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Abbott IJ, Peel TN, Cairns KA, Stewardson AJ. Antibiotic management of urinary tract infections in the post-antibiotic era: a narrative review highlighting diagnostic and antimicrobial stewardship. Clin Microbiol Infect 2023; 29:1254-1266. [PMID: 35640839 DOI: 10.1016/j.cmi.2022.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/03/2022] [Accepted: 05/11/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND As one of the most common indications for antimicrobial prescription in the community, the management of urinary tract infections (UTIs) is both complicated by, and a driver of, antimicrobial resistance. OBJECTIVES To highlight the key clinical decisions involved in the diagnosis and treatment of UTIs in adult women, focusing on clinical effectiveness and both diagnostic and antimicrobial stewardship as we approach the post-antimicrobial era. SOURCES Literature reviewed via directed PubMed searches and manual searching of the reference list for included studies to identify key references to respond to the objectives. A strict time limit was not applied. We prioritised recent publications, randomised trials, and systematic reviews (with or without meta-analyses) where available. Searches were limited to English language articles. A formal quality assessment was not performed; however, the strengths and limitations of each paper were reviewed by the authors throughout the preparation of this manuscript. CONTENT We discuss the management of UTIs in ambulatory adult women, with particular focus on uncomplicated infections. We address the diagnosis of UTIs, including the following: definition and categorisation; bedside assessments and point-of-care tests; and the indications for, and use of, laboratory tests. We then discuss the treatment of UTIs, including the following: indications for treatment, antimicrobial sparing approaches, key considerations when selecting a specific antimicrobial agent, specific treatment scenarios, and duration of treatment. We finally outline emerging areas of interest in this field. IMPLICATIONS The steady increase in antimicrobial resistance among common uropathogens has had a substantial affect on the management of UTIs. Regarding both diagnosis and treatment, the clinician must consider both the patient (clinical effectiveness and adverse effects, including collateral damage) and the community more broadly (population-level antimicrobial selection pressure).
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia; Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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A global perspective on improving patient care in uncomplicated urinary tract infection: Expert consensus and practical guidance. J Glob Antimicrob Resist 2021; 28:18-29. [PMID: 34896337 DOI: 10.1016/j.jgar.2021.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/01/2021] [Accepted: 11/15/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uncomplicated urinary tract infections (uUTIs) are a common problem in women. Management is mainly based on empirical prescribing, but there are concerns about overtreatment and antimicrobial resistance (AMR), especially in patients with recurrent uUTIs. METHODS A multidisciplinary panel of experts met to discuss diagnosis, treatment, prevention, guidelines, AMR, clinical trial design, and the impact of COVID-19 on clinical practice. RESULTS Symptoms remain the cornerstone of uUTI diagnosis, and urine culture is necessary only when empirical treatment fails, or rapid recurrence of symptoms or AMR is suspected. Specific antimicrobials are first-line therapy (typically nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, and pivmecillinam; dependent on availability and local resistance data). Fluoroquinolones are not first-line options for uUTIs due primarily to safety concerns, but also rising resistance rates. High-quality data to support most non-antimicrobial approaches are lacking. Local AMR data specific to community-acquired uUTIs are needed, but representative information is difficult to obtain; instead, identification of risk factors for AMR can provide a basis to guide empirical antimicrobial prescribing. The COVID-19 pandemic has impacted management of uUTIs in some countries and may have long-lasting implications for future models of care. CONCLUSIONS The management of uUTIs in women can be improved without increasing complexity, including simplified diagnosis, and empirical antimicrobial prescribing based on patient characteristics, including review of recent antimicrobial use and past pathogen resistance profiles, drug availability, and guidelines. Current data for non-antimicrobial approaches are limited. The influence of COVID-19 on telehealth could provide an opportunity to enhance patient care in the long term.
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Patel R, Polage CR, Bard JD, May L, Lee FM, Fabre V, Hayden MK, Doernberg SDB, Haake DA, Trautner BW, Grigoryan L, Tsalik EL, Hanson KE. Envisioning Future UTI Diagnostics. Clin Infect Dis 2021; 74:1284-1292. [PMID: 34463708 DOI: 10.1093/cid/ciab749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Urinary tract infections (UTIs) are among the most common bacterial infections in the United States and are a major driver of antibiotic use - both appropriate and inappropriate - across healthcare settings. UTI treatment has become complex due to antibacterial resistance; one quarter of urinary tract isolates of Escherichia coli in the United States in 2017 were resistant to fluoroquinolones and one third to trimethoprimsulfamethoxazole (1), agents with historically predictable activity against E. coli. As a result, more broad-spectrum antibiotics are being used to treat UTIs, contributing to selection of further antibiotic resistance.
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Affiliation(s)
- Robin Patel
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA. Division of Clinical Microbiology, Mayo Clinic, Rochester, MN, USA
| | | | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Larissa May
- Department of Emergency Medicine, University of California-Davis Health, Sacramento, CA, USA
| | - Francesca M Lee
- Division of Infectious Diseases, Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary K Hayden
- Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA
| | - Sarah D B Doernberg
- Division of Infectious Disease, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David A Haake
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, and the Division of Infectious Diseases, Department of Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Larissa Grigoryan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Ephraim L Tsalik
- Duke University Center for Applied Genomics and Precision Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Kimberly E Hanson
- Department of Internal Medicine and Department of Pathology, University of Utah, Salt Lake City, UT, USA
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Michelangeli C, Courjon J, Curlier E, Roger PM. Cotrimoxazole for community-acquired urinary tract infections leads to more adverse effects than fluoroquinolones. Infect Dis Now 2021; 51:374-376. [PMID: 33975674 DOI: 10.1016/j.idnow.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/20/2020] [Accepted: 11/09/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND For several years, we applied an internal guideline for community-acquired urinary tract infections (cUTI), targeting the reduction of fluoroquinolone use (FQ) and thereby favouring cotrimoxazole (CTM) prescription. Our aim was to report adverse effects (AE) and outcome for patients presenting with cUTI and treated with these compounds. METHODS This cohort study was based on the dashboard of our department, bringing together 28 parameters for all patients, including diagnosis, microbiological data, antibiotic therapy, AE, length of hospital stay (LHS) and outcome. We included all patients with cUTI due to Enterobacteriaeae treated with CTM or FQ, and compared these 2 groups on in-hospital AE, LHS, and unfavourable outcome defined as intensive care requirement or death. RESULTS From June 2008 to June 2019, 640 cUTI due to Enterobacteriaeae were observed, among which 295 (46%) treated with CTM and 345 (54%) with a FQ. There were 25 AE (3.9%): 17 (5.7%) in the CTM group, and 8 (2.3%) in the FQ group (P=0.025). Adverse effects were associated with increased LHS compared to patients without AE: 11±6 vs. 7±4 days respectively, P<0.001, 11.4±6.2 days in the CTM group vs. 9.2±5.8 in the FQ group (relative LHS increase of 73.5% and 29.5%, respectively). Unfavorable outcome occurred for 1 patient (0.3%) in the CTM group, and 5 (1.4%) in the FQ group, P=0.297. CONCLUSION Favouring cotrimoxazole for cUTI due to Enterobacteriaceae was associated compared to FQ with more AE and prolonged LHS. A cost-effectiveness analysis to validate such therapeutic strategy is warranted.
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Affiliation(s)
- C Michelangeli
- Infectiologie, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route Saint-Antoine-de-Ginestière 06200 Nice, France
| | - J Courjon
- Infectiologie, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route Saint-Antoine-de-Ginestière 06200 Nice, France; Faculté de médecine, université de Côte d'Azur, 28, avenue de Valombrose, 06100 Nice, France
| | - E Curlier
- Infectiologie, centre hospitalier universitaire, route de Chauvel, 97139 Les Abymes, Guadeloupe, France
| | - P-M Roger
- Infectiologie, centre hospitalier universitaire, route de Chauvel, 97139 Les Abymes, Guadeloupe, France; Faculté de médecine, université des Antilles, Fouillole, 97110 Pointe-à-Pitre, Guadeloupe, France.
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