Comparison of the clinical characteristics of diabetic and non-diabetic women with community-acquired acute pyelonephritis: a multicenter study

Impact of diabetes mellitus on outcomes of patients with sepsis: an updated systematic review and meta-analysis

BACKGROUND

The effect of concurrent diabetes on the outcome of sepsis is not conclusively known. A meta-analysis published in 2017 indicated that diabetes did not influence the mortality of patients with sepsis but increased the risk of acute renal injury. In view of publication of several new studies in recent years, there is a need for updated evidence.

METHODS

A systematic search was conducted using the PubMed, Scopus, Embase, and Google Scholar databases. Studies that were done in patients with sepsis, were observational in design- either cohort or case-control or analysed retrospective data were considered for inclusion. Statistical analysis was performed using STATA software.

RESULTS

A total of 21 studies were included. The risk of in-hospital mortality (RR 0.98, 95% CI 0.93, 1.04) and mortality at latest follow up i.e., within 90 days of discharge (RR 0.94, 95% CI 0.86, 1.04) among diabetic and non-diabetic subjects was statistically similar. There was an increased risk of in-hospital mortality among those with high blood glucose level at admission (RR 1.45, 95% CI 1.01, 2.09). Among those who were diabetic, the risk of acute renal failure (RR 1.54, 95% CI 1.34, 1.78) was higher than non-diabetics. The risk of respiratory failure, adverse cardiac events, need for additional hospitalization post-discharge and length of hospital stay was similar among diabetics and non-diabetics.

CONCLUSIONS

Diabetes is not associated with poor survival outcomes in patients with sepsis but is associated with increased risk of acute renal failure. High blood glucose levels, irrespective of the diabetes status, are associated with increased risk of in-hospital mortality. Findings underscore the need for better evaluation of renal function in diabetic patients with concurrent sepsis.

Hospitalization for urinary tract infections in Japan, 2010-2015: a retrospective study using a national inpatient database

BACKGROUND

Urinary tract infections (UTI) are common and can have severe consequences. However, there are few recent large-scale studies about them. We aimed to determine the incidence of hospitalization for UTI and to elucidate patient characteristics, clinical practice, and clinical outcomes by drawing on a Japanese nationwide database.

METHODS

This was a retrospective observational study using a national database that covers half the acute care inpatients in Japan. Patients aged ≥ 15 years who were hospitalized for UTI were eligible. We did not include patients with lower UTI such as cystitis. We investigated the annual number of patients hospitalized in Japan, those patients' characteristics, and risk factors for in-hospital mortality.

RESULTS

We identified 232,396 eligible patients from 31 million records of discharge between April 2010 and March 2015. The average age was 73.5 years and 64.9% of patients were female. The estimated annual number of hospitalizations because of UTI was 106,508. The incidence was 6.8 per 10,000 for men and 12.4 for women. The median medical care cost was 4250 USD. In-hospital mortality was 4.5%. Risk factors of poor survival included male sex, older age, lower bed capacity, non-academic hospital, admission in winter, higher Charlson Comorbidity Index score, low body mass index, coma on admission, ambulance use, disseminated intravascular coagulation, sepsis, renal failure, heart failure, cerebrovascular diseases, pneumonia, malignancies, use of anti-diabetic drugs, and use of corticosteroid or immunosuppressive drugs.

CONCLUSIONS

We found that older patients of both sexes accounted for a significant proportion of those hospitalized for UTI. The clinical and economic burden of UTI is considerable.

Complicated urinary tract infections with diabetes mellitus

Patients with diabetes mellitus (DM) sometimes exhibited impaired immune function and aggravated infectious diseases. Urinary tract infection (UTI) is one of the major complications of DM. A systematic literature search was performed in PubMed and Cochrane Library using the following keywords: diabetes mellitus, urinary tract infection, asymptomatic bacteriuria, emphysematous pyelonephritis, emphysematous cystitis, renal papillary necrosis, and sodium-glucose co-transporter 2 (SGLT2) inhibitors. The treatment of UTI in DM patients is not different from that in non-DM patients, and asymptomatic bacteriuria should not be screened or treated. Emphysematous pyelonephritis is a life-threatening renal infection with gas in the renal parenchyma or perirenal space, and 95% of affected patients had DM. Abdominal computed tomography is useful for diagnosis and determining treatment strategies. Medical management and percutaneous drainage are standard initial treatment, and subsequent nephrectomy for non-responders is considered. Nephrectomy, as an initial treatment, should be limited to a selected group of patients with severe conditions. In contrast, antibiotics, glycemic control, and bladder drainage are adequate treatment for most cases of emphysematous cystitis. SGLT2 inhibitors significantly increased the incidence of genital tract infection, but not that of UTI, pyelonephritis, or urosepsis. Here, we present cumulative evidence about etiology and management for complicated UTI with DM, but there was little information about racial differences and further evidence focusing on Asian population will be needed.

Asymptomatic bacteriuria among medical inpatients: Data from an Indian teaching hospital

Studies indicate that asymptomatic bacteriuria in medical inpatients is often inappropriately treated with antibiotics. We prospectively studied the proportion of asymptomatic bacteriuria among 200 positive urine cultures which were ordered in hospitalised medical inpatients of a teaching hospital in southern India. We used pre-defined criteria to classify patients as urinary tract infection and asymptomatic bacteriuria. Median age of patients was 53.5 (42-65) years, and 51% were male. In all, 157 (78.5%) patients had urinary tract infection (131 [66.5%] definite and 26 [13%] probable) and 43 (21.5%) had asymptomatic bacteriuria. In patients with asymptomatic bacteriuria, 18 (41.8%) received urinary tract infection-directed antibiotics; broad spectrum antibiotics were used in 10 (23%). Patients with asymptomatic bacteriuria were younger, more likely to be on a urinary catheter, had higher prevalence of chronic kidney disease and congestive cardiac failure and had lower prevalence of pyuria and lower total leucocyte counts. Urine cultures should be ordered only in indicated patients. Inappropriate antibiotic treatment in patients with asymptomatic bacteriuria should be avoided.

Diabetes on sepsis outcomes in non-ICU patients: A cohort study and review of the literature

AIMS

We sought to determine whether primary outcomes differ between non-ICU septic patients with and without type 2 diabetes (T2D).

METHODS

This study utilized the Hellenic Sepsis Study Group Registry, collecting nationwide data for sepsis patients since 2006, and classified patients upon presence or absence of T2D. Patients were perfectly matched for a) Sepsis 3 definition criteria (including septic shock) b) gender, c) age, d) APACHE II score and e) Charlson's comorbidity index (CCI). Independent sample t-test and chi-square t-test was used to compare prognostic indices and primary outcomes.

RESULTS

Of 4320 initially included non-ICU sepsis patients, 812 were finally analysed, following match on criteria. Baseline characteristics were age 76 [±10.3] years, 46% male, APACHE II 15.5 [±6], CCI 5.1 [±1.8], 24% infection, 63.8% sepsis and 12.2% septic shock. No significant difference was noted between two groups in qSOFA, SOFA, or suPAR1 levels (p = 0.7, 0.1 & 0.3) respectively. Primary sepsis syndrome resolved in 70.9% of cases (p = 0.9), while mortality was 24% in 28-days time. Cause of death was similar between patients with and without T2D (sepsis 17.8% vs 15.8%, heart event 3.7% vs 3.2%, CNS event 0.5% vs 0.5%, malignancy 0.7% vs 2% respectively, p = 0.6).

CONCLUSIONS

DM does not appear to negatively affect outcomes in septic patients not requiring ICU.

Glycated Hemoglobin < 6.5% Is Associated With Uroseptic Shock in Diabetic Patients With Urinary Tract Infection

This study aimed to compare the clinical characteristics and treatment outcomes of diabetic and non-diabetic individuals with urinary tract infection (UTI) and determine whether glycated hemoglobin (HbA1c) levels <6. 5% leads to uroseptic shock in diabetic individuals. We retrospectively collected and analyzed the clinical data of 1,363 individuals with UTIs in Taiwan from January 2006 to January 2018. Of the 345 diabetic individuals, 61 (17.7%) developed uroseptic shock. Diabetic patients who developed uroseptic shock tended to be older and males and, had a history of congestive heart failure, urolithiasis, higher serum creatinine level during hospitalization, lower serum HbA1c level, bacteremia, and acute kidney injury. Backward stepwise multivariate logistic regression analysis showed that male gender [odds ratio (OR), 1.861; 95% confidence interval (CI), 1.009–3.433; P = 0.047], congestive heart failure (OR, 4.036; 95% CI, 1.542–10.565; P = 0.004), bacteremia (OR, 2.875; 95% CI, 1.539–5.370; P = 0.001), and HbA1c level <6.5% (OR, 2.923; 95% CI, 1.580–5.406; P = 0.001) were associated with an increased risk of developing uroseptic shock among diabetic patients during hospitalization due to UTI. HbA1c level <6.5% is independently associated with uroseptic shock in diabetic patients with UTI.

Diabetes Mellitus Does Not Predict Discharge in Hospitalized Patients With Acute Pyelonephritis: A Study From Karachi, Pakistan

Introduction

The incidence of acute pyelonephritis (APN) in the diabetic population is comparatively higher and tends to be more complicated, with serious outcomes. Although complicated pyelonephritis (PN) needs hospital admission and intravenous antibiotics, the magnitude of hospital stay due to comorbidities is limited. This study's aim was to assess the impact of diabetes mellitus on length of hospital stay among patients with PN.

Methods

We did a retrospective data review of 520 randomly selected hospitalized patients of PN from March 2015 to December 2019 from a tertiary care center. Electronic medical records were used for identifying medical conditions through ICD-10 coding. Length of stay (LOS) was categorized as < five days and ≥ five days. Chi‐squared tests were used to compare categorical parameters. Logistic regression models were used for multivariate analyses.

Results

The study included 520 patients with PN; 194 (37.3 %) men and 326 (62.7%) women. Overall, there were 353 (67.8 %) and 167 (32.1 %) patients with LOS < five and ≥ five days respectively. Most of the patients had lower urinary tract symptoms (90%); among them, the majority (92%) were discharged within five days. Likewise, half of the patients had diabetes (51.2); among them, 53% were discharged after five days. Older age (OR:1.7, 95%CI: 1.1 - 2.6), upper urinary tract symptoms (OR:1.6, 95%CI: 1.1 - 2.4), lower urinary tract symptoms (OR:1.9, 95%CI: 1.1 - 3.5), creatinine greater than 1.5 mg/dl (OR:1.6, 95% CI: 1.1 - 2.4) was positively associated with LOS ≥ 5 days after adjusting for other covariates. Diabetes mellitus was not found to be associated with LOS ≥ 5 days (OR: 0.9, 95%CI: 0.8 - 1.5).

Conclusion

In patients with acute PN, diabetes mellitus is not independently associated with prolonged hospital stay beyond five days.

Molecular Epidemiology of Ciprofloxacin-Resistant Escherichia coli Isolated from Community-Acquired Urinary Tract Infections in Korea

Background

Escherichia coli is the predominant causative pathogen for community-acquired urinary tract infections (UTIs), and the increase in fluoroquinolone-resistant E. coli is of great concern in Korea. The objectives of this study were to investigate the genotypic characteristics and molecular epidemiology of ciprofloxacin-resistant (CIP-R) E. coli isolated from community-acquired UTIs in Korea.

Materials and Methods

E. coli samples isolated from the blood or urine were collected from patients with community-acquired acute pyelonephritis aged 15 years and more who were admitted to 12 Korean hospitals from 1st April 2010 to 29th February 2012. Phylogenetic typing, multilocus sequence typing, and molecular characterization of β-lactamase and plasmid-mediated quinolone resistance determinants were performed for CIP-R E. coli isolates.

Results

A total of 569 E. coli isolates were collected, and 122 (21.4%) isolates were CIP-R isolates. The most prevalent sequence type (ST) was ST131 (28.7%, 35/122), followed by ST393 (14.7%, 18/122), ST1193 (13.1%, 16/122), ST38 (9.0%, 11/122), and ST405 (8.2%, 10/122). The antimicrobial resistance rates of ST131 to cefepime (22.9%, 8/35), ST38 to gentamicin (100%, 11/11), and ST405 to cefotaxime (66.7%, 6/9) were significantly higher than the resistance rates of all other STs combined. Notably, 40% (4/10) of ST405 clones produced extended-spectrum β-lactamases and were co-resistant to trimethoprim/sulfamethoxazole. aac(6′)-1b-cr (20%, 7/35) and CTX-M-14 (40%, 4/10) were more frequently observed in ST131 and ST405 compared with other clones, respectively.

Conclusions

Among the CIP-R uropathogenic E. coli isolates in this study, ST131, ST38, and ST405 were specifically associated with antimicrobial resistance.

Microbiologic profile and clinical practices in urinary tract infections in a tertiary care center in Southern India

Context:

Studies reported differences in clinical profiles of urinary tract infections (UTIs) in patients with and without type 2 diabetes mellitus (T2DM). Studies on the impact of the pattern of antibiotic resistance of organisms causing UTI on actual clinical practice are lacking.

Objectives:

1. To study the clinical and microbiologic profiles of UTIs. 2. To compare treatment given with the prevailing antimicrobial sensitivity.

Settings and Design:

This is a cross-sectional study conducted in a tertiary care hospital.

Methods and Materials:

Retrospective chart review of inpatients with UTI (N = 200, 100 each of patients with and without T2DM), aged >18 years with a positive urine culture.

Statistical Analysis:

We used the statistical package SPSS version 17. The categorical variables were analyzed by the Chi-square test. Data were considered significant if P value was less than 0.05.

Results:

Similar to previous Indian studies, T2DM patients with UTI had significantly more asymptomatic bacteriuria, asymptomatic bacteriuria (32% vs. 6%), previous history of UTI (25% vs. 2%), and prior catheterization (16% vs. 1%). Escherichia coli (E. coli) was the most common organism isolated and showed sensitivity pattern of meropenem > netilmicin > amikacin > nitrofurantoin. Ceftriaxone was the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. All ASB cases were treated unlike recommendations.

Conclusions:

Ceftriaxone is the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. Cases of ASB were treated unlike recommendations.

Clinical impact of perinephric fat stranding detected on computed tomography in patients with acute pyelonephritis: a retrospective observational study

Perinephric fat stranding (PFS) is often detected on computed tomography (CT) in patients with acute pyelonephritis (APN). However, its clinical impact remains unclear. This study aimed to evaluate the clinical impact of PFS detected on CT in patients with APN. This retrospective observational study included patients with APN who underwent CT (median age, 79.5 years). Patients were classified into PFS (patients with PFS observed on CT) and non-PFS (patients without PFS observed on CT) groups, which were further classified into bacteraemia and non-bacteraemia groups. Clinical findings between the groups were compared. Among 194 patients who underwent CT, 111 (57.2%) patients demonstrated PFS. The rate of bacteraemia was significantly higher in the PFS group than in the non-PFS group (55.2 vs. 23.1%, p < 0.001). CT findings other than PFS were not associated with bacteraemia. The median peak body temperature was significantly higher in the PFS group than in the non-PFS group (38.8 vs. 38.5 °C, p < 0.001); however, the duration of fever and in-hospital mortality rates were not significantly different between the groups. Concordance between blood and urine culture results was observed in 75.0% of the patients; the presence of PFS was not different between patients with concordant and discordant results, regardless of the pre-treatment antibiotic used. Our findings suggest that the presence of PFS in patients with APN predicts bacteraemia; thus, clinicians should consider obtaining blood cultures if PFS is found on CT in patients with APN, even if the patients had received antibiotics prior to admission.

Progression into sepsis: an individualized process varying by the interaction of comorbidities with the underlying infection

Background

Development of sepsis is a process with significant variation among individuals. The precise elements of this variation need to be defined. This study was designed to define the way in which comorbidities contribute to sepsis development.

Methods

Three thousand five hundred nine patients with acute pyelonephritis (AP), community-acquired pneumonia (CAP), intraabdominal infections (IAI) or primary bacteremia (BSI) and at least two signs of the systemic inflammatory response syndrome were analyzed. The study primary endpoint was to define how comorbidities as expressed in the Charlson’s comorbidity index (CCI) and the underlying type of infection contribute to development of organ dysfunction. The precise comorbidities that mediate sepsis development and risk for death among 18 comorbidities recorded were the secondary study endpoints.

Results

CCI more than 2 had an odds ratio of 5.67 for sepsis progression in patients with IAI between significantly higher than AP and BSI. Forward logistic regression analysis indicated seven comorbidities that determine transition into sepsis in patients with AP, four comorbidities in CAP, six comorbidities in IAI and one in BSI. The odds ratio both for progression to sepsis and death with one comorbidity or with two and more comorbidities was greater than in the absence of comorbidities.

Conclusions

The study described how different kinds of infection vary in the degree to which they lead to sepsis. The number of comorbidities that enhances the risk of sepsis and death varies depending on the underlying infections.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3156-z) contains supplementary material, which is available to authorized users.

The Predictive Value of Glycated Hemoglobin and Albumin for the Clinical Course Following Hospitalization of Patients with Febrile Urinary Tract Infection

Background

Diabetes is considered a risk factor for acquisition of febrile urinary tract infection (f-UTI), but information on the association of diabetes with subsequent course of the disease is lacking. Thus, we investigated the clinical variables including diabetic status which determined the clinical course in patients with community-acquired f-UTI.

Materials and Methods

Patients hospitalized consecutively for f-UTI between February 2016 and January 2018 were used for this single center study. The routine laboratory tests including blood glucose and glycated hemoglobin (HbA1c) were done and empiric treatment with parenteral antibiotics was commenced on admission. The clinical course such as duration of fever (DOF) and length of hospital stay (LOS) were compared among groups classified by the clinical variables.

Results

Among the101 patients admitted for f-UTI, 15 patients with diabetes (14.9%) experienced significantly longer febrile period and hospitalization compared to those with hyperglycemia (n = 18, 17.8%) or those without diabetes and hyperglycemia (n = 68, 67.3%). Of the laboratory parameters tested on admission and several clinical factors, the presence of diabetes and risk factors for severe complicated infection (hydronephrosis, urosepsis, and disseminated intravascular coagulopathy) as well as HbA1c and albumin were identified as predictors for LOS by univariate analysis, whereas none of the variables failed to predict DOF. In the subsequent multivariate analysis, HbA1c levels and albumin levels were isolated as independent predictors of LOS.

Conclusion

Patients with higher HbA1c and lower albumin levels required the longest period of hospitalization. Thus, an evaluation of diabetic and nutritional status on admission will be feasible to foretell the clinical course and better manage the subset of patients at risk of prolonged hospitalization.

Retrospective Comparison of Clinical Characteristics and In-Hospital Outcomes among Diabetic and Non-Diabetic Adults with Acute Pyelonephritis

INTRODUCTION

Acute Pyelonephritis (APN) is a common infection in community. Diabetes Mellitus (DM) may have different effect on clinical characteristics and outcomes of APN compared to non-diabetic individuals.

AIM

To compare clinical characteristics and assess outcomes of APN patients with and without DM.

MATERIALS AND METHODS

A retrospective analysis of 122 patients with DM (n=61) and without DM (n=61) was conducted at a single, private, urban set-up from Gujarat, India. Clinical symptoms, laboratory investigations, antibiotics treatment and outcomes in terms of mortality and prolonged hospitalization (10 days and above) were compared in two groups.

RESULTS

Mean age was significantly higher in diabetics than non-diabetics (55.2±12.5 vs 41.5±17.3, p<0.0001) and females were proportionally higher in both groups (65.6% Vs 62.3%, p=0.706). Fever was most frequent symptom (83.6% Vs 90.2%, p=0.283) followed by nausea/vomiting (50.8% Vs 63.9%, p=0.143), dysuria (66.7% Vs 74.4%, p=0.433) and flank pain (8.2 Vs 13.1, p=0.379). Backache/back pain (47.5% Vs 29.5%, p=0.041) and Chronic Kidney Disease (CKD) (63.9% Vs 45.9%, p=0.045) were significantly higher in diabetics than non-diabetics. Mean hospital stay did not vary significantly in two groups (7.0±3.2 Vs 6.50±2.9, p=0.346) but proportion of patients with longer hospital stay was higher in DM (16.4% Vs 8.2%). Elevated white cell count, erythrocyte sedimentation rate, C-reactive protein, serum creatinine and presence of red cell in urine (> 5/ high power field [hpf]) did not vary significantly in two groups. Cephalosporin-beta-lactamase inhibitor (Cefaperazone-Sulbactam/Cefepime-Tazobactam) was the most prescribed antibiotic in both the groups. No deaths were observed in any group during this evaluation period. Only raised ESR (>30 mm/hr) {Odds Ratio (OR): 1.58, 95% Confidence Interval (CI) 1.36-1.82, p=0.004} and presence of CKD (OR: 1.71, 95% CI 1.30-2.25, p=0.008) were found to be the significant predictors of prolonged hospitalization in overall population.

CONCLUSION

APN in diabetic and non-diabetic patients has similar clinical characteristics. Impact of diabetes on clinical outcomes of mortality and prolonged hospitalization warrants further investigation in a large, randomized, prospective trial.

Urinary Tract Infections in Immunocompromised Patients with Diabetes, Chronic Kidney Disease, and Kidney Transplant

CONTEXT

This paper provides a brief overview of urinary tract infections (UTIs) in immunocompromised patients from the perspective of a practicing urologist.

OBJECTIVE

The primary objective was to provide an update on UTIs in immunocompromised patients. Diabetes mellitus (DM), chronic kidney disease, and kidney transplant (KT) are the most common clinical cases encountered by urologists. Diagnosis, management, and future research needs are summarised.

EVIDENCE ACQUISITION

We conducted a nonsystematic review of the literature. A comprehensive search of the PubMed database between 1996 and 2016 was performed.

EVIDENCE SYNTHESIS

Clinical diagnosis of UTIs in immunocompromised patients is challenging. Causative pathogens in DM are slightly different to those in the general population, but without any difference in resistance profiles. Keeping serum glucose under control is the most important preventive measure. The prevalence of UTIs in patients with autosomal dominant polycystic kidney disease (ADPKD) is 21-75%. Lipophilic antibiotics are effective in the treatment of infected cysts, albeit with a trend for lower effectiveness due to increasing resistance rates. UTIs are the most common infections in KT recipients, with a reported rate of 45-72%. Diagnostic challenges exist for both ADPKD and KT patients who develop UTIs. Treatment of UTIs should be tailored according to individual patient characteristics and the severity classification framework suggested by the European Society of Infections in Urology.

CONCLUSIONS

The underlying pathophysiology of UTIs in immunocompromised patients is not well known, which limits UTI management, including early diagnosis, treatment, and prevention. Future research to identify patients at higher risk of UTIs is necessary.

PATIENT SUMMARY

In this report we looked at patients with a weakened immune system who are more likely to develop a urine infection. We focused on the patient groups most commonly encountered in a urology setting. We found that these patients have a higher risk of urinary infection, but the signs of infection may be different to those in the general population. Early diagnosis is imperative in this group. Further research on early diagnosis and better individualised management strategies are necessary.

Febrile urinary tract infections: pyelonephritis and urosepsis

PURPOSE OF REVIEW

Complicated infections of the urinary tract (UTI) including pyelonephritis and urosepsis are also called febrile UTI. This review describes insights from the literature on this topic since July 2014.

RECENT FINDINGS

Recent studies regarding risk factors and consequences of febrile UTI confirmed existing knowledge. It remains difficult to obtain insight into the epidemiology of febrile UTI because urine and blood cultures are frequently missing. The relationship between host and virulence factors of Escherichia coli was further explored showing that less virulent strains can cause infection in immunocompromised patients. In contrast to obstructive uropathy, diabetes, and being older, neutropenia was not a risk factor for lower UTI or urosepsis. A randomized controlled trial revealed that ceftolozane-tazobactam was marginally superior to levofloxacin as treatment for complicated UTI. Case series supported the notion that xanthogranulomatous and emphysematous pyelonephritis are more common in diabetic patients and that drainage or surgery is often required.

SUMMARY

Neutropenia was not a risk factor for lower UTI or urosepsis. When local resistance percentages to the frequently prescribed fluoroquinolones are high, the combination of ceftolozane-tazobactam may be an alternative as treatment for complicated UTI. Xanthogranulomatous and emphysematous pyelonephritis need to be considered in diabetic patients presenting with UTI symptoms.

A comparison of the clinical characteristics of elderly and non-elderly women with community-onset, non-obstructive acute pyelonephritis

BACKGROUND/AIMS

Acute pyelonephritis (APN) is the most common cause of community-onset bacteremia in hospitalized elderly patients. The objectives of this study were to investigate the differences in the clinical and microbiological data of hospitalized elderly and non-elderly women with community-onset APN.

METHODS

Women with community-onset APN as a discharge diagnosis were identified from January 2004 to December 2013 using an electronic medical records system. We compared the clinical and microbiologic data in elderly and non-elderly women with community-onset APN due to Enterobacteriaceae.

RESULTS

Of the 1,134 women with community-onset APN caused by Enterobacteriaceae, 443 were elderly and 691 were non-elderly women. The elderly group had a lower frequency of upper and lower urinary tract symptoms/signs than the non-elderly. The incidence of bacteremia, extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, patients with a C-reactive protein (CRP) level ≥ 15 mg/dL, and patients with a leukocyte count ≥ 15,000/mm(3) in the blood, were significantly higher in the elderly group than in the non-elderly group. The proportion of patients requiring hospitalization for 10 days or more was significantly higher in the elderly group compared to the non-elderly group (51.5% vs. 26.2%, p < 0.001). The clinical cure rates at 4 to 14 days after the end of therapy were 98.3% (338/344) and 97.4% (519/533) in the elderly and non-elderly groups, respectively (p = 0.393).

CONCLUSIONS

Elderly women with APN exhibit higher serum CRP levels, a higher frequency of bacteremia, a higher proportion of ESBL-producing uropathogens, and require a longer hospitalization than non-elderly women, although these patients may not complain of typical urinary symptoms.

Impact of extended-spectrum β-lactamase production on treatment outcomes of acute pyelonephritis caused by escherichia coli in patients without health care-associated risk factors

Extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) is increasingly identified as a cause of acute pyelonephritis (APN) among patients without recent health care contact, i.e., community-associated APN. This case-control study compared 75 cases of community-associated ESBL-EC APN (CA-ESBL) to 225 controls of community-associated non-ESBL-EC APN (CA-non-ESBL) to identify the risk factors for ESBL-EC acquisition and investigate the impact of ESBL on the treatment outcomes of community-associated APN (CA-APN) caused by E. coli at a Korean hospital during 2007 to 2013. The baseline characteristics were similar between the cases and controls; the risk factors for ESBL-EC were age (>55 years), antibiotic use within the previous year, and diabetes with recurrent APN. The severity of illness did not differ between CA-ESBL and CA-non-ESBL (Acute Physiology and Chronic Health Evaluation [APACHE] II scores [mean ± standard deviation], 7.7 ± 5.9 versus 6.4 ± 5.3; P = 0.071). The proportions of clinical (odds ratio [OR], 1.76; 95% confidence interval [CI], 0.57 to 5.38; P = 0.323) and microbiological (OR, 1.16; 95% CI, 0.51 to 2.65; P = 0.730) cures were similar, although the CA-ESBL APN patients were less likely to receive appropriate antibiotics within 48 h. A multivariable Cox proportional hazards analysis of the prognostic factors for CA-APN caused by E. coli showed that ESBL production was not a significant factor for clinical (hazard ratio [HR], 0.39; 95% CI, 0.12 to 1.30; P = 0.126) or microbiological (HR, 0.49; 95% CI, 0.21 to 1.12; P = 0.091) failure. The estimates did not change after incorporating weights calculated using propensity scores for acquiring ESBL-EC. Therefore, ESBL production did not negatively affect treatment outcomes among patients with community-associated E. coli APN.

Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management

Urinary tract infections are more common, more severe, and carry worse outcomes in patients with type 2 diabetes mellitus. They are also more often caused by resistant pathogens. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. The new anti-diabetic sodium glucose cotransporter 2 inhibitors have not been found to significantly increase the risk of symptomatic urinary tract infections. Symptoms of urinary tract infection are similar to patients without diabetes, though some patients with diabetic neuropathy may have altered clinical signs. Treatment depends on several factors, including: presence of symptoms, severity of systemic symptoms, if infection is localized in the bladder or also involves the kidney, presence of urologic abnormalities, accompanying metabolic alterations, and renal function. There is no indication to treat diabetic patients with asymptomatic bacteriuria. Further studies are needed to improve the treatment of patients with type 2 diabetes and urinary tract infections.

Clinical importance and epidemiology of quinolone resistance

The quinolone class of antimicrobial agents is one of most widely used classes of antimicrobial agents in outpatient and inpatient treatment. However, quinolone resistance in gram-positive and gram-negative bacteria has emerged and increased globally. This resistance limits the usefulness of quinolones in clinical practice. The review summarizes mechanisms of quinolone resistance and its epidemiology and implications in the most common clinical settings, urinary tract infections, respiratory tract infections, intraabdominal infections, skin and skin structure infections, and sexually transmitted diseases.