Clinical investigation of isolated bacteria from urinary tracts of hospitalized patients and their susceptibilities to antibiotics

A Meta-Analysis on Clinical Outcomes of Ceftolozane versus Piperacillin in Combination with Tazobactam in Patients with Complicated Urinary Tract Infections

Objective

To evaluate efficacy and adverse events of ceftolozane/tazobactam in complicated UTI including acute pyelonephritis.

Method

Databases that include PubMed, Embase, Scopus, and TRIP were searched. All randomized controlled trials and cohort studies were considered for the study. Statistical analysis was done using a fixed effects model, and results were expressed in proportion for dichotomous data and risk ratio for continuous data with 95% confidence intervals (CI).

Results

A clinical cure of ceftolozane/tazobactam was found to be 92% with 95% CI of 90-94 while that of piperacillin/tazobactam was only 78% (95% CI, 74-82) in patients with complicated UTI. Microbiological eradication was still higher in the ceftolozane/tazobactam group (83%, 95% CI 81-88) when compared with piperacillin/tazobactam (63% 95% CI, 58.77-65.2). Ceftolozane/tazobactam was more effective in the treatment of complicated urinary tract infections other than acute pyelonephritis as compared to piperacillin/tazobactam (RR = 1.21, 95% CI, 1.07-1.23). Serious adverse events were found comparable in both groups (RR = 1.15, 95% CI, 0.64-2.09).

Conclusion

The analysis showed that ceftolozane/tazobactam has better clinical outcomes including cure rates and low resistance for the treatment of complicated urinary tract infection.

TXH11106: A Third-Generation MreB Inhibitor with Enhanced Activity against a Broad Range of Gram-Negative Bacterial Pathogens

The emergence of multi-drug-resistant Gram-negative pathogens highlights an urgent clinical need to explore and develop new antibiotics with novel antibacterial targets. MreB is a promising antibacterial target that functions as an essential elongasome protein in most Gram-negative bacterial rods. Here, we describe a third-generation MreB inhibitor (TXH11106) with enhanced bactericidal activity versus the Gram-negative pathogens Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa compared to the first- and second-generation compounds A22 and CBR-4830, respectively. Large inocula of these four pathogens are associated with a low frequency of resistance (FOR) to TXH11106. The enhanced bactericidal activity of TXH11106 relative to A22 and CBR-4830 correlates with a correspondingly enhanced capacity to inhibit E. coli MreB ATPase activity via a noncompetitive mechanism. Morphological changes induced by TXH11106 in E. coli, K. pneumoniae, A. baumannii, and P. aeruginosa provide further evidence supporting MreB as the bactericidal target of the compound. Taken together, our results highlight the potential of TXH11106 as an MreB inhibitor with activity against a broad spectrum of Gram-negative bacterial pathogens of acute clinical importance.

Inoculum effect of β-lactam antibiotics

The phenomenon of attenuated antibacterial activity at inocula above those utilized for susceptibility testing is referred to as the inoculum effect. Although the inoculum effect has been reported for several decades, it is currently debatable whether the inoculum effect is clinically significant. The aim of the present review was to consolidate currently available evidence to summarize which β-lactam drug classes demonstrate an inoculum effect against specific bacterial pathogens. Review of the literature showed that the majority of studies that evaluated the inoculum effect of β-lactams were in vitro investigations of Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Haemophilus influenzae and Staphylococcus aureus. Across all five pathogens, cephalosporins consistently displayed observable inoculum effects in vitro, whereas carbapenems were less susceptible to an inoculum effect. A handful of animal studies were available that validated that the in vitro inoculum effect translates into attenuated pharmacodynamics of β-lactams in vivo. Only a few clinical investigations were available and suggested that an in vitro inoculum effect of cefazolin against MSSA may correspond to an increased likeliness of adverse clinical outcomes in patients receiving cefazolin for bacteraemia. The presence of β-lactamase enzymes was the primary mechanism responsible for an inoculum effect, but the observation of an inoculum effect in multiple pathogens lacking β-lactamase enzymes indicates that there are likely multiple mechanisms that may result in an inoculum effect. Further clinical studies are needed to better define whether interventions made in the clinic in response to organisms displaying an in vitro inoculum effect will optimize clinical outcomes.

Relationship between conventional culture and flow cytometry for the diagnosis of urinary tract infection

BACKGROUND

Urine culture is the gold standard for the diagnosis of urinary tract infections (UTI). The use of flow cytometry analyzers (FCA) prior to culture allows for the quantification and recognition of cell components in urine to be automated and makes it possible to relate these data to the urine pathogens subsequently identified in cultures.

METHODS

Urine samples were assessed with the Sysmex UF-1000i analyzer. Those that met the criteria for culture (> 25 leukocytes/μL or > 385 bacteria/μL) were subjected to quantitative urine culture on chromogenic agar. Counts of red blood cells (RBC), white blood cells (WBC), epithelial cells (EC), and the kind of microorganisms identified in cultures were evaluated.

RESULTS

A total of 17,483 samples were processed by FCA. Of these, 9057 met the criteria for culture. Urine cultures were reduced by 48.2%. The most common urine pathogen was Escherichia coli (60.3%). Negative urine cultures were significantly (p < 0.001) associated with a lower WBC count than urine with E. coli, Klebsiella spp. and Proteus spp., but urine with Enterococcus spp. had a lower WBC than negative urine. Contaminated urine had a significantly (p < 0.001) lower WBC than urine with E. coli, Klebsiella spp. and Proteus spp., but no differences were found for Enterococcus spp. (p = 0.729). Negative urine cultures had significantly (p < 0.05) higher EC than all positive urine samples. Contaminated urine was associated (p < 0.001) with higher EC than cultures with E. coli and Klebsiella spp., in comparison with cultures with Enterococcus spp. (p = 0.091) and Proteus spp. (p = 0.251).

CONCLUSION

The use of the Sysmex UF-1000i flow cytometer for screening urine samples allows for a reduction in the number of urine cultures. WBC values correlate well with the main urine pathogens related to UTI. The results observed for Enterococcus spp. suggest a low impact of these pathogens as a cause of UTI.

Urine flow cytometry can rule out urinary tract infection, but cannot identify bacterial morphologies correctly

The diagnosis of urinary tract infection (UTI) by urine culture is a time-consuming and costly procedure. Usage of a screening method, to identify negative samples, would therefore affect time-to-diagnosis and laboratory cost positively. Urine flow cytometers are able to identify particles in urine. Together with the introduction of a cut-off value, which determines if a urine sample is subsequently cultured or not, the number of cultures can be reduced, while maintaining a low level of false negatives and a high negative predictive value. Recently, Sysmex developed additional software for their urine flow cytometers. Besides measuring the number of bacteria present in urine, information is given on bacterial morphology, which may guide the physician in the choice of antibiotic. In this study, we evaluated this software update. The UF1000i classifies bacteria into two categories: 'rods' and 'cocci/mixed'. Compared to the actual morphology of the bacterial pathogen found, the 'rods' category scores reasonably well with 91% chance of classifying rod-shaped bacteria correctly. The 'cocci/mixed' category underperforms, with only 29% of spherical-shaped bacteria (cocci) classified as such. In its current version, the bacterial morphology software does not classify bacteria, according to their morphology, well enough to be of clinical use in this study population.

Role of uropathogenic Escherichia coli outer membrane protein T in pathogenesis of urinary tract infection

OmpT is one of the members of the outer membrane protein family that has been identified as a virulence factor in most of the uropathogenic Escherichia coli (UPEC). However, the exact role of OmpT in the urinary tract infections (UTIs) remains unclear. To determine the role of OmpT in the pathogenesis of UPEC, an isogenic deletion mutant of ompT (COTD) was constructed by the λ Red recombination. Human bladder epithelial cell line 5637(HBEC 5637) was used to evaluate the ability of bacterial adhesion/invasion. A murine model of UTI was established to study the formation of intracellular bacterial communities (IBCs) in the process of UTIs. The cytokines were also examined during the pathogenesis. The results showed that the COTD strain was deficient in bacterial adhesion and invasion as well as in IBC formation compare to the parent strain. ELISA quantification analysis of cytokines showed that the levels of TNF-α, IL-6 and IL-8 in the serum, bladder and kidney tissues of the mice infected with COTD were lower than that of the CFT073 group. In summary, these results suggest that OmpT plays a multifaceted role in pathogenesis of UTI, including increased bacterial adhesiveness/invasiveness, formation of IBCs and upregulated proinflammatory cytokines.

Outbreak of a cluster with epidemic behavior due to Serratia marcescens after colistin administration in a hospital setting

Serratia marcescens causes health care-associated infections with important morbidity and mortality. Particularly, outbreaks produced by multidrug-resistant isolates of this species, which is already naturally resistant to several antibiotics, including colistin, are usually described with high rates of fatal outcomes throughout the world. Thus, it is important to survey factors associated with increasing frequency and/or emergence of multidrug-resistant S. marcescens nosocomial infections. We report the investigation and control of an outbreak with 40% mortality due to multidrug-resistant S. marcescens infections that happened from November 2007 to April 2008 after treatment with colistin for Acinetobacter baumannii meningitis was started at hospital H1 in 2005. Since that year, the epidemiological pattern of frequently recovered species has changed, with an increase of S. marcescens and Proteus mirabilis infections in 2006 in concordance with a significant decrease of the numbers of P. aeruginosa and A. baumannii isolates. A single pulsed-field gel electrophoresis (PFGE) cluster of S. marcescens isolates was identified during the outbreak. When this cluster was compared with S. marcescens strains (n = 21) from 10 other hospitals (1997 to 2010), it was also identified in both sporadic and outbreak isolates circulating in 4 hospitals in Argentina. In132::ISCR1::blaCTX-M-2 was associated with the multidrug-resistant cluster with epidemic behavior when isolated from outbreaks. Standard infection control interventions interrupted transmission of this cluster even when treatment with colistin continued in several wards of hospital H1 until now. Optimizing use of colistin should be achieved simultaneously with improved infection control to prevent the emergence of species naturally resistant to colistin, such as S. marcescens and P. mirabilis.

Clinical factors associated with shock in bacteremic UTI

PURPOSE

Urinary tract infection (UTI) often causes bacteremia, resulting in shock. The purpose of this study is to investigate urological bacteremia and bacteremia shock cases and seek for the clinical factors associated with urological bacteremic shock.

METHODS

Seventy consecutive cases with bacteremia caused by UTI from the Department of Urology, Kobe University Hospital were studied. These cases were diagnosed from 2000 to 2010 and had full data available for analysis. We investigated the potential clinical factors associated with bacteremic shock (systolic blood pressure ≤ 90 mmHg with UTI), including: (1) the number of basal general diseases (such as diabetes, malignancy, immune diseases, heart diseases, liver diseases, and kidney diseases), (2) causative bacteria, (3) antibiotics and therapeutic intervention, (4) gram-negative bacteria, (5) resistance to imipenem (which is often used in this infection), and (6) serum white blood cell counts and C-reactive protein (CRP) at the time of diagnosis of bacteremic UTI.

RESULTS

A total of 81 causative bacteria were isolated: 42 cases were gram-negative and 39 were gram-positive bacteria. In detail, Escherichia coli was the most common, followed by Methicillin-resistant Staphylococcus aureus. The comparison data revealed that urological bacteremic shock cases had significantly increased CRP (p < 0.001). Our univariate analyses showed indwelling urinary tract catheters (p = 0.02) as a significant clinical factor associated with urological bacteremic shock and multivariate analyses showed that the presence of indwelling urinary tract catheters before UTI was a significant clinical factor associated with urological bacteremic shock (p = 0.04).

CONCLUSIONS

Indwelling urinary catheters before UTI and high CRP were clinical factors associated with urological bacteremic shock. This result should be considered during decision-making for UTI treatments in high risk cases or urological bacteremia cases.

A novel human antimicrobial factor targets Pseudomonas aeruginosa through its type III secretion system

Pseudomonas aeruginosa is an important opportunistic bacterial pathogen. Despite its metabolic and virulence versatility, it has not been shown to infect articular joints, which are areas that are rarely infected with bacteria in general. We hypothesized that articular joints possess antimicrobial activity that limits bacterial survival in these environments. We report that cartilages secrete a novel antimicrobial factor, henceforth referred to as the cartilage-associated antimicrobial factor (CA-AMF), with potent antimicrobial activity. Importantly, CA-AMF exhibited significantly more antimicrobial activity against P. aeruginosa strains with a functional type III secretion system (T3SS). We propose that CA-AMF represents a new class of human antimicrobial factors in innate immunity, one which has evolved to selectively target pathogenic bacteria among the beneficial and commensal microflora. The T3SS is the first example, to the best of our knowledge, of a pathogen-specific molecular target in this antimicrobial defence system.

Management of complicated urinary tract infections in the era of antimicrobial resistance

Complicated urinary tract infections (cUTIs) are a major cause of hospital admissions and are associated with significant morbidity and health care costs. Patients presenting with a suspected UTI should be screened for the presence of complicating factors, such as anatomic and functional abnormalities of the genitourinary tract. In the setting of cUTIs, the etiology and susceptibility of the causative organism is not predictable; therefore, when infection is suspected, patients should undergo a urinalysis in addition to culture and sensitivity testing. Although not warranted in all cases of complicated pyelonephritis, blood cultures are appropriate in some clinical settings. With the increased prevalence of antimicrobial resistance, and the lack of well-designed clinical trials, treatment of cUTIs can be challenging for clinicians. Although resistant organisms are not always implicated as the causative agent, all patients with cUTIs should be assessed for predisposing risk factors. Consideration of an optimal antimicrobial agent should be based on local resistance patterns, patient-specific factors, including anatomic site of infection and severity of disease, pharmacokinetic and pharmacodynamic principles, and cost. Resistance to first-line antimicrobial agents, including fluoroquinolones, has become increasingly common in Escherichia coli. Fluoroquinolones should not be used as a first-line option for empiric treatment of serious cUTIs, especially when patients exhibit risk factors for harboring a resistant organism, such as previous or recent use of fluoroquinolones. Fluoroquinolones, trimethoprim-sulfamethoxazole, and nitrofurantoin are still appropriate empiric options for mild lower cUTIs. However, empiric treatment for serious cUTIs, where risk factors for resistant organisms exist, should include broad-spectrum antibiotics such as carbapenems or piperacillin-tazobactam. Once organisms and susceptibilities are identified, treatment should be targeted accordingly. Nitrofurantoin and fosfomycin have limited utility in the setting of cUTIs and should be reserved as alternative treatment options for lower cUTIs following confirmation of the causative organism. Aminoglycosides, tigecycline, and polymyxins can be used for the treatment of serious cUTIs when first-line options are deemed to be inappropriate or patients fail therapy. The duration of treatment for cUTIs has not been well established; however, treatment durations can range from 1 to 4 weeks based on the clinical situation.

The Rcs signal transduction pathway is triggered by enterobacterial common antigen structure alterations in Serratia marcescens

The enterobacterial common antigen (ECA) is a highly conserved exopolysaccharide in Gram-negative bacteria whose role remains largely uncharacterized. In a previous work, we have demonstrated that disrupting the integrity of the ECA biosynthetic pathway imposed severe deficiencies to the Serratia marcescens motile (swimming and swarming) capacity. In this work, we show that alterations in the ECA structure activate the Rcs phosphorelay, which results in the repression of the flagellar biogenesis regulatory cascade. In addition, a detailed analysis of wec cluster mutant strains, which provoke the disruption of the ECA biosynthesis at different levels of the pathway, suggests that the absence of the periplasmic ECA cyclic structure could constitute a potential signal detected by the RcsF-RcsCDB phosphorelay. We also identify SMA1167 as a member of the S. marcescens Rcs regulon and show that high osmolarity induces Rcs activity in this bacterium. These results provide a new perspective from which to understand the phylogenetic conservation of ECA among enterobacteria and the basis for the virulence attenuation detected in wec mutant strains in other pathogenic bacteria.

Susceptibility of Pseudomonas aeruginosa clinical isolates in Japan to doripenem and other antipseudomonal agents

We investigated the susceptibility of 694 Pseudomonas aeruginosa clinical isolates to nine antipseudomonal agents including doripenem. Test strains were collected from 23 Japanese medical facilities from 1992 to 2004. Doripenem showed a minimum inhibitory concentration for 90% of the organisms (MIC(90)) of 8 microg/mL, which was the lowest among the tested antipseudomonal agents. The MIC(90) of doripenem was 2-fold lower than that of meropenem, imipenem and amikacin and was > or =4-fold lower than that of piperacillin/tazobactam, ceftazidime, cefepime, ciprofloxacin and tobramycin. Amikacin showed the lowest rate of resistance against all clinical isolates (5.8%) followed by doripenem (7.1%). No remarkable changes were observed from 1992 to 2004 in the frequency of P. aeruginosa strains resistant to the tested agents, except for imipenem. Of 116 ceftazidime-resistant strains, from 44.0% to 50.8% were susceptible to the three carbapenems, but only 2.6% to cefepime. Of 138 imipenem-resistant strains, from 44.2% to 51.4% were susceptible to doripenem and both cephems, but 25.4% to meropenem. Doripenem was more active against imipenem- or ceftazidime-resistant strains than meropenem, although the activity of doripenem correlated well with that of meropenem. In conclusion, doripenem had the most potent in vitro activity against P. aeruginosa clinical isolates among the tested antibiotics. Considering the trend of antimicrobial resistance of the clinical isolates in well-focused surveillance, pseudomonal infections should be treated with appropriate chemotherapy using antimicrobial agents with potent antipseudomonal activity and low resistance rates, such as doripenem, in order to prevent the outbreak of resistant strains.