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102
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Solera J, Jarava G. Avances en la antibioterapia empírica. Aplicaciones prácticas al tratamiento de las neumonías, de las infecciones urinarias, abdominales, de partes blandas y de sepsis de origen desconocido. Medicine (Baltimore) 2007; 9:5959-5966. [PMID: 32287926 PMCID: PMC7143694 DOI: 10.1016/s0211-3449(07)74762-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023] Open
Affiliation(s)
- J Solera
- Servicio de Medicina Interna. Hospital General Universitario de Albacete. Facultad de Medicina de Albacete. Universidad de Castilla La Mancha. Albacete
| | - G Jarava
- Servicio de Medicina Interna. Hospital General Universitario de Albacete. Facultad de Medicina de Albacete. Universidad de Castilla La Mancha. Albacete
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103
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Schimpf MO, Murdza M, O'Sullivan DM, Tulikangas PK, LaSala CA. Can community-dwelling women reliably identify infected urine? Int Urogynecol J 2007; 18:1357-61. [PMID: 17356798 DOI: 10.1007/s00192-007-0343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 02/25/2007] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to evaluate whether community-dwelling women can reliably identify infected urine samples. A convenience sample of 25 women judged six urine samples. Of these, two were normal, two contained culture-proven infections, and two were intentionally abnormal because of ingestion of asparagus or vitamins. The women decided if each sample was infected based on its color, clarity, and odor. For the two normal samples, 56 and 96% women correctly identified them. Of the two samples positive for infection, women were correct 80 and 100% of the time. Of the two samples designed to be abnormal, women were correct in 92 and 64% of their evaluations. Using the 150 total evaluations of urine samples, the sensitivity was 90%, and the specificity was 77%. Based on this small sample, community-dwelling women can detect infected samples of urine. However, women should still be screened for factors that might have distorted normal urine.
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Affiliation(s)
- Megan O Schimpf
- Department of Obstetrics and Gynecology, Division of Urogynecology, Hartford Hospital, Hartford, CT, USA.
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104
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Venmans LMAJ, Sloof M, Hak E, Gorter KJ, Rutten GEHM. Prediction of complicated urinary tract infections in patients with type 2 diabetes: a questionnaire study in primary care. Eur J Epidemiol 2007; 22:49-54. [PMID: 17203360 DOI: 10.1007/s10654-006-9077-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Accepted: 11/03/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Relatively few data are available to predict a complicated course of community-acquired complicated urinary tract infections (UTIs) in patients with diabetes type 2 (DM2). The aim of this study was to assess predictors for a complicated course of UTIs in DM2 patients in primary care. METHOD We conducted a cross-sectional questionnaire study among DM2 patients aged over 45 years as part of an educational trial. The combined outcome measure was a complicated course of UTI, defined as a self-reported episode of acute pyelonephritis, prostatitis or recurrent cystitis in the 12 months before the trial. Patients with an outcome were all verified by review of medical records. A prediction model was derived with multivariable logistic regression analysis. RESULTS Of the 1151 trial participants, 94 (8%) had a self-reported community-acquired complicated course of UTIs and 62 (66%) of these were medically-attended. Independent predictors for a complicated course were age above 60 years (adjusted odds ratio (OR): 1.74; 95% confidence interval (CI): 0.99-3.03), chronic use of antibiotics (adjusted OR: 5.50; 95% CI: 2.31-13.08), more than 6 physician contacts in previous year (adjusted OR: 3.60; 95% CI: 2.00-6.49), hospitalization in previous year (adjusted OR: 1.36; 95% CI: 1.00-1.85), renal disease (adjusted OR: 4.92; 95% CI: 1.59-15.18) and incontinence of urine (adjusted OR: 3.78; 95% CI: 1.93-7.38). Area under the receiver-operating curve was 0.72 (95% CI: 0.66-0.78). Analysis according to medically attended complicated UTIs did not change our findings. CONCLUSION Easily obtainable predictors from medical history can be used to accurately predict a complicated course of UTIs in DM2 patients.
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Affiliation(s)
- Leonie M A J Venmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. 85500, 3508 6A Utrecht, The Netherlands.
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105
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Aagaard EM, Nadler P, Adler J, Maselli J, Gonzales R. An interactive computer kiosk module for the treatment of recurrent uncomplicated cystitis in women. J Gen Intern Med 2006; 21:1156-9. [PMID: 16879705 PMCID: PMC1831661 DOI: 10.1111/j.1525-1497.2006.00575.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To validate and implement a computer module for the management of uncomplicated urinary tract infections (UTI). PARTICIPANTS Women age 18 to 64 years, with a previous UTI, voiding symptoms, and absence of complicating features (comorbidities, vaginal discharge, back pain, emesis, and fever/chills). MEASUREMENTS The computer module was validated against clinician diagnosis and urine culture. Following validation, the module was implemented in the urgent care clinic as a management option for women with suspected UTI; computer-directed therapy (CDT)-eligible women received antibiotic treatment without a clinician examination. Patient satisfaction with the module and return visits for UTI-related complaints were assessed. RESULTS In the validation study, 18 of 68 women (26%) were CDT-eligible. Clinicians diagnosed 17/18 CDT-eligible women with uncomplicated UTI. Sixty-seven percent of CDT-eligible women had a positive urine culture. Since implementation, 162 women have accessed the module, and 35% have received CDT. Ninety-eight percent (95% confidence interval: 95% to 100%) found the program easy to use and 95% (89% to 100%) would recommend it to friends/family. Two (4%) CDT-treated women had a return visit to our institution for a UTI-related illness within 2 weeks. CONCLUSIONS A computer module accurately identifies women with culture-confirmed, uncomplicated UTIs. Patients are highly satisfied with the module.
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Affiliation(s)
- Eva M Aagaard
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA.
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106
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Abstract
Recurrent urinary tract infections (RUTI) are a frequent clinical problem in sexually active young women, pregnant or postmenopausal women and in patients with underlying urological abnormalities. The present chapter reviews RUTI based on their classification: relapses, which usually occur early (< 1 month), are caused by the same microorganism and are associated with underlying urological abnormalities, and reinfections, which usually occur later and are caused by a new distinct microorganism (or by the same microorganism usually located in the rectum or uroepithelial cells). The pathogenesis of RUTI is reviewed and the risk factors associated with RUTI in premenopausal women (usually related to sexual activity), postmenopausal women (in whom estrogen deficiency has a significant effect on the vaginal Lactobacillus flora), and in pregnant women are discussed. Likewise, an extensive review of the distinct therapeutic strategies to prevent RUTI is provided: self-treatment of cystitis, continuous antibiotic prophylaxis, postcoital antibiotic prophylaxis, topical vaginal estrogens, Lactobacillus, cranberry juice, intravesical administration of non-virulent E. coli strains and vaccines, among others. Several diagnostic-therapeutic algorithms are included. These algorithms are based on the type of urinary infection (relapse-reinfection), on the type of patient (young, postmenopausal, or pregnant women) and on the number of episodes of RUTI.
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Affiliation(s)
- Carlos Pigrau-Serrallach
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Universidad Autónoma, Barcelona, España.
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107
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Abstract
UTI continues to be a common problem for otherwise healthy adult women. Treatment of UTI has become more difficult because of the rising levels of resistance to commonly used antibiotics. Further research is needed to develop new antibiotic therapies and nonantibiotic prevention measures.
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Affiliation(s)
- Christopher A Czaja
- Department of Medicine, University of Washington School of Medicine, Seattle 98195, USA.
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108
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Hickerson AD, Carson CC. The treatment of urinary tract infections and use of ciprofloxacin extended release. Expert Opin Investig Drugs 2006; 15:519-32. [PMID: 16634690 DOI: 10.1517/13543784.15.5.519] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Urinary tract infections (UTIs) are one of the most common reasons people seek medical attention. There are > 50% of women who will have at least one UTI during their lifetime and most of these will require a physician visit and antibiotic treatment. The high prevalence continues to the in-patient setting where genitourinary infections are the most common nosocomial infection. The efficient diagnosis and effective treatment of UTIs is a major healthcare concern. Factors such as economic efficiency and emerging resistance are increasingly becoming more important considerations in providing patient care. In out-patient uncomplicated UTIs, Escherichia coli has been implicated in < or = 75-90% of cases. Although the prevalence in the in-patient setting decreases, E. coli is still the most common bacteria identified and present in 21-54% of urinary isolates. Trimethoprim-sulfamethoxazole has been the preferred first-line agent for uncomplicated out-patient UTIs where local resistance is < 10 - 20%. In recent years, resistance has superseded this threshold in most regions of the US and Europe. In these areas with increased resistance, fluoroquinolones have become a common first-line agent. Ciprofloxacin has been one of the most widely used fluoroquinolones and has a well-known safety profile, as well as excellent activity against most of the common uropathogens. Ciprofloxacin extended release (ER) is a recently released once-daily formulation that has been increasingly used with good clinical success. The pharmacokinetic and pharmacodynamic parameters of ciprofloxacin ER are shown to be at least equal to twice-daily ciprofloxacin and may even confer superiority as ciprofloxacin ER achieves a higher maximum serum concentration. This is supported by clinical studies, which have shown at least as effective clinical cure and bacteriological eradication rates. These studies have also demonstrated similar tolerability and side-effect profiles. Ciprofloxacin ER combines traditional ciprofloxacin's proven track record of efficacy and safety with favourable pharmacokinetics and convenient once-daily dosing. Increased patient compliance is associated with decreased treatment failures and can help slow the development of antimicrobial resistance. Economic considerations are also increasingly important and providing convenient and effective treatment leading to high clinical success decreases overall costs.
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Affiliation(s)
- Adam D Hickerson
- University of North Carolina, Division of Urology, 2140 Bioinformatics Building, Chapel Hill, NC27599-7235, USA.
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109
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Abstract
Urinary tract infections (UTI) are among the most frequent bacterial infections in women. Mostly young women and, to some extent, postmenopausal women are affected by recurrent UTI (rUTI), defined as >or=3 UTI/year. Modifiable predisposing factors are rare. The differential diagnosis between relapse and reinfection is decisive for therapy. Antibiotic prophylaxis has emerged as one of the most important therapeutic principles in rUTI. Depending on the drug utilized, the various modes of action are described as reducing the number of uropathogens in the gut and vaginal flora and/or in repeatedly eliminating bacteria from the urine. According to the European Association of Urology guidelines, nitrofurantoin, trimethoprim, and cotrimoxazole are available as first-line drugs. Cephalexin and the quinolones should be restricted to specific indications. Depending on the case, long-term antibiotic prophylaxis for 6 months, postcoital single dose prophylaxis, or patient-initiated self-start therapy can all be used successfully. Given the correct indications, the recurrence rate of rUTI can be reduced by 95%.
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Affiliation(s)
- M Ludwig
- Urologische Praxis Dres. A. von Keitz, M. Schwickardi, M. Ludwig, Marburg.
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110
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. TNF, . MN, . AHM, . BSM, . ER. Prevalence of Chlamydia Trachomatis Within Culture Negative Urine Specimens in Southeast of Iran. JOURNAL OF MEDICAL SCIENCES 2006. [DOI: 10.3923/jms.2006.245.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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111
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Fourcroy JL, Berner B, Chiang YK, Cramer M, Rowe L, Shore N. Efficacy and safety of a novel once-daily extended-release ciprofloxacin tablet formulation for treatment of uncomplicated urinary tract infection in women. Antimicrob Agents Chemother 2006; 49:4137-43. [PMID: 16189090 PMCID: PMC1251530 DOI: 10.1128/aac.49.10.4137-4143.2005] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The efficacy and safety of a novel once-daily extended-release ciprofloxacin (ciprofloxacin ER) 500-mg dose were compared with those of an immediate-release ciprofloxacin (ciprofloxacin IR) 250-mg twice-daily dose, each administered orally for 3 days in the treatment of acute uncomplicated urinary tract infection (uUTI) in women. Adult female outpatients (mean age, 39 years) with clinical signs and symptoms of acute uUTI and a positive pretreatment urine culture (> or =10(5) CFU/ml) were enrolled in a multicenter, randomized, double-blind, noninferiority trial. Patients were assessed at a test-of-cure visit (4 to 11 days posttreatment) and a late-posttreatment visit (4 to 6 weeks posttreatment) for microbiological and clinical outcomes and safety. The primary efficacy endpoint and microbiological eradication rate at the test-of-cure visit in the ciprofloxacin ER group (254/272; 93.4%) were noninferior to those in the ciprofloxacin IR group (225/251; 89.6%) (95% confidence interval [CI] of difference, -0.99%, 8.59%). Clinical-cure rates at the test-of-cure visit were 85.7% (233/272) for ciprofloxacin ER and 86.1% (216/251) for ciprofloxacin IR (95% CI of difference, -6.37%, 5.57%). At the late-posttreatment visit, microbiological and clinical outcomes were similar for the two treatments and consistent with test-of-cure results. Both treatments were well tolerated, but the frequencies of nausea and diarrhea were lower in the ciprofloxacin ER group than in the ciprofloxacin IR group (nausea, ER, 0.6%; IR, 2.2%; P = 0.033; diarrhea, ER, 0.2%; IR, 1.4%; P = 0.037). Once-daily ciprofloxacin ER was safe, effective, and noninferior to twice-daily ciprofloxacin IR in the treatment of acute uUTI. Additionally, ciprofloxacin ER was associated with significantly reduced frequencies of nausea and diarrhea.
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Affiliation(s)
- Jean L Fourcroy
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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112
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Abstract
Urinary tract infections are the second most common infections, causing considerable anxiety and morbidity in women. Care is not always optimal—prophylaxis is rarely considered and unnecessary investigations are requested. This evidence based approach to management of urinary tract infections in women highlights that some common recommendations, such as postcoital voiding, have no evidence base
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Affiliation(s)
- Josip Car
- Department of Primary Care and Social Medicine, Imperial College, London W6 8RP.
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113
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Horcajada JP, García-Palomo D, Fariñas MC. Tratamiento de las infecciones no complicadas del tracto urinario inferior. Enferm Infecc Microbiol Clin 2005; 23 Suppl 4:22-7. [PMID: 16854355 DOI: 10.1157/13091445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Empirical antibiotic treatment of lower urinary tract infections should be based on the patient's clinical data and on local sensitivity data. Because of the increase in resistance among uropathogens, recommendations on the empirical treatment of urinary tract infections have been modified. Currently, the empirical use of co-trimoxazole, ampicillin, and first-generation cephalosporins and quinolones is not recommended. Fluoroquinolones have been demonstrated to be highly effective in comparative studies but, because of the increase in resistance, the type of patient who can benefit from these antimicrobial agents must be selected. Second- and third-generation cephalosporins still have high sensitivity rates, although the higher recurrence rates associated with their use and the emergence of extended-spectrum beta-lactamase-producing enterobacterial in the community should be taken into account. Amoxicillin-clavulanate is less effective in eradicating infections than quinolones. Fosfomycin-trometamol has resistance rates of below 2% and single-dose therapy has been demonstrated to be safe and effective. Nitrofurantoin is also currently active, although it must be administered for 7 days and can produce toxicity. Both agents are currently recommended as alternative therapeutic options to fluoroquinolones in uncomplicated infections of the lower urinary tract.
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Affiliation(s)
- Juan Pablo Horcajada
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, España.
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114
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Abstract
Urinary tract infection (UTI) is one of the most common bacterial infections in women, and one in four of these women will develop a recurrence. Various risk factors predispose women of different age groups to recurrence. These factors include sexual intercourse, use of contraception, antimicrobials, oestrogen, genetics, and the distance of the urethra from the anus. Of the different pathogens, Escherichia coli is the organism most commonly isolated. A variety of treatment options has been proposed, including long-term or post-intercourse prophylaxis and patient-initiated therapy. Oestrogen and cranberry juice have also been used as prophylactic treatment adjuncts. At present, other therapeutic and preventive modalities are being investigated, including the development of vaccines to treat those most severely affected.
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Affiliation(s)
- Anna Virginia M Franco
- Department of Urogynaecology and Pelvic Reconstruction, 4th Floor Lanesborough Wing, St George's Hospital, Blackshaw Road, London SW17 0QT, UK.
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115
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Poletto KQ, Reis C. [Antimicrobial susceptibility of the uropathogens in out patients in Goiânia City, Goiás State]. Rev Soc Bras Med Trop 2005; 38:416-20. [PMID: 16172759 DOI: 10.1590/s0037-86822005000500011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Due to the fact that the number of multiresistant microorganisms which cause cystitis is increasing, the objective of this study was to identify the pathogens that cause urinary tract infection in women and determine antimicrobial susceptibility. We analyzed 442 urine samples from June 2002 to August 2003. Identification through biochemical and enzymatic assays, and the antibiogram by Disk diffusion method were performed. Out of these samples, 78 were positive for urinary tract infection (17.6%). Escherichia coli were the microorganisms that most frequently caused infections (67.9%). Gram-negative bacteria exhibited resistance to amoxicillin in 74.6% of the cases. Most were ceftazidime and gentamicin sensitive. Gram-positive bacteria were resistant in 72.7% of the samples to ampicillin, and they were trimethoprim/sulfamethoxazole, vancomycin and linezolid sensitive. It was concluded that investigation of bacterial resistance is necessary to provide information for new therapeutic options.
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Affiliation(s)
- Karine Queiroz Poletto
- Departamento de Microbiologia, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, GO.
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116
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Klimberg I, Shockey G, Ellison H, Fuller-Jonap F, Colgan R, Song J, Keating K, Cyrus P. Time to symptom relief for uncomplicated urinary tract infection treated with extended-release ciprofloxacin: a prospective, open-label, uncontrolled primary care study. Curr Med Res Opin 2005; 21:1241-50. [PMID: 16083534 DOI: 10.1185/030079905x56358] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Few studies have investigated symptom relief in urinary tract infections. This innovative exploratory trial aimed to measure the time to improvement of the signs and symptoms of uncomplicated urinary tract infection (UTI) in women receiving extended-release ciprofloxacin. Time to return to normal daily activities was also evaluated. RESEARCH DESIGN AND METHODS An open-label, multicenter US study in adult female outpatients with uncomplicated UTI. Patients completed serial questionnaires: the Urinary tract infection Symptom Assessment [USA], tracking time to symptom improvement, and the Activity Impairment Assessment [AIA], measuring the time to return to normal daily activities, using hand-held electronic diaries. Severity on the USA questionnaire was categorized using a 4-point Likert-type scale, with improvement defined as a reduction of at least one degree of symptom severity. All patients received once-daily extended-release ciprofloxacin 500 mg tablets for 3 days. RESULTS Of 276 female patients aged 18-78 years who enrolled at 28 sites, 273 (99%) were safety-valid, 264 (96%) completed at least 24 h of questionnaires and were valid for symptom relief analysis, and 170 (62%) had pre-therapy pathogen(s) > or = 10(3) CFU/mL and were valid for efficacy analysis. Six hours after the first dose of study drug, 50% of patients reported symptom improvement; 87% by 24 h and 91% by 48 h. At study entry, 54% of patients reported considerably decreased time at work or other activities; reduced to 23% by Day 2 and 10% by Day 3. At the test-of-cure visit (5-11 days post-therapy), 96% (163/170) of patients were clinical cures. Drug-related adverse events were reported by 18 (7%) patients and were consistent with previous extended-release ciprofloxacin studies (e.g., gastrointestinal disturbance, fungal superinfections). There were no serious adverse events or discontinuations due to adverse events. CONCLUSION This open-label, non-comparative trial in adult women demonstrated a rapid improvement in uncomplicated UTI symptom severity (6-24 h) and the ability to return to work within 24 h following extended-release ciprofloxacin treatment. Clinical cure rate and tolerability profile were similar to results of previous extended-release ciprofloxacin studies.
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Affiliation(s)
- Ira Klimberg
- Florida Foundation for Healthcare Research, Ocala, FL 34474, USA.
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117
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Gormley EA. Recurrent urinary tract infection in women: Emerging concepts regarding etiology and treatment considerations. Curr Urol Rep 2003; 4:399-403. [PMID: 14499065 DOI: 10.1007/s11934-003-0015-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Recurrent urinary tract infections are caused by a combination of host factors and bacterial virulence. The patient with symptoms suggestive of recurrent urinary tract infections benefits from cultures to confirm the diagnosis of recurrent infections. The community also benefits because they allow for the tracking of resistant patterns. Once a patient has been diagnosed with recurrent urinary tract infections, there are a number of treatment choices in terms of initial treatment and prophylaxis. Treatment of the acute infection should follow the published guidelines of the Infectious Diseases Society of America taking into account local patterns of resistance. Younger patients can prevent infections by avoiding spermicides and taking cranberry tablets. Older patients may prevent infections by using estrogen and emptying their bladders fully. All patients may benefit from using antibiotic prophylaxis.
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Affiliation(s)
- E Ann Gormley
- Dartmouth-Hitchcock Medical Center, Section of Urology, One Medical Center Drive, Lebanon, NH 03756, USA.
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118
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Affiliation(s)
- Stephan D Fihn
- Northwest Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, and the University of Washington, Seattle 98108, USA.
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119
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Abstract
Empirical antimicrobial treatment for acute cystitis in women requires continuing reassessment as the antimicrobial susceptibility of community isolates of Escherichia coli evolves. Current recommendations for 3 days trimethoprim or trimethoprim/sulphamethoxazole are compromised by increasing resistance of community E. coli to these agents. Fluoroquinolones are an alternate 3-day therapy, but increasing resistance is being reported from some countries, and widespread community use may promote resistance, limiting effectiveness of these agents for more serious infections. Alternate regimens supported by recent clinical trials suggest pivmecillinam given twice daily for 7 days is as effective as 3 days of quinolone therapy, while microbiological cure is 80% with 3 days therapy twice daily, and 90% with 3 days therapy thrice daily. Nitrofurantoin given for 7 days has a cure rate of 80-85%. Fosfomycin trometamol as a single dose has cure rates of 75-85%. All these agents are effective, but a compromise in efficacy or duration of therapy compared with current 3-day regimens may have to be considered.
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Affiliation(s)
- Lindsay E Nicolle
- Department of Internal Medicine, Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Room GG443, Winnipeg, Manitoba, Canada R3A 1R9.
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120
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Hooton TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am 2003; 17:303-32. [PMID: 12848472 DOI: 10.1016/s0891-5520(03)00004-7] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Acute uncomplicated UTI is one of the most common problems for which young women seek medical attention and accounts for considerable morbidity and health care costs. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials, although resistance is increasing to some of the commonly used agents, especially TMP-SMX. In women with risk factors for infection with resistant bacteria, or in the setting of a high prevalence of TMP-SMX-resistant uropathogens, a case can be made for using a fluoroquinolone or nitrofurantoin. Use of nitrofurantoin for the empiric treatment of mild cystitis is supportable from a public health perspective in an attempt to decrease uropathogen resistance because it does not share cross-resistance with more commonly prescribed antimicrobials. Beta-lactams and fosfomycin should be considered second-line agents for empiric treatment of cystitis. Acute pyelonephritis in an otherwise healthy woman may be considered an uncomplicated infection. Fluoroquinolone regimens are superior to TMP-SMX for empiric therapy because of the relatively high prevalence of TMP-SMX resistance among uropathogens causing pyelonephritis. TMP-SMX, effective for patients with mild to moderate disease, is an appropriate drug if the uropathogen is known to be susceptible. It is reasonable to use a 7- to 10-day oral fluoroquinolone regimen for outpatient management of mild to moderate pyelonephritis in the setting of a susceptible causative pathogen and rapid clinical response to therapy. Most women with acute uncomplicated pyelonephritis are now managed safely and effectively as outpatients. Acute uncomplicated cystitis or pyelonephritis in healthy adult men is very uncommon but is generally caused by the same spectrum of uropathogens with the same antimicrobial susceptibility profile as that seen in women. The choice of antimicrobials is similar to that recommended for cystitis in women except that nitrofurantoin is not considered a good choice. Treatment duration should generally be longer than that recommended for women.
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Affiliation(s)
- Thomas M Hooton
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA, USA
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121
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Abstract
Urinary tract infections (UTIs) are a common infectious disease in primary care practice. This article reviews topics highlighting recent research, including UTIs in pregnancy and pediatric UTIs. The authors also discuss catheter-associated UTIs, given the large number of hospitalized patients undergoing catheterization and residents of long-term care facilities, in whom catheters are used frequently, and complicated UTIs.
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Affiliation(s)
- Pat F Bass
- Division of General Internal Medicine, University of Louisville, School of Medicine, 500 South Preston Street, Instructional Building, Louisville, KY 40292, USA.
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122
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Bent S, Saint S. The optimal use of diagnostic testing in women with acute uncomplicated cystitis. Dis Mon 2003; 49:83-98. [PMID: 12601339 DOI: 10.1067/mda.2003.9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute uncomplicated cystitis is a common and costly disorder in women, and there is considerable variation in the diagnostic strategies currently used in clinical practice. Because the diagnosis of cystitis can be established in most patients using the history alone, the clinician's responsibility is to determine which patients require additional diagnostic testing. Patients with typical symptoms (i.e., dysuria, frequency, urgency, hematuria), without risk factors for complicated infection or pyelonephritis, and without a history of vaginal discharge, have a very high probability of cystitis and are appropriate candidates for empiric treatment. It is more difficult, however, to rule out infection in patients with suspected cystitis. Because the prevalence of culture-proven infection is very high in women who present with >or=1 symptom, and because the treatment threshold for this condition is low, a urine culture is generally required to rule out infection in patients with atypical symptoms, even in the presence of a negative dipstick test. In population-based, before-and-after studies, use of diagnostic algorithms has been shown to significantly decrease the use of urinalysis, urine culture, and office visits while increasing the percentage of patients who receive recommended antibiotics. These strategies have substantially reduced the cost of managing cystitis without an increase in adverse events or a decrease in patient satisfaction. Randomized controlled trials are needed to more closely examine the outcomes, costs of care, and patient satisfaction from different diagnostic and management strategies.
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Abstract
Urinary tract infections (UTIs) are common bacterial infections, particularly in women. Antimicrobial therapy is seldom indicated for asymptomatic infection, but antimicrobial therapy is usually indicated for amelioration of symptoms. Management of acute uncomplicated UTI (cystitis) is generally straightforward, with a predictable distribution of uropathogens isolated. First-line treatment of acute uncomplicated UTI has traditionally involved a 3-day regimen of trimethoprim-sulfamethoxazole (TMP-SMX) or TMP alone for patients with sulfa allergies. Increasing resistance among community-acquired Escherichia coli to TMP-SMX worldwide has led to a reassessment of the most appropriate empiric therapy for these infections. Alternative first-line agents include the fluoroquinolones, nitrofurantoin, and fosfomycin. Factors to be considered in the selection of appropriate antimicrobial therapy include pharmacokinetics, spectrum of activity of the antimicrobial agent, resistance prevalence for the community, potential for adverse effects, and duration of therapy. Ideal antimicrobial agents for UTI management have primary excretion routes through the urinary tract to achieve high urinary drug levels. In addition, there are special considerations in the management of UTI among selected populations, including postmenopausal and pregnant women, and for women with frequent recurrent UTIs.
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Heller RF, Heller TD, Pattison S. Putting the public back into public health. Part II. How can public health be accountable to the public? Public Health 2003; 117:66-71. [PMID: 12802908 DOI: 10.1016/s0033-3506(02)00008-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The practice of public health involves the application of evidence to improving population health, and should be accountable to the public. Accountability to the public can be considered either at the individual doctor-patient interface or through population-level policy making. The public, at both patient and population levels, should join the professionals at each stage of the 'population health evidence cycle'-in asking for, collecting, understanding and using evidence. A greater appreciation of the non-professional, public perspective would represent a substantial commitment to transforming our understanding and needs for different kinds of evidence required to improve the health of the population.
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Affiliation(s)
- R F Heller
- Evidence for Population Health Unit, School of Epidemiology and Health Sciences, Medical School, University of Manchester, Oxford Road, Manchester M13 9PT, UK.
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125
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Abstract
PURPOSE OF REVIEW Recurrent urinary tract infection is a common problem and can affect women of all ages, particularly the elderly and pregnant women. Obstetricians and gynaecologists need to have up-to-date knowledge of the diagnosis, pathophysiology and management of this condition. RECENT FINDINGS The diagnosis of urinary tract infection is made on the basis of symptoms and bacteriuria of more than 103 bacteria per ml. Host and bacterial virulence factors are important in the pathogenesis of recurrent urinary tract infections. General host factors predisposing to recurrent infection are genetic factors, ageing, the menopause, urogenital dysfunction, sexual behaviour, and previous pelvic surgery. Urinary tract infection is common in pregnancy, and recent studies have suggested an association with mental retardation and developmental delay. Women with recurrent urinary tract infection in pregnancy should be considered for long-term antibiotic prophylaxis. Intravaginal oestrogens and cranberry juice have been found to be effective for prevention, although more research is required. Women with recurrent urinary tract infection should have at least a 3-day course of trimethoprim or cotrimoxazole, or a 5-day course of beta-lactams or nitrofurantoin, with perhaps a 10-day course in the elderly. Women with frequent urinary tract infection (more than three episodes per year) should be offered prophylactic antibiotics, which can be patient-initiated, postcoital, or long-term low-dose therapy. In the future, vaccines against specific uropathogenic bacteria may be useful in urinary tract infection prophylaxis. SUMMARY More research is required, by all medical disciplines, on various aspects of urinary tract infection.
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Affiliation(s)
- Peter L Dwyer
- Department of Urogynaecology, Mercy Hospital for Women & Royal Women's Hospital, Melbourne, Australia.
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Abstract
Urinary tract infections (UTIs) are common bacterial infections, particularly in women. Antimicrobial therapy is seldom indicated for asymptomatic infection, but antimicrobial therapy is usually indicated for amelioration of symptoms. Management of acute uncomplicated UTI (cystitis) is generally straightforward, with a predictable distribution of uropathogens isolated. First-line treatment of acute uncomplicated UTI has traditionally involved a 3-day regimen of trimethoprim-sulfamethoxazole (TMP-SMX) or TMP alone for patients with sulfa allergies. Increasing resistance among community-acquired Escherichia coli to TMP-SMX worldwide has led to a reassessment of the most appropriate empiric therapy for these infections. Alternative first-line agents include the fluoroquinolones, nitrofurantoin, and fosfomycin. Factors to be considered in the selection of appropriate antimicrobial therapy include pharmacokinetics, spectrum of activity of the antimicrobial agent, resistance prevalence for the community, potential for adverse effects, and duration of therapy. Ideal antimicrobial agents for UTI management have primary excretion routes through the urinary tract to achieve high urinary drug levels. In addition, there are special considerations in the management of UTI among selected populations, including postmenopausal and pregnant women, and for women with frequent recurrent UTIs.
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Affiliation(s)
- Lindsay E Nicolle
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Abstract
Acute uncomplicated cystitis is a common and costly disorder in women, and there is considerable variation in the diagnostic strategies currently used in clinical practice. Because the diagnosis of cystitis can be established in most patients using the history alone, the clinician's responsibility is to determine which patients require additional diagnostic testing. Patients with typical symptoms (i.e., dysuria, frequency, urgency, hematuria), without risk factors for complicated infection or pyelonephritis, and without a history of vaginal discharge, have a very high probability of cystitis and are appropriate candidates for empiric treatment. It is more difficult, however, to rule out infection in patients with suspected cystitis. Because the prevalence of culture-proven infection is very high in women who present with >/=1 symptom, and because the treatment threshold for this condition is low, a urine culture is generally required to rule out infection in patients with atypical symptoms, even in the presence of a negative dipstick test. In population-based, before-and-after studies, use of diagnostic algorithms has been shown to significantly decrease the use of urinalysis, urine culture, and office visits while increasing the percentage of patients who receive recommended antibiotics. These strategies have substantially reduced the cost of managing cystitis without an increase in adverse events or a decrease in patient satisfaction. Randomized controlled trials are needed to more closely examine the outcomes, costs of care, and patient satisfaction from different diagnostic and management strategies.
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Affiliation(s)
- Stephen Bent
- Department of Medicine, University of California, San Francisco, USA.
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Affiliation(s)
- Walter E Stamm
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle 98195, USA
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Affiliation(s)
- Timothy Jancel
- Department of Clinical Pharmacy, University of California, San Francisco, Medical Center 521 Parnassus Ave, Room C-152 San Francisco, CA 94143-0622, USA.
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Sobel JD. Clinical Trials Report. Curr Infect Dis Rep 2001; 3:527-528. [PMID: 11722809 DOI: 10.1007/s11908-001-0089-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jack D. Sobel
- Division of Infectious Diseases, Harper Hospital, 4 Brush Center, Room 411, 3990 John R, Detroit, MI 48201, USA
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Women's Health LiteratureWatch. JOURNAL OF WOMEN'S HEALTH & GENDER-BASED MEDICINE 2001; 10:821-6. [PMID: 11703895 DOI: 10.1089/15246090152636587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
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