[Urinary tract infections in women--possibilities of differentiated approach in treatment and prevention]

Urinary tract infections (UTIs) are among the most urgent health problems for which women in working age see their physician (whether the general practitioner, urologist or gynecologist). The most common manifestation of UTIs in women is acute uncomplicated cystitis the diagnosis and treatment of which is usually straightforward. When selecting an appropriate antimicrobial agent, it is advisable to consider its pharmacokinetics, expected spectrum of efficacy and effect on the vaginal flora. Short-term therapy of three to five days is preferred. In women with recurrent cystitides, it is necessary, in addition to performing comprehensive urological examination to rule out functional or anatomic abnormalities, to perform urine culture and targeted treatment according to sensitivity. The review article presents differentiated options of treatment and prevention of recurrent infections with both antimicrobial agents and regimen measures as well as preparations not included in the group of antimicrobial agents; however, when correctly indicated, their administration may bring long-term relief to these women. The article also deals with complicated infections in women and asymptomatic bacteriuria in elderly women.

[Urology in 2011]

In 2011, therapeutic acquisitions in urology allow optimizing management of acute uncomplicated cystitis and acute pyelonephritis by female patients and in men clinical implications of benign prostatic hyperplasia opposed to prostate cancer detection as well as hormonal treatment of advanced prostate cancer.

Positive effects of local therapy with a vaginal lactic acid gel on dysuria and E.coli bacteriuria question our current views on recurrent cystitis

OBJECTIVE

We tested the effect of vaginally applied lactic acid gel on symptoms and bacteriuria in acutely exacerbated recurrent Eschericia coli cystitis.

METHODS

Carnoy fixed samples of the morning urine from 20 women with a history of recurrent E.coli cystitis were prospectively investigated for bacteriuria using fluorescence in situ hybridization (FISH).

RESULTS

In 11/20 women with acute cystitis, the symptoms and bacteriuria were regressive with lactic acid gel treatment, without the need for antibiotic treatment. The complete regression of symptoms took between 1 week (7 women) and 4 weeks (4 women). In parallel with this regression, the microscopic shape of E.coli bacteria in these women changed from short rods to long curly filaments starting within the first days of therapy. The filamentous transformation affected 100% of the E.coli population in six women and at least 50% of E.coli population in five women and was not observed in urine samples from untreated women or in women without clinical response to lactic acid gel. This could not happen if the bladder was the origin of the infection.

CONCLUSIONS

A number of recurrent and probably acute cystitis is a local vagino-urethritis caused by an adhesive invasive E.coli biofilm of the vaginal surface.

Controversy about reversibility of cysts in cystic cystitis in children

Most cystic cystitis cases in children exhibit cysts for an extended period, even after successful treatment of the underlying infection. Not much is known about the dynamics of cyst appearance and disappearance. In long-term follow-up some clinicians suggest complete eradication of the cysts. Contrary, histological studies describe the cystic cystitis as an irreversible process in von Brunn's nests. The endoscopic differentiation from reversible follicular cystitis is hard and uncertain. A group of 21 children with cystic cystitis was diagnosed and staged in a 10-year period. All of them clinically presented with recurrent uroinfections. We examined cystoscopic changes of cystic cystitis before and during the treatment of urinary infection to find objective signs of improvement in endoscopic findings after prolonged antibiotic therapy. Control cystoscopy was performed after a period of six infection-free months. In the average period of 20 months after the beginning of treatment there were no changes in cystic cystitis stage. The examined period seems to be too short for the changes of cystic cystitis to disappear. It is unclear if prolonged antibacterial treatment bears any influence on the number of cysts.

[A multicenter comparative observation on the effectiveness and the rapidness of the effect of Cystostop Rapid versus antibiotic therapy in patients with uncomplicated cystitis]

The currently available treatment for uncomplicated urinary tract infections includes only antibiotics and chemotherapeutic agents. Experience in the management of acute uncomplicated infections using non-antibiotic products is very limited. The aim of this observation was to study to what extent the response to Cystostop Rapid would be more rapid and more effective compared to antibiotic therapy in patients with acute uncomplicated urinary bladder infections. The secondary objective was to determine the time to improvement of cystitis symptoms following the start of treatment, as well as the duration of patients' disablement. A total of 158 female subjects were included, assessed microbiologically, and evaluated for incidence and severity of symptoms, before the start of treatment and after completion of treatment. A visual analogue scale was used for patient self-assessment of the severity of symptoms, the improvement of symptoms, as well as the time to improvement of symptoms.

RESULTS

158 females, eligible according to the inclusion criteria of the study, were allocated to one of the two groups according to time of enrollment: Group A included 86 subjects: assigned to Cystostop Rapid for 3 days and administered according to the manufacturer's recommended regimen; and Group B included 72 women: assigned to ciprofloxacin 500 mg twice daily for 3 days according to the Product Registration File with the BDA. The clinical and microbiological effectiveness of Cystostop Rapid was comparable to that of ciprofloxacin, providing a two-fold more rapid improvement of cystitis symptoms, at a mean time to improvement of 24 hours (p < 0.02) versus 46 hours for ciprofloxacin. Clinical improvement within 48 hours of Cystostop Rapid regimen occurred in 97% (p < 0.02) of patients, vs. 65.3% of patients on ciprofloxacin. Improvement of symptoms within 12 hours was reported in 36% of patients on Cystostop Rapid vs. 5.5% of patients in the ciprofloxacin group (p < 0.02). No adverse events or intolerability to the therapy were reported throughout the course of the study.

Simple cystitis: symptoms persist longer without antibiotics

A randomised trial has shown that antibiotic therapy can be avoided in 20% to 25% of women with simple cystitis, with no increase in the risk of complications but with longer duration of symptoms.

[Etiological structure and antibiotic sensitivity of uropathogens in chronic recurrent infection of the lower urinary tract]

While acute infections of the lower urinary tract (UT) have been studied in detail and antibiotic therapy of such infections is well known, etiology and choice of antibacterial treatment in recurrent chronic UT infection are not so clear. In our trial we aimed at elucidation of etiological structure of chronic cystitis recurrences by means of microbiological investigation of urine samples from 72 women on extended spectrum of nutrient media. In all the cases urine was infected with both aerobic and non-clostridial anaerobic bacteria. We determined prevalent pathogens and their antibiotic sensitivity and compared them with standard pathogens and their sensitivity in acute lower UT infection. We came to the conclusion that it is necessary to develop new recommendations on antibiotic treatment of recurrent chronic cystitis in women.

[Panavir in combined treatment of chronic cystitis with hyperplastic changes in urinary bladder mucosa]

Human papilloma virus was detected by polymerase chain reaction in patients suffering from chronic cystitis with hyperplastic changes in urinary bladder mucosa. In most of the examinees (90%) it was HPV of highly oncogenic type 16. Panavir added to combined treatment of such patients produced a significant positive result in long-term period. Improvement was observed both in subjective assessment and the absence of dysuria episodes.

[Antibiotic treatment of uncomplicated cystitis in non-pregnant women up to menopause]

OBJECTIVES

To review treatment recommendations for UC in non-pregnant women up to menopause, using the scale Strength of Recommendation Taxonomy (SORT).

DATA SOURCE

Medline, UpToDate, Cochrane, Bandolier, Database of Abstracts of Reviews of Effects, National Guideline Clearinghouse, Guidelines Finder and the website of the Portuguese Urology Association.

METHODS

Research of systematic reviews (SR), meta-analyses (MA), randomized controlled trials (RCT) and guidelines, published in english and portuguese, between 2000 and 2008.

RESULTS

Two MA, two SR, four RCT and six Guidelines were included. Three-day treatments are preferable to those of seven to ten days, mainly because of higher compliance and lower cost and incidence of adverse effects (A). Longer regimens are acceptable for bacterial eradication. Trimethoprim/sulfamethoxazole (TMP/SMX) is the option where resistance levels are lower than 10-20% (A). As a clinical and microbiological alternative, evidence seems to point out the Fluoroquinolones (FQ) (C) which are equally efficient among themselves, although showing different safety profiles.

CONCLUSIONS

In case of allergy or high resistance to TMP/SMX, FQ are the most efficacious alternative, both prescriptions recommended for three days. However, due to the risk of worsening resistance to FQ, the options consist on nitrofurantoin and fosfomicine.

A randomized trial of computer kiosk-expedited management of cystitis in the emergency department

OBJECTIVES

The objective was to assess the efficiency and safety of an interactive computer kiosk module for the management of uncomplicated urinary tract infections (UTI) in emergency departments (EDs).

METHODS

This was a prospective unblinded randomized trial. Women age 18 to 64 years seeking care for suspected UTI in three urban EDs were referred to a computer kiosk after triage. The kiosk evaluated women for uncomplicated UTI (based on patient report of at least one irritable voiding symptom within 7 days and absence of complicating features), and eligible patients were randomized to expedited management or usual ED care. Expedited management consisted of a brief clinician encounter to confirm computer kiosk responses and selection of one of four standard antibiotic regimens. Study outcomes included urine culture results, duration of ED visit, time to illness resolution, return visits, and satisfaction with care.

RESULTS

Seventeen percent (n = 103) of 624 participants with suspected UTI fulfilled uncomplicated criteria and were randomized. Sixty-nine percent of these women had a positive urine culture. Compared with the control group, the computer-expedited management group had lower median visit duration (89 minutes, interquartile range [IQR] = 65 to 150 minutes vs. 146 minutes, IQR = 105 to 216 minutes) for a decrease of 57 minutes (95% confidence interval [CI] = 27 to 87, p = 0.004). They had similar time to illness resolution, number of return visits, and satisfaction with care.

CONCLUSIONS

An interactive computer kiosk accurately, efficiently, and safely expedited the management of women with uncomplicated UTI in a busy, urban ED. Expanding the use of this technology to other conditions could help to improve ED patient flow.

Diagnosis and treatment of acute uncomplicated cystitis

Urinary tract infections are the most common bacterial infections in women. Most urinary tract infections are acute uncomplicated cystitis. Identifiers of acute uncomplicated cystitis are frequency and dysuria in an immunocompetent woman of childbearing age who has no comorbidities or urologic abnormalities. Physical examination is typically normal or positive for suprapubic tenderness. A urinalysis, but not urine culture, is recommended in making the diagnosis. Guidelines recommend three options for first-line treatment of acute uncomplicated cystitis: fosfomycin, nitrofurantoin, and trimethoprim/sulfamethoxazole (in regions where the prevalence of Escherichia coli resistance does not exceed 20 percent). Beta-lactam antibiotics, amoxicillin/clavulanate, cefaclor, cefdinir, and cefpodoxime are not recommended for initial treatment because of concerns about resistance. Urine cultures are recommended in women with suspected pyelonephritis, women with symptoms that do not resolve or that recur within two to four weeks after completing treatment, and women who present with atypical symptoms.

Septic peritonitis and uroperitoneum secondary to subclinical omphalitis and concurrent necrotizing cystitis in a colt

A 15-day-old American Quarter horse colt was presented for depression and pyrexia. Peritonitis was diagnosed following peritoneal fluid analysis. Exploratory laparotomy revealed an area of focal necrosis over the dorsal wall of the urinary bladder leading to peritonitis and uroperitoneum. The affected area of the urinary bladder was resected and the peritonitis resolved with medical treatment.

[Do general practitioners follow the therapeutical recommendations of cystitis in women? INURA study]

OBJECTIVE

The management of lower urinary tract infections varies from physician to physician. The aim of this study was to assess whether general practitioners follow the evidence-based guidelines for the management of cystitis in women.

METHODS

Cross-sectional study carried out from March to July 2009 in which physicians consecutively registered in a template during a 8-week period the first six episodes of cystitis by means attended at the medical consultation. Age, episode of infection, associated morbidity, antibiotic prescription, and type of antibiotic course (short or long regimen) were determined.

RESULTS

Out of 176 physicians invited to participate, 110 included 658 women with lower urinary tract infections with antibiotic treatment being administered in 634 cases. Short courses were given to 385 women (60.7%) and 249 women were given long schedules (39.3%). A total of 343 out of all noncomplicated cystitis were treated with short courses (62.9%) and 75 out of complicated cystitis were treated with long courses (66.4%). First-choice antibiotics were administered as empiric treatment in only 111 women (17.5%).

CONCLUSIONS

These results highlight a poor adherence of general practitioners to current recommendations of clinical practice guidelines in cystitis with a low utilization of first-choice antibiotics.

Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis

OBJECTIVE

To analyze the costs of nitrofurantoin use compared to those of other antibiotics recommended for treatment of uncomplicated urinary tract infection (UTI).

PATIENTS AND METHODS

We used a decision analysis model to perform cost-minimization and sensitivity analyses to determine the level of trimethoprim-sulfamethoxazole (TMP-SMX) and fluoroquinolone resistance that would favor the use of nitrofurantoin as a first-line empirical treatment of uncomplicated UTIs. The model used a program perspective to evaluate costs.

RESULTS

Nitrofurantoin was cost-minimizing when the prevalence of fluoroquinolone resistance exceeded 12% among uropathogens or the prevalence of TMP-SMX resistance exceeded 17%. On 2-way sensitivity analysis, variables that had a significant impact on our cost-minimization threshold included cost of antibiotics and probability of clinical cure with antibiotics.

CONCLUSION

From a payer perspective, nitrofurantoin appears to be a reasonable alternative to TMP-SMX and fluoroquinolones for empirical treatment of uncomplicated UTIs, especially given the current prevalence of antibiotic resistance among community uropathogens. On the basis of efficacy, cost, and low impact on promoting antimicrobial resistance, clinicians should consider nitrofurantoin as a reasonable alternative to TMP-SMX and fluoroquinolones for first-line therapy for uncomplicated UTIs.

Higher proportions of peripheral CD19+CD5+ B cells predict the effect of corticosteroid in patients with late-onset hemorrhagic cystitis after allogeneic hematopoietic stem cell transplantation

BACKGROUND

The cause of late-onset hemorrhagic cystitis (LOHC) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains obscure. In clinical practice, some LOHC patients respond to immunosuppression. The aim of this study was to determine the immune pathogenesis of LOHC post allo-HSCT.

METHODS

With the diagnosis of LOHC, patients were given initial treatment consisting of fluid hydration, alkalization and forced diuresis, and empirical anti-viral therapy for 10 - 14 days or until a week after the virus became negative. The nonresponders were applied corticosteroid. Seven to ten days later, patients' response was evaluated. Along with treatment, CD19(+) B lymphocyte subsets were measured at various study points.

RESULTS

From October 2009 to March 2010, we found 28 cases of LOHC occurred in 25 patients who underwent allo-HSCT in our hospital. Except that three cases were not treated according to the protocol, the other 25 cases were divided into three groups: anti-virus responders (Group A, n = 6), corticosteroid responders (Group B1, n = 16), corticosteroid and anti-virus nonresponders (Group C, n = 3) according to their clinical response. Percentages of CD19(+)CD5(+) B lymphocytes were not significantly different among three groups at onset of LOCH. However, in Group B1 after the first anti-virus phase, percentages of CD19(+)CD5(+) lymphocytes significantly increased comparing with those at onset (P = 0.022), and then significantly decreased at PR (P = 0.003) and CR (P = 0.002) with corticosteroid treatment. But significant change was not observed in Groups A and C.

CONCLUSION

The immune etiology seems to be involved in the development of LOHC and the proportion of CD19(+)CD5(+) lymphocytes may serve as a cellular biomarker to predict the response to corticosteroid in LOHC.

[Cefixim: clinical pharmacology and role in therapy of urogenital infections]

Cefixim belongs to oral cephalosporins of the third generation and has the longest half-life period among all oral cephalosporins and, therefore can be taken once a day. Moreover, cefixim presents in high concentrations in the urine, kidneys and urinary tract. In vitro, this drug has high activity against basic pathogens of urogenital infection. A randomized clinical trial has found that cefixim has higher clinical and microbiological efficacy than ciprofloxacin in patients with acute uncomplicated cystitis.

[Russian results of the international epidemiological study of clinical aspects and resistance to antimicrobial medicines of cystitis uropathogens in females (ARESC): significance of empiric therapy]

A total of 656 female patients from Russia aged between 18 to 65 years with uncomplicated cystitis entered the international ARESC trial, of them 647 were eligible for final analysis. Positive cultural urine tests ( > 10(4) CFU/ml) were in 419 (64.7%) patients, 393 (93.8%) patients had monoinfection. The central laboratory of Genoa (to which the isolated samples were sent) has tested 416 uropathogens from 399 patients. The following pathogens were isolated: E. coli (72.6%), enterococcus (7.0%), Klebsiella pneumoniae (4.6%), Staphylococcus saprophyticus (3.6%), Proteus mirabilis (2.4%) and Staphylococcus aureus (1.7%). E. coli was most sensitive to phosphomycin (99.3%), mecillinam (97.3%), nitrofurantoin (94.7%), ciprofloxacin (87.4%). The lowest sensitivity was to ampicillin (42.1%) and cotrimoxasol (69.4%). As to the whole bacterial spectrum, the highest sensitivity was found to phosphomycin (96.5%), nitrofurantoin (85.6%) and citrofloxacin (82.8%), the less sensitivity--to ampicyllin (44.3%) and co-trimoxasol (70.1%). Phosphomycin, mecillinam (not registered in Russia) and nitrofurantoin showed activity in vitro and can be considered as drugs of choice for empiric therapy of cystitis. Because of high resistance of pathogens, co-trimoxasol (trimetoprim) and fluoroquinalones are not recommended as first-line treatment for uncomplicated cystitis in females.

Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate: a placebo-controlled randomised trial

BACKGROUND

Urinary tract infection (UTI) is a prevalent condition in women during their lifetime with a high rate of recurrence within 3-6 mo.

OBJECTIVES

Our aim was to investigate the efficacy and tolerability of the intravesical administration of combined hyaluronic acid (HA) and chondroitin sulphate (CS) in female patients with a history of recurrent UTI.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a prospective, randomised, double-blind, placebo-controlled study comparing the intravesical instillation of HA-CS with placebo in women with recurrent UTI.

INTERVENTION

Participants were randomised to receive 50 ml of sterile sodium HA 1.6% and CS 2.0% solution (IALURIL(®)) weekly for 4 wk and then monthly for 5 mo.

MEASUREMENTS

The primary end point of the study was defined as the mean number of UTI per patient per year. Participants were evaluated addressing UTI status/urinary symptoms and with a general health-related quality-of-life (QoL) questionnaire at baseline and after 3, 6, 9, and 12 mo.

RESULTS AND LIMITATIONS

In the intention-to-treat analysis, 57 women were randomly allocated to HA-CS (n=28) or placebo (n=29). The UTI rate per patient per year at the end of the study (12 mo) (mean±SD: -86.6%±47.6 vs -9.6%±24.6; mean difference: 77%; 95% confidence interval, 72.3-80.8; p=0.0002) and the mean time to UTI recurrence (52.7±33.4 vs 185.2±78.7 d; p<0.001) were significantly reduced after treatment with HA-CS compared with placebo. Overall urinary symptoms and QoL measured by questionnaires significantly improved compared with placebo (Pelvic Pain and Urgency/Frequency questionnaire symptom score: 14.53±4.32 vs 9.88±6.77; p=0.004; SF-36 QoL score: 78.6±6.44 vs 53.1±4.72; p<0.001). No serious adverse event was reported.

CONCLUSIONS

Compared with placebo, HA-CS intravesical instillations significantly reduced UTI rate without severe side effects while improving symptoms and QoL over a 12-mo period in patients with recurrent UTI.

TRIAL REGISTRATION

ISRCTN 76354426.

Comparison between Japanese and non-Japanese features of lupus cystitis based on case reports including novel therapy and a literature review

OBJECTIVE

This study was carried out to determine the characteristics of lupus cystitis and to compare those of Japanese cases with those of non-Japanese cases. We also report a novel therapy for lupus cystitis refractory to corticosteroid.

METHODS

For the literature search, published reports on lupus cystitis were searched by MEDLINE and ICHUSHI WEB. The inclusion criterion was interstitial cystitis, fulfilling the SLE classification criteria of American College of Rheumatology in 1997 and with either hydronephrosis detected by image studies (either computed tomography or ultrasonography) or bladder histopathology consistent with lupus cystitis. Interstitial cystitis without the fulfillment of the classification criteria was excluded. Patient demographic data and clinical data were retrieved from the literature and analyzed.

RESULTS

Including the present 2 cases, a total of 78 cases were identified as definitive cases of lupus cystitis (35 non-Japanese cases and 43 Japanese cases). Female patients accounted for 90.7%. The preceding gastrointestinal symptoms and subsequent urinary symptoms were the most frequent. Anti-double strand DNA antibody most often expressed in the 76.1% of the patients. Mean age and the prevalence of vomiting were significantly higher among Japanese patients compared to non-Japanese cases and the prevalence of CNS involvement was lower among Japanese patients (p=0.03, 0.04 and 0.001). We report a novel therapy (cetirizine hydrochloride) for lupus cystitis refractory to corticosteroid in one of the present cases.

CONCLUSION

Lupus enteritis, female gender, and positive anti-dsDNA antibody are risk factors for lupus cystitis. Japanese cases showed older age, a higher prevalence of vomiting and a lower prevalence of CNS involvement. We also report the efficacy of the novel use of cetirizine hydrochloride for lupus cystitis refractory to corticosteroid.

[Efficacy and safety of cefixim and ciprofloxacin in acute cystitis (a multicenter randomized trial)]

A prospective multicenter randomized trial enrolled 104 females aged 18-55 years with acute un-complicated cystitis. The patients were randomized into two groups: 49 patients of group 1 received cefixim in a single dose 400 mg/day for 5 days; 55 patients of group 2 were given ciprofloxacin in a dose 250-500 mg twice a day for 5 days. Clinical and microbiological assessment of efficacy and safety was made before treatment and on treatment day 8 and 28. Significant differences were found between groups 1 and 2 in parameters of bacteriological and clinical efficacy. Eradication of the agent and persistent bacteriological response was seen in 95.9 and 100% patients of group 1, 66 and 100% patients of group 2, respectively. Complete and partial response was observed in 55.1 and 75.5% patients of group 1, 37.3 and 58.1% patients of group 2, respectively. Thus, cefixim in a single dose 400 mg/day for 5 days has a higher microbiological efficacy than ciprofloxacin in a dose 250-500 mg twice a day. Side effects occurred less frequently in the treatment with cefixim.

Lupus cystitis in an Omani girl

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by multiple organs involvement. Bladder involvement (Lupus cystitis) is a rare manifestation of SLE, and occurs in association with gastrointestinal manifestations. We report a case of lupus interstitial cystitis with bladder irritation and bilateral hydroureteronephrosis in an adolescent female who was treated with intravenous methylprednisolone pulse therapy followed by oral prednisolone and mycofenolate mofetil (MMF). Her symptoms ameliorated, and the hydroureteronephrosis improved. She was presented again with systemic flare up of the disease together with hydrouretronephrosis, but without bladder irritation symptoms. The diagnosis of lupus cystitis was confirmed by radiographic abnormalities, cystoscopy and bladder biopsy.

[Renal and urethral gas production as a complication to infection of the urinary tract]

Emphysematous pyelonephritis (EPN) is a bacterial infection characterised by gas production in the renal parenchyma. We present a case with EPN caused by Klebsiella pneumoniae sepsis. The 74-year-old woman was admitted in septic shock. An acute computed tomography revealed gas bubbles bilaterally in the renal parenchyma, left urethra and bladder. Treatment consisted of three types of antibiotics and intravenous fluids. She was discharged two months later without need for surgical treatment or haemodialysis despite the seriousness of her initial condition.

Clinical effects of 2 days of treatment by fosfomycin calcium for acute uncomplicated cystitis in women

Fosfomycin calcium is a fosfomycin antimicrobial agent with a characteristic structure. After oral administration, the drug is absorbed and excreted via the kidneys in the unchanged form, without being metabolized in the body. It is, therefore, indicated for the treatment of urinary tract diseases, including cystitis and pyelonephritis. In the present study, the clinical usefulness of fosfomycin calcium (FOSMICIN® TABLETS 500) administered orally at the dosage of 1 g (two tablets) three times daily for 2 days was examined in female patients, who were at least 20 years of age, with acute uncomplicated cystitis of bacterial origin. Of the 48 patients enrolled between February 2008 and August 2008, 39 were evaluable for efficacy and safety. Overall evaluation of the cure revealed that microbiological eradication rate (microbiological outcome) and clinical efficacy rate (clinical outcome) at 5-9 days after drug administration (visit 2) were 94.9%. Determination of the microbiological and clinical outcomes for the evaluation of recurrence at 4-6 weeks after drug administration (visit 3) were 75.8 and 85.7%, respectively. Of the 48 patients, 40 (83.3%) returned to the clinic at visit 3. The causative bacterial species for cystitis was Escherichia coli in 31 (79.5%) of the 39 patients evaluable for efficacy and safety. Adverse drug reactions observed during the administration and follow-up periods included mild diarrhea and loose stools in 1 patient each, neither requiring any specific treatment. Evaluation of cure at visit 2 in patients in whom the causative bacterial species for the infection was E. coli revealed a microbiological outcome of 93.5%, and clinical outcome was 96.8%. Furthermore, evaluation for recurrence at visit 3 revealed a microbiological outcome of 74.1% and clinical outcome of 82.1%. When the patients were divided by age into an under 60 years of age group and an over 60 years of age group, the microbiological and clinical outcomes determined for evaluation of cure at visit 2 were 96.4 and 92.9%, respectively, and the corresponding rates determined for the evaluation of recurrence at visit 3 were 87.0 and 96.0%, respectively, in the under 60 years of age group. In the over 60 years of age group, the corresponding microbiological outcome and clinical outcome rates evaluated for cure were 90.9 and 100%, respectively, and those evaluated for recurrence were 50.0 and 60.0%, respectively. These results indicate the usefulness of fosfomycin calcium administered at 1 g three times daily for 2 days for acute uncomplicated cystitis.

[Combined treatment of chronic cystitis in postmenopausal women with application of AMUS-01-INTRAMAG device and rectomassager attachment]

Sixty eight postmenopausal women with chronic recurrent cystitis received local antibacterial treatment consisting in bladder ionophoresis and vaginal exposure to estrogens and vibromagnetic action of RECTOMASSAGER attachment and AMUS-01-INTRAMAG device. This local treatment proved superior to systemic one as 1-year follow-up registered a 3.1-fold reduction in recurrence rate vs control patients.

[Treatment of acute iatrogenic cystitis secondary to bladder chemo-immuno-instillation or pelvic radiotherapy]

The onset of cystitis during intravesical chemo-immunotherapy for the treatment of non-muscle invasive transitional cell bladder tumor, or after pelvic radiotherapy mainly for prostate cancer, is a frequent clinical situation, not easily manageable due to the lack of responsiveness to symptomatic drugs, often resulting in discontinuation of cancer treatment in many cases.?The similarity of symptoms with those of the painful bladder syndrome, otherwise called interstitial cystitis, has led us to use the same treatment with intravesical sodium hyaluronate in order to obtain an improvement of symptomatology. We therefore performed a prospective study on 55 consecutive male symptomatic patients, aged from 54 to 81 years: 11 after radiotherapy, 17 after BCG and 27 after Mitomicyn C bladder instillations ,12 of whom in combination with bladder hyperthermia.?All subjects underwent bladder instillations with sodium hyaluronate 40 mg in 50 mL weekly for 8 to 24 weeks depending on the time needed to the resolution of the symptoms.?During the first 4 weeks 32 mg of dexamethasone were also instilled intravesically, mixed with hyaluronate, in order to obtain a stronger anti-inflammatory activity due also to its higher capacity of penetration in the bladder mucosa. The symptoms intensity was evaluated through a Visual Analogue Score (VAS) of the discomfort and pain perceived from 0 to 10, and bladder capacity was recorded with micturition diary before and after the treatment.?After 16 weeks VAS improved in every case of chemical cystitis from an initial mean value of 8.6 to a final mean value of 1(with 3 as a maximum value recorded). The difference was highly significant (p <0.001). Bladder capacity increased in all cases of chemical cystitis from a mean value of 56 to 276 mL with a highly significant improvement (p <0.001) and in all cases of post-actinic cystitis from a mean bladder capacity of 89 to a final mean value of 239 mL, with a significant improvement (p= 0.05). We did not observe any side effect due to our treatment. Therefore, we can conclude that bladder instillation with sodium hyaluronate for at least 8 weeks and dexamethasone in the first 4 weeks can solve the symptoms of iatrogenic cystitis secondary to chemo-immunotherapy or pelvic radiotherapy, without incurring in side effects. To our knowledge this treatment has never been published before in scientific medical literature.

[Efficacy of combined treatment of women with chronic cystitis associated with intracellular infections]

Forty female patients with urethrocystitis received sparfloxacin in a daily dose 400 mg for 20 days in combination with canefron H (50 drops three times a day for 8 weeks). Twenty patients received one more course of canefron H 4 months after etiopathogenetic therapy. The analysis of the treatment results allows the conclusion that sparfloxacin is highly effective in urethrocystitis associated with intracellular infections. Sparfloxacin provides complete urine sterility. 97.5% females after the combined treatment had no recurrences for a year while before the treatment remission lasted for 4.1 +/- 1.7 months. A preventive administration of canefron H improves microcirculation in the bladder wall and prevents recurrence in patients with urethrocystitis associated with intracellular infections given basic sparfloxacin therapy.

Efficacy of sodium hyaluronate in the management of chemical and radiation cystitis

Onset of cystitis in patients receiving immuno-chemotherapeutic agents by intravesical instillation for non-muscle invasive transitional cell carcinoma of the bladder or after radiotherapy for prostatic cancer is frequent and problematic, since it responds poorly and slowly to the usual symptomatic treatments. This iatrogenic complication often means that cancer therapy has to be interrupted on account of the bladder pathology symptoms and of course this has further clinical implications. The symptoms resemble those of the urgency/frequency and painful bladder syndromes, so we tested the treatment used for these disorders to see whether it helped in this difficult clinical situation. This prospective study therefore enrolled 69 male consecutive patients, between 54 to 81 years of age, with iatrogenic acute cystitis; in 15 the symptoms had appeared after radiotherapy for prostatic cancer, in 24 after intravesical BCG, in 30 after instillation of Mitomycin C (with Synergo thermotherapy for 12 of them). All patients were given intravesical instillations of sodium hyaluronate, 40 mg/50 mL, weekly for from 8 to 24 weeks, depending on how the symptoms released. In the first four weeks dexamethasone 32 mg was mixed in as a "cocktail", on account of its prompt and effective topical antiinflammatory action and good mucosal penetration. Longer use of cortisone is contraindicated because of the high risk of sensitization and it provided no evidence of any ability to overcome the severe urinary disturbances with lasting effect. In order to allow patients with marked overactive bladder to keep these drugs within the bladder, we instilled lidocaine 2% 30 mL, 30 minutes before. Patients recorded their bladder capacity (BC) by filling a micturition diary. Pain was assessed using a Visual Analog Scale (VAS) from 0 to 10 for the chemical cystitis cases at the beginning and end of treatment. After only four weeks BC increased in all patients, and urgency and pain disappeared. Treatment was continued, however, for another four weeks, even in patients with total remission of their symptoms as we had seen earlier that if it was stopped too soon the symptoms could return. In the chemical cystitis group the VAS score dropped from an initial mean of 8.6 to 0.9 at the end of treatment (P<0.0001). Mean BC rose from 58.4 to 283.7 mL in the chemical cystitis cases (P<0.0001), and from 85 to 243.3 mL (P<0.0001) in the radiotherapy patients. Overall 67 patients (97%) reported complete relief of dysuria and pain. Two treatment failures were due to a reduced compliance to treatment by the patients themselves. No adverse reactions were observed related to the catheters or drugs used. Patients with non-invasive bladder tumors were able to restart their cancer therapy. For cystitis induced by intravescical immuno-chemotherapy or pelvic radiotherapy this approach appears to achieve an effective and rapid cure with no adverse reactions, allowing the conclusion of treatments for non-invasive transitional cell-bladder cancer. Patients with chemical cystitis responded a little better than those who had received radiotherapy. Subsequent urinary cytology and cystoscopy ruled out bladder cancer progression in these cases after temporary postponement of the oncological treatment. Intravescical sodium hyaluronate seems a valid and quick therapeutic solution for iatrogenic cystitis from chemo or radiotherapy. After review literature, this strategy does not appear to have been used before for this particular problem.

Bacterial cystitis in women

BACKGROUND

A woman presenting with symptoms suggestive of bacterial cystitis is a frequent occurrence in the general practice setting. One in three women develop a urinary tract infection (UTI) during their lifetime (compared to 1 in 20 men).

OBJECTIVE

In this article we provide an outline of the aetiology, pathogenesis and treatment of bacterial cystitis in the primary care setting. We suggest measures that may assist before urological referral and work through a common clinical scenario.

DISCUSSION

Bacterial cystitis in unlikely if the urine is both nitrite and leuco-esterase negative. Empirical antibiotics are justified if symptoms are present with positive urinary dipstick, but microscopy, culture and sensitivity of urine is warranted to ensure appropriate empirical therapy and identification of the causative organism. Risk factors for UTI in women include sexual intercourse, use of contraceptive diaphragms and, in postmenopausal women, mechanical and/or physiologic factors that affect bladder emptying such as cystocoele or atrophic vaginitis. Discussion regarding risk factors and UTI prevention is important. Women with recurrent UTIs (defined as three or more episodes in 12 months or two or more episodes in 6 months) should be screened for an underlying urinary tract abnormality (ultrasound) and may benefit from prophylactic therapy. Patients with complex or recurrent UTIs, persistent haematuria, persistent asymptomatic bacteriuria, or urinary tract abnormalities on imaging may benefit from referral to a urologist.

Diffuse rash and cough in elderly woman with a UTI

A 66-year-old woman came into the emergency department with a diffuse rash and a cough. She had a rash on the palms of her hands, which had developed the day before, but had improved a bit. She also had a rash on her feet, legs, and lower abdomen, which had developed that morning. She said that over the previous 2 days she had had a fever, dry cough, and some difficulty breathing. Her past medical history was significant for asthma, diabetes, hypertension, and osteoarthritis. Her medications included atenolol, celecoxib, metformin, pioglitazone, and an albuterol inhaler, as needed. In addition, she was on the ninth day of a 10-day course of nitrofurantoin for acute cystitis. She was allergic to ampicillin and erythromycin. On physical exam, she had a fever of 101.5 degrees Fahrenheit. On lung examination, she had diffuse wheezes and mild bibasilar crackles. Examination of her skin revealed a nonpainful, nonpruritic, erythematous, maculopapular rash located on the palms and legs, as well as on her lower abdomen. Chest radiograph showed mild opacification in the bases of the lungs. What is your diagnosis?

Virulence characteristics and phylogenetic background of ciprofloxacin resistant Escherichia coli in the urine samples from Korean women with acute uncomplicated cystitis

To clarify the characteristics of the virulence factors (VFs) of ciprofloxacin resistant Escherichia coli (CFRE) with acute uncomplicated cystitis (AUC), we determined the VFs and the phylogenetic background of all 54 CFRE strains and the 55 randomly selected ciprofloxacin sensitive E. coli strains (CFSE) from patients with AUC in 22 Korean hospitals. The prevalence of the VFs was as follows: fimA, papEF, papGIII, sfaI, dafaBC, cnf1, and hlyA were presented in 96%, 54%, 68%, 91%, 49%, 72%, and 29% of the samples, respectively. The expressions of papEF, cnf1, and hlyA were significantly more prevalent in the CFSE. Moreover, the expressions of cnf, and papEF significantly reduced the risk of ciprofloxacin resistance. The CFSE was also marginally associated with the group B2 (P=0.05). Although the presence of pyuria and a previous cystitis history were not related with the phylotyping and the expressions of VFs, group B2, and fimA and papEF were more expressed in the younger age patients (P<0.05). In conclusion, the CFRE exhibits a selective loss of VFs and the non-B2 phylotype in Korean AUC patients. The group B2 and the presence of fimA and papEF are associated with a younger age of AUC patients.

A prospective multi-center trial of Escherichia coli extract for the prophylactic treatment of patients with chronically recurrent cystitis

We have assessed the efficacy and safety of Escherichia coli extract (ECE; Uro-Vaxom) which contains active immunostimulating fractions, in the prophylactic treatment of chronically recurrent cystitis. Forty-two patients with more than 2 episodes of cystitis in the proceeding 6 months were treated for 3 months with one capsule daily of ECE and observed for a further 6 months. The primary efficacy criterion was the number of episodes of recurrent cystitis during the 6 months after treatment compared to those during the 6 months before treatment. At the end of the 9-month trial, 34 patients (all women) were eligible for statistical analysis. Their mean age was 56.4 yr (range, 34-75 yr), and they had experienced recurrent urinary tract infections for 7.2+/-5.2 yr. The number of recurrences was significantly lower during the 6-month follow-up period than during the 6 months preceding the trial (0.35 vs. 4.26, P<0.001). During the follow-up, 28 (82.4%) patients had no recurrences and 4 (11.8%) had 1 each. In patients who relapsed, ECE alleviated cystitis symptoms, including painful voiding, frequency and urgency. There were no serious adverse events related to the study drug. Our study demonstrates the efficacy and safety of ECE in the prophylactic treatment of chronically recurrent cystitis.

[From cystitis to bacterial prostatitis: experience with levofloxacin]

According to data reported by Naber (2008), urinary tract infections (UTIs), represent the main nosocomial acquired infection (40%); these infections are second, in order of frequency, only to respiratory tract infections in ambulatory setting, and account for 20% of ambulatory uro-nephrologic disease. Nowadays, the UTI's classification recognizes five different groups, represented by acute, non complicated lower urinary tract infections (cystitis), acute non complicated pyelonephritis, complicated UTI's with/without pyelonephritis, urosepsis and special forms, such as prostatitis, epididimitis, and orchitis. With regard to therapy, and specifically to fluoroquinolones, the European urologists' scientific community is unanimous in considering that levofloxacin plays a very important activity in the urological field, its antimicrobial spectrum being extended to Gram positive and atypical microorganisms as well.

[Gemifloxacin for the treatment of uncomplicated urinary infections (acute cystitis)]

Uncomplicated urinary infections are a significant and growing cause of morbidity amongst young women. Commonly these infections are caused by Escherichia coil or Staphylococcus saprophyticus. Escherichia coil is resistant to several empirical antibiotics: amoxicilin, trimetoprima-sulfametozaxol and, more recently, to some more old flouroquinolons. Gemifloxacin is a flouroquinolon with an excellent in vitro activity against many community acquired bacteria which cause respiratory or urinary infections. This antibiotic has a very unique and dual action mechanism directed against girasa and topoisomerasa II DNA, which grants minimum low inhibitory concentrations against Escherichia coil, Klebsiella and S. saprophyticus species and others attacking respiratory system. Young women with uncomplicated urinary infections were evaluated in two random clinical studies; they were treated with 320 mg gemifloxacin once a day for three days. Gemifloxacin was compared to ofloxacin or ciprofloxacin in approved doses and durations and it proved to be useful with clinical success rates of 95% or more in both studies. Gemifloxacin showed to be safe and well tolerated. A dose a day is a safe and useful alternative amongst current empirical options to treat patients with uncomplicated urinary infections.

[A comparison of efficacy and tolerance of furamag and norbactin in the treatment of acute cystitis in females]

Efficacy and tolerance of furamag and norbactin were compared in a prospective controlled trial with participation of 82 females aged 18-60 years with acute uncomplicated cystitis. All the women were divided into two groups. Group 1 (n=42) received norbactin (norfloxacin) in a dose 400 mg twice a day for 7 days. Group 2 (n=40) was given furamag in a dose 50 mg 3 times a day for 10 days. The results were evaluated 2 weeks after the treatment. The comparison of the treatment results showed that a new nitrofuranic drug furamag has significantly higher clinical and bacteriological efficacy: acute cystitis was cured in 95% patients, eradication of the infective agent occurred in 96.4% patients, tolerance was good in 97.5% patients. Sensitivity of the agents causing acute cystitis to nitrofurans reached 98.2% while to norbactin--only 86%.

[A case of eosinophilic cystitis that was treated with oral suplatast tosilate (IPD-1151T)]

A 51-year-old woman with a chief complaint of micturition pain and sensation of incomplete voiding was suspected of suffering from a bladder tumor, according to the findings of cystoscopy and ultrasonography. Transurethral punch biopsy of the submucosa of the bladder wall revealed eosinophilic infiltration without malignancy. Conservative treatment with corticosteroids resulted in excellent relief of symptoms and objective remission of the bladder lesions. However, her symptoms recurred 11 weeks after finishing the treatment. She was then treated with a combination of corticosteroid and suplatast tosilate, followed by monotherapy with suplatast tosilate. The treatment was effective for the improvement of symptoms, and serum immunoglobulin E and blood eosinophil levels were reduced. No disease progression was noted after the treatment with suplatast tosilate. To our knowledge, this is the first case of eosinophilic cystitis treated with suplatast tosilate.

Presenting manifestations of eosinophilic cystitis in two Filipino children

Eosinophilic cystitis is a very rare clinical disease entity in the pediatric population. We report two cases of Filipino children with eosinophilic cystitis who presented with irritative voiding symptoms, gross hematuria, peripheral eosinophilia, and hydroureteronephrosis and urinary bladder wall thickening visualized on ultrasonography and CT urography. Cystoscopy and transurethral biopsy confirmed the diagnosis. Both patients were started with corticosteroid with or without an antihistamine. Resolution from the signs and symptoms were observed in both patients as documented by disappearance of peripheral eosinophilia, normal urinalysis results, and resolution of the hydroureteronephrosis and urinary bladder wall thickening on ultrasonography on follow-up.