass index,

menopausal status, co-morbidities and pharmacotherapy

(p value > 0.05). The population enrolled in the study

was stratified according to the age, benign prostatic

hyperplasia (BPH), menopausal status, different birthing

modalities, hypertension/heart diseases, diabetes, dysthyroidism,

gynaecological and urological surgery or

other pathologies, called “Other” (such as osteoporosis,

dyslipidaemia, depressive illness, etc.) as indicated in

Table 2. During the treatment, 5 patients spontaneously

Archivio Italiano di Urologia e Andrologia 2017; 89, 1 47

Prospective study to compare antibiosis versus the association of N-acetylcysteine, D-mannose and Morinda citrifolia fruit extract in...

Archivio Italiano di Urologia e Andrologia 2017; 89, 1

G. Palleschi, A. Carbone, P.P. Zanello, et al.


abandoned the study due to scarce interest in continuing

the protocol: 2 of them (both men) belonged to the

Group A and 3 (1 man and 2 women) belonged to the

Group B. Patients who left the study have been excluded

from the final evaluation. At the end of the study, 75

patients have been evaluated: 38 belonging to the group

A and 37 belonging to the group B. They have been

divided in other sub-groups according to sex: therefore,

21/38 patients (55%) of

group A and 18/37 patients

(49%) of group B were men,

while 17/38 patients (45%)

of group A and 19/37

patients (51%) of group B

were women. None patient

reported side effects in both

treatment groups. Schematic

overview of experimental

design and results obtained

are represented in Figure 1.

Obtained data denotes the

same UTIs incidence in the

two observed groups: 3/38

(7.89%) of the group A and

2/37 (5.4%) of the group

B developed UTIs (p value =

0.671) (Table 3).

Considering the laboratory

examinations performed at the

follow-up visit, the results

didn't show significant differences

between the group A

and B in terms of incidence

of UTIs.

All the patients with UTIs

were symptomatic; they were

Prulifloxacine Ausilium NAC

Men Women Tot Men Women Tot

Patients n = 21 n = 17 n = 38 n = 18 n = 19 n = 37

Average age (± 95%) 65 (± 1.62) 56 (± 1.39) 65.4 (± 1.03) 64 (± 1.45) 54.42 (± 1.88) 65.4 (± 1.09)

Diabets 3 1 4 4 1 5

Menopausal status / 12 12 / 11 11

B.P.H.* 15 / 15 12 / 12

Hypertension/heart disease 2 2 4 1 2 3

Dysthyroidism 1 1 2 / 1 1

Natural childbirth / 3 3 / 4 4

Urological surgery 2 / 2 2 / 2

Uro-gynaecological surgery / 3 3 / 5 5

Other / 4 4 / 2 2

* Benign Prostatic Hyperplasia.

Figure 1.

Schematic overview of experimental design and results obtained in the study.

Table 3.

Percentage of UTIs occurred and germ isolated in the patients from group A, group B and sub-groups according to the sex.

Table 2.

Clinical and demographic characteristics of the two experimental groups performed.

Patients Group A Group B

analyzed Prulifloxacine D-mannose and N-acetylcysteine

Sex Men Women Tot Men Women Tot

N° patients 75 21 17 38 18 19 37

% UTIs 9.5% 5,8% 7.89% 5.5% 5.2% 5.4%

Germ isolated Escherichia coli 100% Escherichia coli 100%

treated with antibiotics basing on antibiogram, followed

by further laboratory check after 15 days to ensure that

UTI was cured.

The group A and B have been divided in other two subgroups

in relation to the sex. Only 2/21 (9.5%) male

patients and 1/17 (5.8%) female patients of the group A

and 1/18 (5.5%) male patients and 1/19 (5.2%) female

patients of the group B developed UTI after urodynamic

procedures (p value = 0.946).

The results of this further division did not show particular

predispositions to UTIs depending on the sex, antibiotics

or nutraceuticals in urodynamic.


The results of this study show that there was no significant

difference regarding the incidence of UTIs between

patients undergone treatment with fluorochinolones and

those who assumed Ausilium NAC®.

The phytotherapic product combines D-mannose, able to

reduce bacterial adhesion, N-acetylcysteine, a mucolitic

molecule useful to destroy bacterial biofilms and

Morinda citrifolia extract, with anti-inflammatory,

immune stimulating and analgesic properties, in UTIs

after urodynamics procedures. Therefore, assumption of

Ausilium NAC®, two vials/day for one week provided the

same protective effect in preventing UTIs respect to the

prophylaxis with fluorochinolone Prulifloxacine. The two

compared cohorts were substantially similar regarding

comorbidities and clinical features, therefore this result

has been not conditioned by clinical and demographical

differences between the populations and it has to be

specifically related to the action of treatments used. In

case of invasive diagnostic urological procedure, which

potentially carry the risk to induce UTIs, a very careful

protocol is essential, such as sterility of instruments or

correct prophylaxis post-intervention. As an additional

strategy to reduce the risk of UTIs, instead of using

antibiotics it should be preferable to use natural substances,

basing on the evidence that these agents could

provide the same protection especially when microbial

load is still very low.

In vitro studies and preliminary clinical experiences

demonstrated that D-mannose and N-acetylcysteine can

provide a favourable effect in preventing UTIs (12, 15-

20). The present study shows that D-mannose, N-acetylcysteine

in association with Morinda citrifolia fruit extract

in the formulation of Ausilium NAC®, like plurifloxacine,

may provide a favourable effect in preventing UTI in case

of mini-invasive diagnostic procedures which require

bladder catheterism. An important advantage of

nutraceutical agents is that a natural mechanism to prevent

infections can avoid an unnecessary use of antibiotics,

limiting the risk to develop germ resistance.

Furthermore, even if it did not happen in our study, usually

antibiotics are more responsible for dysbiosis and

side effects if compared with natural substances. As a

further consideration, patients accepted with pleasure to

assume a nutraceutical agents rather than antibiotic prophylaxis

to prevent UTIs.

The results obtained suggest to better explore, on larger

case series, the advantage of this particular association of

nutraceuticals, whose action mechanisms are of particularly

suitable interest in UTIs prevention.

The synergy between D-mannose, N-acetylcysteine, and

Morinda citrifolia fruit extract, has suggested a great role

in recurrent UTIs prevention (15-21).

A larger experience is needed, also in different type of

populations, to amplify the outcomes shown in the present

study. In fact, the limit of this study is represented by

the single centre experience and the relatively limited

number of subjects enrolled. However, the stratification

of patients and the prospective design can partially balance

these limits. Another criticism could be represented

by the absence of a “non-treatment” group, but this was

not allowed by the Local Ethical Committee. As a further

consideration, it has to be underlined that, as various

type of infections, also the risk of UTI may be strongly

reduced by some other natural and non invasive prevention

strategies. Behavioural aspects, reduction of comorbidities

and attention to precipitating factors, are the

most important. As a favourable consequence, a better

management of antibiotics could limit the development

of germ resistance which is becoming a serious health

problem, particularly in hospitalized patients (8).

In fact, in the last years, many Authors reported the

increased of UTI secondary to germs resistant to conventional

antibiotic treatment (21). It is a common experience

in real life management to face UTI sustained by

germs which show multiple resistance, and one of the

main factors that has led to multiple resistance is the

indiscriminate use of antibiotics. Those circumstances

require difficult strategies of treatment. Sometimes it is

necessary the help of experts in contagious disease, a large

dose of medicines and also hospitalization. Furthermore,

in the last years considering the large availability of efficacious

antibiotics, clinicians have made an excessive use

and at the same time the research for new molecules has

been decreased; therefore new classes of drugs suitable for

the treatment of infections caused by multidrug-resistant

germs are not currently available. For these reasons

antibiosis prophylaxis must be restricted and replaced

with alternative treatment whenever possible.


This study proved that Ausilium NAC® is as efficient as the

plurifloxacin in order to prevent UTIs potentially associated

with urodynamic examination. This result should

induce to consider that the assumption of nutraceutical

substances without antibiotic effect can reduce the risk of

UTIs, for less invasive urological procedures. The limited

use of antibiotics in selected cases will contribute to

reduce the development of antibacterial agents resistance.

Further studies are requested to support the encouraging

results of this experience, focusing the attention on a more

careful use of antibiotics for UTIs prevention related to

diagnostic procedures.


All Authors have contributed equally to the drafting of

the manuscript. All Authors read and approved the final

version of the manuscript.

Archivio Italiano di Urologia e Andrologia 2017; 89, 1 49

Prospective study to compare antibiosis versus the association of N-acetylcysteine, D-mannose and Morinda citrifolia fruit extract in...

Archivio Italiano di Urologia e Andrologia 2017; 89, 1

G. Palleschi, A. Carbone, P.P. Zanello, et al.



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Giovanni Palleschi, MD

Antonio Carbone, MD

Antonino Leto, MD

Andrea Fuschi, MD

Yazan Al Salhi, MD

Gennaro Velotti, MD

Gianluca Coppola, MD

Angela Maurizi, MD

Antonio L. Pastore, MD (Corresponding Author)

Unit of Urology, Department of Sciences and Medico Surgical

Biotechnologies, Sapienza, University of Rome, Latina

Corso della Repubblica 79 - 04100 Latina, Italy

Pier Paolo Zanello, MD

Researcher in microbiology and virology, Deakos Consultant

Rita Mele, MD

Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy

Samer Al Rawashdah, MD

Urology Unit, Special Surgery Department, Faculty of Medicine, Mutah

University, Karak, Jordan

Serena Maruccia, MD

Unit of Urology, IRCCS Policlinico San Donato Milanese, Milano, Italy


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