An age-related investigation of urinary tract symptoms and infection following urodynamic studies

One hundred and thirty-nine patients undergoing urodynamic investigation were studied. Urine samples taken at the time of the test and at 72 hours afterwards were cultured and data on symptoms following the test were collected. The overall infection rate was 15.8%. Men and women aged over 70 years were no more likely than younger subjects to become infected. A high residual urine volume was not associated with an increased risk of infection. The only clinical feature associated with infection following the test was an increase in incontinence. These findings were all in contradiction to previous studies on smaller numbers of patients.

An in vitro characterization of cefditoren, a new oral cephalosporin

Cefditoren (ME 1206) is a new cephalosporin available for oral administration as the pivaloyloxymethyl ester (ME 1207). The effect of medium formulation. pH, cation concentration and inoculum on the in vitro activity of cefditoren was investigated prior to determining its comparative antibacterial potency against a wide range of clinical bacterial isolates, its bactericidal activity against susceptible strains and the duration of its post-antibiotic effect (PAE). Cefditoren was shown to possess a broad-spectrum of cidal antibacterial activity against both Gram-positive and Gram-negative species with stability to many beta-lactamases of clinical importance. Its activity against Gram-positive species was similar to augmentin and cefuroxime, but superior to that of cefaclor and cefixime, while its beta-lactamase stability was similar to that of cefixime and ceftazidine, characterizing it as a third generation cephalosporin. Investigation of the effect of laboratory variables on the in vitro activity of cefditoren indicates that it will present no special problems when tested in the clinical setting against bacterial pathogens. PAE of 0.9 h, or greater, for Staphylococcus spp, Streptococcus pneumoniae and Moraxella catarrhalis may support the use of an extended dose-interval when cefditoren is used for the treatment of respiratory tract infections.

Mandatory use of confirmation stage with Chlamydiazyme during urinary sediment analysis

AIMS

To assess whether false positive results found when the first stage Chlamydiazyme test is performed on urinary sediment could be reduced by using the more specific second stage blocking assay.

METHODS

Sediment from 173 urine samples from patients with suspected urinary tract infection caused by Gram negative bacteria and 23 control urine samples were tested using the Chlamydiazyme assay system, which included a blocking assay.

RESULTS

A reaction result with the first stage Chlamydiazyme assay test was seen in 102 (58.9%) of the test urine samples. First stage reactivity was not blocked by the Chlamydiazyme confirmatory assay performed on repeat testing. All were correctly identified as true negative (first test false positive) results.

CONCLUSIONS

Use of a second (specific) blocking assay for the analysis of urinary sediment using Chlamydiazyme eliminates false positive results in Gram negative urinary tract infections.

Suction tip contamination in the ultraclean-air operating theatre

The surgical suction tip forms a reservoir for microorganisms during total hip replacement in conventional operating theatres. We assessed the colonisation of the tip in an ultraclean-air operating theatre in 39 patients, and found that 41% of them had evidence of bacterial colonisation with one or more bacteria. To avoid contamination we suggest that the suction tip is changed before preparation of the femoral canal and insertion of cement and prosthesis.

The domiciliary management of genital tract infection

Present treatment schedules for lower genital tract infections are far from ideal. Members of the 4-quinolone antibiotic class are highly active against Neisseria gonorrhoeae, and some of the newer agents are active against Chlamydia trachomatis. Clinical success has been reported with, for example, a single daily dose of ofloxacin for one week. New macrolides are active against C. trachomatis and N. gonorrhoeae. Azithromycin has been shown to be effective in a single oral dose. The role of newer agents in the therapy of bacterial vaginosis is largely unproven, but there are encouraging signs. The importance of attempting to make a firm diagnosis is emphasized.

Comparison of azithromycin and doxycycline in the treatment of non-gonococcal urethritis in men

Azithromycin has activity in vitro against Chlamydia trachomatis, and its novel pharmacokinetics suggest that even single doses may be effective in the treatment of non-gonococcal urethritis (NGU). This study compared the efficacy and safety of a single 1 g oral dose of azithromycin versus doxycycline 100 mg bid for seven days in the treatment of NGU. Men with symptoms and/or signs of NGU, and with > or = 5 polymorphonuclear leucocytes/high-power field in a Gram's-stained urethral smear, were recruited. Investigations included endourethral swabs for C. trachomatis cell culture. Patients were randomized to receive azithromycin or doxycycline, and were re-assessed on day 7-10 and on day 14-21. Of the 143 men recruited, C. trachomatis was isolated from 51 (40%) of the 128 evaluable patients. Both treatments were well tolerated and had comparable cure rates. Azithromycin 1 g appears to be an effective and safe alternative to doxycycline for the treatment of chlamydial and non-chlamydial urethritis, and its single-dose administration is an advantage in terms of patient compliance.

Audit of prescription and assay of aminoglycosides in a UK teaching hospital

Despite potential nephrotoxicity and ototoxicity, aminoglycosides are widely used in the treatment of severe sepsis but monitoring of serum levels is necessary. The use and assay of aminoglycosides, together with microbiologists' and pharmacists' advice on dosage and potential toxicity were examined in a teaching hospital group during an eight week period. A total of 480 courses of aminoglycoside was recorded in 440 hospital in-patients and of these, 306 (64%) were for prophylaxis. For 79 (45%) of 174 therapeutic courses, bacteriological results were available at the start and the choice of antibiotic was appropriate in 69 cases. Serum aminoglycoside assays were performed in 86% (149/174) of therapeutic courses. Correct assay request forms were used in 79% of 473 assay requests, and the clinical diagnosis was given on 73% of forms. In so-called peak samples with a documented time of collection, this ranged from 5 min to over 9 h post dose. Potentially toxic concentrations were present in 56 (12%) serum samples from 50 courses, in ten of which there was a serum creatinine rise of > 40 microM. However, there were confounding factors in five cases. Probable nephrotoxicity was rare, although assays were not performed in 14% of therapeutic courses. There were no symptomatic cases of ototoxicity but audiometry and vestibular studies were not performed. Closer liaison between the microbiologists, pharmacists and clinical staff is essential to improve clinical practice. Computer notification of inadequately monitored courses would be helpful. The routine therapeutic use of aminoglycosides needs to be reviewed in the light of the rising costs of assay litigation and the increasing number of alternative antibiotics available.

Comparison of an enzyme immuno assay (Antigenz Chlamydia) with cell culture for the detection of genital chlamydial infection in high and low risk populations

OBJECTIVE

To evaluate a new enzyme immuno assay, Antigenz Chlamydia, for the detection of chlamydial antigen in urogenital samples using cell culture as the gold standard for comparison and direct immuno fluorescence to aid resolving the discrepancies.

SUBJECTS

212 men and 303 women attending an STD clinic and 404 women of child bearing age attending gynaecological clinics.

RESULTS

Sensitivity, specificity, predictive value of positive result and predictive value of negative result of the new test were 77.6%, 99.0%, 94.3%, and 95.7% respectively in the high risk population with a prevalence of 16.5%. In the low risk population the figures were 84.2%, 94.5%, 43.2% and 99.2% respectively with a prevalence of 4.7%.

CONCLUSION

Antigenz Chlamydia is an easy and quick test to perform. The test is suitable for use in high risk and low risk populations provided all positive samples are confirmed.

Quinolones in sexually transmitted diseases

The role of quinolones in the treatment of sexually transmitted diseases is assessed. Little is known of their activity against Treponema pallidum. These compounds are all highly active against Neisseria gonorrhoeae, and have produced good in vivo results with a single dose. Only the more recent compounds show useful antichlamydial activity in vitro. Clinical trials with ofloxacin demonstrate the efficacy of a single daily dose for 7 days for chlamydial genital infection in men and women. Results for treatment of bacterial vaginosis have so far been disappointing. Ciprofloxacin and fleroxacin are effective for chancroid. The potential for treating pelvic inflammatory disease with new quinolones is discussed.

Coxiella burneti endocarditis in a patient with positive chlamydial serology

A 41-year-old man who habitually slept in a car park presented with a culture-negative endocarditis. Serological tests indicated infection with both Coxiella burneti and Chlamydia psittaci. He was treated with doxycycline and clindamycin and required aortic valve replacement. Culture of the excised value for both agents was negative but electron microscopy was suggestive of coxiella endocarditis.

Treponemal infection coexisting with systemic lupus erythematosus

A patient with systemic lupus erythematosus (SLE)/erosive arthritis overlap is described who was also shown to have late latent treponemal infection. The possibility of serological reactivation is discussed. Since antiphospholipid antibodies are the basis of the reagin tests for syphilis as well as being present in patients with SLE, difficulties with diagnosis may ensue.

Comparison of ofloxacin and metronidazole for the treatment of bacterial vaginosis

The efficacy and safety of ofloxacin, 200 mg twice daily for 7 days, was compared with metronidazole, 400 mg twice daily for 7 days, for the treatment of bacterial vaginosis (BV). Diagnosis of BV was confirmed by at least 3 of the following 4 criteria: the presence of an abnormal vaginal discharge on examination, clue cells on microscopy of vaginal specimens, vaginal pH greater than 5.0 and a positive amine test. Vaginal specimens were examined for Mobiluncus spp, analysed for the succinate/lactate (S/L) ratio and cultured for Trichomonas vaginalis, Gardnerella vaginalis, Bacteroides spp. and Mycoplasma hominis. Patients were reviewed on completion of treatment (visit 2) and 14 days later (visit 3). The diagnosis of BV was accepted in 119 of 149 patients recruited, 60 of whom received treatment with ofloxacin and 59 received metronidazole. Sixty-two patients, 31 in each treatment group, completed the study. Diagnostic cure at visit 2 was significantly better in the metronidazole group with cure rates of 56% (metronidazole) vs 23% (ofloxacin) (P = 0.001); this was associated with higher eradication rates for G. vaginalis (100% vs 56%) and Bacteroides spp. (97% vs 49%). There were no significant differences between the two groups in clinical cure at either visit 2 or 3 or in diagnostic cure at visit 3. Both treatments were well tolerated. We conclude that metronidazole is likely to remain the first choice of treatment for BV but ofloxacin offers a safe and effective alternative.

Evaluation of an enzyme immunoassay (Chlamydiazyme) with confirmatory test for the detection of chlamydial antigen in urine from men

First catch urine specimens from 312 male patients were examined for the presence of chlamydial antigen by an enzyme immunoassay (Chlamydiazyme). Positive results were repeated and confirmed using a blocking assay. In addition, urethral swabs were examined by cell culture for Chlamydia trachomatis. Discrepant results were further analysed by direct immunofluorescence (IF) of the spun urine deposit. Paired specimens were positive from 26 subjects, and negative from 276 subjects. Eight paired specimens were urethral culture positive, and urine EIA negative. Two specimens, urine EIA positive but urethral culture negative, were positive on direct IF. The sensitivity, specificity, predictive value of a positive result, and predictive value of a negative result for urine EIA against cell culture and/or direct IF were 77.8%, 100%, 100% and 97.2% respectively.

Melioidosis in a patient from Bangladesh

A 54 year old Bangladeshi man presented with a history and chest X-ray appearances suggestive of pulmonary tuberculosis. Following deterioration 4 weeks later, he required ventilation. Although a blood culture isolate was subsequently found to be Pseudomonas pseudomallei, it was initially misidentified and dismissed as a contaminant. Further cultures demonstrated the organism, but the patient died, despite treatment with ceftazidime. The case illustrates the importance of taking a detailed travel history and having a high index of suspicion in patients from South East Asia and the Indian sub-continent, including Bangladesh, where the disease has not previously been considered endemic.

Azithromycin vs doxycycline in the treatment of non-gonococcal urethritis

Azithromycin is a novel azalide macrolide active against Chlamydia trachomatis and Ureaplasma urealyticum. High persistent tissue concentrations allow short courses or even single doses to be considered. Sixty-two patients were studied, 19 received azithromycin 1 g in a single dose, 22 received azithromycin 500 mg in a single dose on day 1 followed by 250 mg once daily for 2 days and 21 received doxycycline 200 mg in a loading dose followed by 100 mg every 12 h for 7 days. Efficacy of these 3 regimens was compared in the treatment of non-gonococcal urethritis (NGU). Clearance of C. trachomatis from post-treatment cultures was satisfactory with all regimens. Response defined as the absence of symptoms and reduction in polymorphonuclear leucocytes in a Gram stained smear of urethral secretion to less than 5 cells per hpf (x 100 objective) was statistically better for the 3 day regimen of azithromycin than for the other 2 regimens. All treatments were well tolerated. Three days or single doses of azithromycin compared to 7 days of tetracycline (or 10-14 days as is often prescribed) have obvious advantages for patient compliance.