Management of acute uncomplicated urinary tract infection in adults

Early Stone Manipulation in Urinary Tract Infection Associated with Obstructing Nephrolithiasis

A urinary tract infection (UTI) and sepsis secondary to an obstructing stone are one of the few true urological emergencies. The accepted management of infected ureteral stones includes emergent decompression of the collecting system as well as antibiotic therapy. Despite this, no consensus guidelines clarify the optimal time to undergo definitive stone management following decompression. Historically, our institution has performed ureteroscopy with laser lithotripsy (URS-LL) treatment at least 1 to 2 weeks after decompression to allow for clinical improvement and completion of an antibiotic course. In this case series, we retrospectively review four cases in which patients had a documented UTI secondary to an obstructive ureteral stone. The patients underwent urgent decompression and, based on labs and clinical improvement, were subsequently treated with URS-LL. The presented patients received URS-LL within 5 days of decompression and antibiotics. The patients had no sepsis related postoperative complications from the accelerated course of treatment, resulting in discharge within 2 days following URS-LL. We provide a detailed examination of each patient presentation to describe our institution's experience with treating infected kidney stones within days of urgent decompression in order to question the previous standard of treating an infected kidney stone with a more delayed intervention.

Cystitis: from urothelial cell biology to clinical applications

Cystitis is a urinary bladder disease with many causes and symptoms. The severity of cystitis ranges from mild lower abdominal discomfort to life-threatening haemorrhagic cystitis. The course of disease is often chronic or recurrent. Although cystitis represents huge economical and medical burden throughout the world and in many cases treatments are ineffective, the mechanisms of its origin and development as well as measures for effective treatment are still poorly understood. However, many studies have demonstrated that urothelial dysfunction plays a crucial role. In the present review we first discuss fundamental issues of urothelial cell biology, which is the core for comprehension of cystitis. Then we focus on many forms of cystitis, its current treatments, and advances in its research. Additionally we review haemorrhagic cystitis with one of the leading causative agents being chemotherapeutic drug cyclophosphamide and summarise its management strategies. At the end we describe an excellent and widely used animal model of cyclophosphamide induced cystitis, which gives researches the opportunity to get a better insight into the mechanisms involved and possibility to develop new therapy approaches.

Recurrent Urinary Tract Infections Management in Women: A review

Urinary tract infections (UTIs) are one of the most frequent clinical bacterial infections in women, accounting for nearly 25% of all infections. Around 50-60% of women will develop UTIs in their lifetimes. Escherichia coli is the organism that causes UTIs in most patients. Recurrent UTIs (RUTI) are mainly caused by reinfection by the same pathogen. Having frequent sexual intercourse is one of the greatest risk factors for RUTIs. In a subgroup of individuals with coexisting morbid conditions, complicated RUTIs can lead to upper tract infections or urosepsis. Although the initial treatment is antimicrobial therapy, use of different prophylactic regimens and alternative strategies are available to reduce exposure to antibiotics.

The management of urinary infections: what have we learned in the past decade?

User-friendly, cost-effective practices to manage urinary infection should become routine. The vast majority of inflections are relatively easy to treat and many of these can be prevented with appropriate interventions. Additional research is urgently needed to compare various clinical strategies and determine which is most acceptable to patients at a reasonable cost with satisfactory health outcomes.

Effectiveness and safety of patient initiated single-dose versus continuous low-dose antibiotic prophylaxis for recurrent urinary tract infections in postmenopausal women: a randomized controlled study

This study evaluated patient-initiated single-dose antibiotic prophylaxis and continuous long-term low-dose daily antibiotic use for the prevention of recurrent urinary tract infections (UTI) in 68 postmenopausal women. The women were randomized to take a low-dose antibiotic each night (continuous group, n = 37) or a single-dose antibiotic each time they experienced conditions predisposing to UTI (intermittent group, n = 31). During the 12-month study, 1.4 and 1.9 UTIs/patient developed in the continuous and the intermittent groups, respectively, which was significantly lower than the incidence of UTIs in the previous 12 months in these patients (4.7 and 5.1 UTIs/patient, respectively). The incidence of gastro intestinal adverse events was significantly lower in the intermittent group compared with the continuous group (9.1% versus 30.0%). In conclusion, patient-initiated single-dose intermittent antibiotic prophylaxis was as effective as low-dose daily antibiotic prophylaxis in the treatment of recurrent UTIs in post menopausal women and was associated with fewer gastrointestinal adverse events.

Levofloxacin in the treatment of complicated urinary tract infections and acute pyelonephritis

Levofloxacin is a widely used fluoroquinolone approved for the treatment of complicated urinary tract infections and acute pyelonephritis. A comprehensive review of the medical literature identified five publications evaluating levofloxacin for the treatment of either complicated urinary tract infections or acute pyelonephritis. All trials, although variable in their inclusion criteria and levofloxacin dosing strategies, reported microbiologic, clinical, and safety-related outcomes. High microbiologic eradication rates, ranging from 79.8% to 95.3%, were observed in all studies. Escherichia coli was the most commonly isolated uropathogen. Data on levofloxacin resistance, both at baseline and after therapy, were limited. Clinical success was observed to range from 82.6% to 93% when measured after the completion of therapy. These clinical and microbiologic results were comparable to the fluoroquinolone comparators in all trials. Insufficient data are available to evaluate the outcomes in any meaningful patient subgroups, including catheterized patients, and those with other specific complicating factors. Levofloxacin was well tolerated in these studies, with headache, gastrointenstinal effects, and dizziness being the most commonly reported adverse events. The published data support the use of levofloxacin in complicated urinary tract infections and acute pyelonephritis. Further trials are necessary to evaluate levofloxacin within specific patient sub-populations.

Quinolones for uncomplicated acute cystitis in women

BACKGROUND

Uncomplicated acute cystitis is one of the most common bacterial infections in adults. The percentage of women who have at least one episode of acute cystitis is estimated to be between 40% to 50%. Quinolones are recommended for acute cystitis in regions where the level of resistance to other antimicrobials namely co-trimoxazole is high. However the efficacy, safety and tolerance of quinolones needs investigation.

OBJECTIVES

To compare the efficacy, safety and tolerance of different quinolones in women with uncomplicated acute cystitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library Issue 3, 2003), MEDLINE (1966 - September 2003), EMBASE (1988 - September 2003), reference lists of articles and abstracts from conference proceedings without language restriction. Reference lists of urology, infectious diseases and nephrology textbooks, review articles and relevant studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing two or more different quinolones in women (>/= 16 years) with uncomplicated acute cystitis were selected.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We identified 11 studies enrolling 7535 women. There were no significant differences in clinical or microbiological efficacy between quinolones. Photosensitivity reactions were more frequently observed for sparfloxacin when compared to ofloxacin. Any adverse event, adverse events causing withdrawal, skin adverse events, photosensitivity reactions were more common for lomefloxacin when compared to norfloxacin. Any adverse event, adverse drug reactions, CNS adverse events were more common for ofloxacin when compared to ciprofloxacin. CNS adverse events and insomnia were more often reported for rufloxacin when compared to pefloxacin. Adverse drug reactions occurred frequently for ofloxacin than levofloxacin. Insomnia was reported more frequently for enoxacin than ciprofloxacin.

AUTHORS' CONCLUSIONS

We found no significant differences in clinical or microbiological efficacy between quinolones but some differences in occurrence and spectrum of quinolone safety.

The resistance of Escherichia coli strains isolated from community-acquired urinary tract infections

Urinary tract infections (UTIs) are the most common infections caused by Escherichia coli. Most recent research demonstrates that antibiotic resistance has reached a critical point throughout the world, as increased use of antibiotics among nonhospitalized patients encourages the growth of drug-resistant pathogens among that population. The goal of this study was to determine the antimicrobial drug resistance of E coli strains isolated from community-acquired UTIs in 5 different regions in Turkey. The minimum inhibitory concentrations of ciprofloxacin, gentamicin, sulfamethoxazole, trimethoprim, trimethoprim-sulfamethoxazole, and ampicillin and for E coli were determined with the agar dilution method. Among the 480 strains isolated, 8.3% were resistant to ciprofloxacin, 3.3% to gentamicin, 35.4% to sulfamethoxazole, 33.3% to trimethoprim, 27.9% to trimethoprim-sulfamethoxazole, and 40.8% to ampicillin. These results show that the antibiotics currently most effective against E coli are ciprofloxacin and gentamicin. Local epidemiologic trends should be considered when prescribing antibacterial therapy. More research in bacterial gene mapping will be necessary to elucidate the influence of regional antimicrobial drug use and resistance in epidemiologic trends among the general population.

All dysuria is local. A cost-effectiveness model for designing site-specific management algorithms

OBJECTIVE

To determine the cost-effectiveness of management strategies for dysuria in different office settings.

DESIGN

Decision and cost-effectiveness analyses, assuming the payer's perspective. Data on disease prevalence, test characteristics, treatment efficacy, and adverse effects were drawn from the English language literature using medline searches and bibliographies.

SETTING

Hypothetical primary care practice.

PATIENTS

Otherwise healthy, nonpregnant women with symptoms of dysuria, urgency, and frequency.

INTERVENTIONS

All reasonable combinations of urinalysis, urine culture, pelvic examination, chlamydia and gonorrhea cultures, and empiric treatment with trimethoprim-sulfamethoxazole.

RESULTS

The cost-effectiveness of strategies varied substantially among different patient settings. In all settings, empiric trimethoprim-sulfamethoxazole for all patients was least expensive and least effective. Most testing increased both cost and effectiveness. Compared to empiric antibiotics, performing pelvic examination and urine culture for women with normal urinalyses had a marginal cost-effectiveness ratio of $4 to $32 per symptom-day avoided (SDA). Adding urine culture for patients with pyuria had a marginal cost of $34 to $107 per SDA, which fell to $40/SDA when the prevalence of resistance to trimethoprim-sulfamethoxazole exceeded 40%. Pelvic examination and urine culture for all patients regardless of urinalysis results achieved the greatest benefit but at the highest cost (>$300 per SDA).

CONCLUSIONS

In otherwise healthy women with symptoms of dysuria and no vaginal complaints, performing pelvic exam and urine culture based on urinalysis offers a reasonable alternative to empiric therapy. Other testing may be warranted, depending on antibiotic resistance and the value of avoiding a day of dysuria.

Evaluation of VITEK 2 for analysis of Enterobacteriaceae using the Advanced Expert System (AES) versus interpretive susceptibility guidelines used at Dynacare Kasper Medical Laboratories, Edmonton, Alberta

OBJECTIVE

To evaluate the applicability and adaptability of the bioMérieux VITEK 2 Advanced Expert System (AES) to the customized interpretive susceptibility guidelines used at Dynacare Kasper Medical Laboratories (DKML).

METHODS

Three hundred isolates of Enterobacteriaceae (not more than 30% Escherichia coli) were tested on the VITEK 2 system and the API 20E for identification. Susceptibility testing for these isolates was performed on the VITEK 2 system and the Pasco broth microdilution panels. Minimal inhibitory concentrations (MICs) and interpreted results according to the AES and DKML antimicrobial susceptibility guidelines were compared.

RESULTS

Of 300 isolates tested for susceptibility, 13 did not give AES interpretations. Of the remaining 287 isolates, interpretations between AES and DKML guidelines were compared for 10 antibiotics. The overall correlation between the AES and DKML interpretations was 96.2%.

CONCLUSION

This study demonstrated the benefits and limitations of the bioMérieux AES. Automated knowledge-based systems provide a useful laboratory tool for the interpretation of susceptibility results.

Emerging antibiotic resistance in urinary tract pathogens

In vitro antimicrobial resistance is an evolving and growing problem in UTI. Much of the increase is occurring in acute uncomplicated cystitis, an infection that has traditionally been simple to treat. The current trend of rising TMP-SMX and beta-lactam resistance rates is worrisome. Of more concern, however, are the emerging issues of fluoroquinolone resistance and MDR among community-acquired urinary isolates. Judicious use of antibiotics and development of novel nonantimicrobial-based methods of prevention of UTI are important strategies to help slow the progression of resistance. In the meantime, ongoing surveillance of resistance trends and enhanced understanding of the determinants of resistance are crucial for optimal management of UTIs.

A cost-effectiveness analysis of treatment strategies for acute uncomplicated pyelonephritis in women

At least 250,000 episodes of acute uncomplicated pyelonephritis are treated annually in the emergency department (ED). Trimethoprim-sulfamethoxazole (TMP-SMX) and norfloxacin have both been used as treatments for acute uncomplicated pyelonephritis.

OBJECTIVES

To investigate the cost-effectiveness of two outpatient treatment strategies, TMP-SMX and norfloxacin, for acute uncomplicated pyelonephritis in adult women between the ages of 18 and 65 years.

METHODS

Common principles of cost-effectiveness analysis were used for this evaluation. The authors developed a decision tree to estimate the costs and effectiveness of two different treatment strategies: TMP-SMX 160/800 mg twice per day for 10 days and norfloxacin 400 mg twice per day for 10 days. The time frame of the decision tree was 11 days. Outcomes were expressed in U.S. dollars, quality-adjusted life-days (QALDs), and dollars per QALD. Sensitivity analyses were performed on most variables.

RESULTS

Norfloxacin is more effective and less costly than the alternative, TMP-SMX. Norfloxacin treatment will save $195.85 per patient, resulting in an aggregate saving of more than $40 million annually. Patients are expected to enjoy a better quality of life with an incremental 0.0601 QALD per patient, if they are treated with norfloxacin. These results are robust across a wide range of probabilities and costs.

CONCLUSIONS

In this analysis, norfloxacin 400 mg twice a day was a more cost-effective treatment than TMP/SMX 160/800 mg twice a day for women with pyelonephritis.

Addressing antibiotic resistance

Management of uncomplicated urinary tract infections (UTIs) has traditionally been based on 2 important principles: the spectrum of organisms causing acute UTI is highly predictable (Escherichia coli accounts for 75% to 90% and Staphylococcus saprophyticus accounts for 5% to 15% of isolates), and the susceptibility patterns of these organisms have also been relatively predictable. As a result, empiric therapy with short-course trimethoprim-sulfamethoxazole (TMP-SMX) has been a standard management approach for uncomplicated cystitis.However, antibiotic resistance is now becoming a major factor not only in nosocomial complicated UTIs, but also in uncomplicated community-acquired UTIs. Resistance to TMP-SMX now approaches 18% to 22% in some regions of the United States, and nearly 1 in 3 bacterial strains causing cystitis or pyelonephritis demonstrate resistance to amoxicillin. Fortunately, resistance to other agents, such as nitrofurantoin and the fluoroquinolones, has remained low, at approximately 2%. Preliminary data suggest that the increase in TMP-SMX resistance is associated with poorer bacteriologic and clinical outcomes when TMP-SMX is used for therapy. As a result, these trends have necessitated a change in the management approach to community-acquired UTI. The use of TMP-SMX as a first-line agent for empiric therapy of uncomplicated cystitis is only appropriate in areas where TMP-SMX resistance prevalence is <10% to 20%. In areas where resistance to TMP-SMX exceeds this rate, alternative agents need to be considered.

Hydrophilic carboxylic acids and iridoid glycosides in the juice of American and European cranberries (Vaccinium macrocarpon and V. oxycoccos), lingonberries (V. vitis-idaea), and blueberries (V. myrtillus)

Analysis of the hydrophilic fraction of cranberry juice by reversed-phase HPLC using an Aqua LUNA column with diode array or MS detection revealed the presence of quinic acid, malic acid, shikimic acid, and citric acid. For the first time, two iridoid glucosides were found in the juice. The two iridoid glucosides were shown to be monotropein and 6,7-dihydromonotropein by MS and NMR spectroscopy. A fast reversed-phase HPLC method for quantification of the hydrophilic carboxylic acids was developed and used for analyses of cranberry, lingonberry, and blueberry juices. The level of hydrophilic carboxylic acids in cranberries was 2.67-3.57% (w/v), in lingonberries 2.27-3.05%, and in blueberries 0.35-0.75%. In lingonberries both iridoid glucosides were present, whereas only monotropein was present in blueberries.

Urinary tract infections in women with or at risk for human immunodeficiency virus infection

OBJECTIVE

The purpose of this study was to determine the risk for urinary tract infection in women with or at risk for human immunodeficiency virus infection.

STUDY DESIGN

A prospective study of 871 women who were human immunodeficiency virus seropositive and 439 women who were human immunodeficiency virus seronegative was conducted, with additional semiannual interviews, human immunodeficiency virus serologic evaluation, human immunodeficiency viral load determination, T-cell subset test, urinalysis, pregnancy test, and selected quantitative urine culture examination.

RESULTS

At baseline, 26 women (3.0%) who were human immunodeficiency virus seropositive and 14 women (3.2%) who were human immunodeficiency virus seronegative women had urinary tract infections(P =.97). During 4280 person-years of follow-up, incident urinary tract infections was associated significantly with <12 years education (adjusted risk ratio, 1.43; 95% CI, 1.01-2.00), public assistance (adjusted risk ratio, 1.70; 95% CI, 1.11-2.60), pregnancy (adjusted risk ratio, 3.04; 95% CI, 2.04-4.53), and recent previous urinary tract infection (adjusted risk ratio, 1.82; 95% CI, 1.16-2.86), but not with human immunodeficiency virus infection. Among women who were human immunodeficiency virus seropositive, risk was associated with viral load (adjusted risk ratio, per log(10) increase 1.30; 95% CI, 1.03-1.63), but not with CD(4+) lymphocyte count.

CONCLUSION

Risk for urinary tract infection is not associated with human immunodeficiency virus infection but is associated with viral load among women who are infected with human immunodeficiency virus.

Addressing antibiotic resistance

Management of uncomplicated urinary tract infections (UTIs) has traditionally been based on 2 important principles: the spectrum of organisms causing acute UTI is highly predictable (Escherichia coli accounts for 75% to 90% and Staphylococcus saprophyticus accounts for 5% to 15% of isolates), and the susceptibility patterns of these organisms have also been relatively predictable. As a result, empiric therapy with short-course trimethoprim-sulfamethoxazole (TMP-SMX) has been a standard management approach for uncomplicated cystitis.However, antibiotic resistance is now becoming a major factor not only in nosocomial complicated UTIs, but also in uncomplicated community-acquired UTIs. Resistance to TMP-SMX now approaches 18% to 22% in some regions of the United States, and nearly 1 in 3 bacterial strains causing cystitis or pyelonephritis demonstrate resistance to amoxicillin. Fortunately, resistance to other agents, such as nitrofurantoin and the fluoroquinolones, has remained low, at approximately 2%. Preliminary data suggest that the increase in TMP-SMX resistance is associated with poorer bacteriologic and clinical outcomes when TMP-SMX is used for therapy. As a result, these trends have necessitated a change in the management approach to community-acquired UTI. The use of TMP-SMX as a first-line agent for empiric therapy of uncomplicated cystitis is only appropriate in areas where TMP-SMX resistance prevalence is <10% to 20%. In areas where resistance to TMP-SMX exceeds this rate, alternative agents need to be considered.

Correlation between pharmacokinetic/pharmacodynamic parameters and efficacy for antibiotics in the treatment of urinary tract infection

Antibiotic treatment of urinary tract infection (UTI) depends on the antibiotic being able to inhibit the growth or to kill the bacteria present in the urinary tract. The pharmacokinetics of antibiotics in the urinary tract including the kidneys, the bladder and the prostate are briefly reviewed. The conclusion is that high urinary antibiotic concentrations can eradicate bacteria in the urine, but in the kidney tissue levels must surpass the MIC of the infecting pathogen to achieve effect. Pharmacodynamic studies in UTI are relatively scarce, but recent studies have shown, that as for other types of infections, beta-lactam antibiotic treatment of UTI depends on the T(>MIC), i.e. the time the antibiotic concentration remains above the MIC. This counts for activity against bacteria in the kidneys as well as in the urine. Bacterial counts in the bladder are curiously resistant to the activity of most antibiotics. For drugs with concentration dependent time-kill activity such as the fluoroquinolones and the aminoglycosides, the effect in UTIs is dependent on the peak/MIC ratio or AUC/MIC ratio. The aminoglycosides are difficult to evaluate in this context, since they are bound in high concentrations to the renal cortex. For clinical studies the author reviews the literature for aminopenicillins (ampicillin and amoxycillin) as representatives of beta-lactam antibiotics. Data from 16 studies of uncomplicated UTI encompassing 20 treatment groups showed a significant correlation between the cumulative T(>MIC) and bacteriological cure, such that a cumulative T(>MIC) of 30 h was necessary for a maximal cure rate of 80-90%. Incorporating these data including the T(>MIC) for the aminopenicillins, the optimal dose with minimal consumption of drug can be calculated, i.e. for amoxycillin 500 mg TID for 4 days. Further research is needed to calculate optimal dosages for other types of antibiotics, especially in order to prevent development of resistance.

Treatment of uncomplicated urinary tract infections: exploring differences in adherence to guidelines between three European countries. Drug Education Project Group

OBJECTIVE

To evaluate adherence of general practitioners to treatment guidelines regarding urinary tract infections in three European countries and to investigate whether differences in adherence at the prescribing level within and between countries could be explained by general practitioners' knowledge and attitudes, characteristics, or national setting.

DESIGN

Prescribing data collected in 1994-1995 were analyzed regarding use of first-choice drugs and duration of treatment, knowledge and attitudes were assessed with a questionnaire, and multiple regression analysis was used to explain differences in prescribing behavior within and between countries.

RESULTS

Our study is based on data from 85.6% of the 584 general practitioners who were scheduled to participate in a continuing education program. The mean proportion of responses in agreement with the guidelines regarding first-choice drugs was 0.69 in Sweden, 0.78 in the Netherlands, and 0.79 in Norway; regarding duration of treatment, the mean proportion was 0.56 in Sweden, 0.67 in the Netherlands, and 0.59 in Norway. The proportion of first-choice drugs prescribed for women (18-75 y) was 0.55 in Sweden, 0.83 in the Netherlands, and 1.00 in Norway (patients >16 y). The duration of treatment was 7.6 defined daily doses per prescription in Sweden, 5.9 in the Netherlands, and 6.6 in Norway. Knowledge and attitudes explained 0-17% of the variation in prescribing. Years in practice explained 0-11%, and the general practitioners' gender had no explanatory value. The national setting explained most of the variation between countries.

CONCLUSIONS

Differences in prescribing behavior can be explained only to a small extent by deviations from the guidelines in terms of knowledge and attitudes. Between countries, differences in regulation, marketing, and distribution of drugs seem to be of much greater importance.

Development of a long-term ascending urinary tract infection mouse model for antibiotic treatment studies

A model of ascending unobstructed urinary tract infection (UTI) in mice was developed to study the significance of the antibiotic concentration in urine, serum, and kidney tissue for efficacy of treatment of UTI in general and pyelonephritis in particular. Outbred Ssc-CF1 female mice were used throughout the study, and Escherichia coli was used as the pathogen. The virulence of 11 uropathogenic E. coli isolates and 1 nonpathogenic laboratory E. coli strain was examined. Strain C175-94 achieved the highest counts in the kidneys, and this strain was subsequently used as the infecting organism. The model gave reproducible bladder infections, i.e., bacteria were recovered from 22 of 23 control mice after 3 days, and histological examination of kidney tissue showed that of 14 infected kidneys, 7 (50%) showed major histological changes, whereas 3 of 36 uninfected kidneys showed major histological changes (P = 0.018). Once the model was established, the efficacies of different doses of cefuroxime and gentamicin, corresponding to active concentrations in urine only or in urine, serum, and kidney tissue simultaneously, were examined. All cefuroxime doses resulted in significantly lower counts in urine than control treatments, but the dose which produced concentrations of cefuroxime only in urine and not in serum or kidney tissue had no effect on kidney infection. Even low doses of gentamicin (0.05 mg/mouse) resulted in concentrations in renal tissue for prolonged times due to accumulation. All gentamicin doses had a significant effect (compared to the effect of the control treatment) on bacterial counts in urine and kidneys. The antibiotic effect on bacterial counts in bladders was negligible for unknown reasons. Use of the mouse UTI model is feasible for study of the effect of an antibiotic in the urinary system, although the missing antibacterial effect in the bladder needs further evaluation.

Are resistance patterns in uropathogens published by microbiological laboratories valid for general practice?

During 7 months from August 1994, 171 urine samples were collected consecutively in general practice in Western Norway from female patients with suspected lower urinary tract infection. For each of the 171 samples, 2 samples from adult females received from general practice at the microbiological laboratory on the same day were selected using a predetermined system. Samples noted as treatment controls and samples from pregnant patients were discarded. Bacteriuria was found in 101/171 (59.1%) vs 220/342 (64.3%) of the samples. The general practice material contained more bacteriuric samples with Escherichia coli (83.2% vs 71.8%, p<0.05) and Staphylococcus saprophyticus (11.9 vs 6.4%), and fewer with other Gram-negative rods (4.0% vs 15.9%, p<0.01) and enterococci (1.0% vs 5.9%, p<0.01). The frequency of resistant isolates was substantially lower in the samples from general practice for all antibacterial agents tested: amoxycillin 18.9% vs 23.9%, mecillinam 1.1% vs 4.7%, trimethoprim 12.9% vs 18.5%, cotrimoxazole 12.0% vs 15.4%, sulphonamide 20.0% vs 28.4%, nitrofurantoin 3.0% vs 9.7% (p<0.05). Data from local laboratories exaggerate the resistance problems among uropathogens found in urine samples in general practice.

Comparison of sparfloxacin and ciprofloxacin in the treatment of community-acquired acute uncomplicated urinary tract infection in women. Sparfloxacin Multicenter Uncomplicated Urinary Tract Infection Study Group

Urinary tract infection (UTI) is a common illness, with > or =30% of all women experiencing a UTI during their lifetime. Less than a decade ago, the standard therapy for acute uncomplicated UTIs involved treatment with > or =7 days of an antibacterial agent, but recent studies using a variety of newly introduced antibiotics, including the fluoroquinolones, have demonstrated that a 1- to 5-day treatment regimen can be equally effective. This randomized, double-masked, multicenter study was conducted to compare the efficacy and tolerability of a single dose of sparfloxacin with those of a 3-day regimen of sparfloxacin and a 7-day regimen of ciprofloxacin in the treatment of women with community-acquired acute uncomplicated urinary tract infection. A total of 1175 women were enrolled; 395 received sparfloxacin as a single 400-mg dose on day 1, 394 received sparfloxacin as a 400-mg loading dose on day 1 followed by 200 mg once daily for 2 additional days, and 386 received ciprofloxacin 250 mg twice daily for 7 days. Patients were comparable with respect to demographic characteristics and underlying conditions. A total of 954 patients were clinically assessable; 490 of these were also bacteriologically assessable. All patients treated were included in the tolerability analysis. Escherichia coli (75.4%), Klebsiella pneumoniae (4.9%), Enterococcus faecalis (4.6%), and Staphylococcus saprophyticus (4.1%) were the most commonly isolated organisms. In the all-treated population, clinical success was achieved 5 to 9 days after therapy in 91.8%, 92.2%, and 91.6% of patients in the single-dose sparfloxacin, 3-day sparfloxacin, and 7-day ciprofloxacin groups, respectively; bacteriologic success was observed in 91.7%, 92.6%, and 96.6% of those in the 3 groups. Sustained clinical success rates 4 to 6 weeks after therapy were 76.6%, 80.2%, and 79.5% in the single-dose sparfloxacin, 3-day sparfloxacin, and 7-day ciprofloxacin groups, respectively; sustained bacteriologic success rates were 80.7%, 90.1%, and 92.6%. The most common adverse events were nausea, headache, vaginal thrush, dizziness, and diarrhea; >92% of adverse events were mild or moderate in severity. The 2 drugs had comparable frequencies of adverse events, except for photosensitivity, which occurred in 3.3% of the 3-day sparfloxacin group, 1.3% of the single-dose sparfloxacin group, and 0.3% of the ciprofloxacin group (P = 0.005). The 3-day sparfloxacin regimen was effective and well tolerated. The initial response to single-dose sparfloxacin treatment was comparable to the response to the other 2 regimens, but the single-dose regimen proved less effective over time, with higher rates of clinical recurrence and bacteriologic relapse. Sparfloxacin provides an alternative to ciprofloxacin for patients with acute uncomplicated urinary tract infection who are not at risk for photosensitivity reactions or adverse events associated with a prolonged corrected QT interval.

The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women

PURPOSE

Acute uncomplicated urinary tract infection is a common and costly disorder in women. To reduce potentially unnecessary expense and inconvenience, a large staff-model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing. We sought to evaluate the effects of the guideline.

SUBJECTS AND METHODS

We performed a population-based, before-and-after study with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on resource utilization and on the occurrence of potential adverse outcomes. We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cystitis or sexually transmitted disease or who developed pyelonephritis within 60 days of the initial diagnosis. Relative risks (RR) and 95% confidence intervals (CI) were estimated, adjusting for the effects of clustering within clinics.

RESULTS

A total of 3,889 eligible patients with presumed acute uncomplicated cystitis were evaluated. As compared with baseline, guideline implementation significantly decreased the proportion of patients with presumed cystitis who received urinalysis (RR = 0.75; CI, 0.70 to 0.80), urine culture (RR = 0.73; CI, 0.68 to 0.79), and an initial office visit (RR = 0.67; CI, 0.62 to 0.73), while increasing the proportion who received a guideline-recommended antibiotic 2.9-fold (CI, 2.4 to 3.7-fold). In the prospective comparison of the 22 intervention and two control clinics, the guideline decreased the proportion of patients who had urinalyses performed (RR = 0.80; CI, 0.65 to 0.98) and increased the proportion of patients who were prescribed a guideline-recommended antibiotic (RR = 1.53; CI, 1.01 to 2.33). Adverse outcomes did not increase significantly in either comparison.

CONCLUSION

Guideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis.

Evaluation of and antimicrobial therapy for recurrent urinary tract infections in women

The problem with recurrent urinary tract infections in women is enormous and contributes significantly to national health care costs. As the role of office urology and the external "cost-effective" pressures placed on the practicing urologist have heightened, a consistent, logical approach towards diagnosis and management of urinary tract infection becomes essential. This article briefly discusses the cause and pathophysiology behind recurrent urinary tract infections in women. A practical discussion of proper evaluation and treatment options will also be provided in hopes of offering the clinician a simple, stepwise approach to this sometimes difficult condition.

A comparison between single-dose fosfomycin trometamol (Monuril) and a 5-day course of trimethoprim in the treatment of uncomplicated lower urinary tract infection in women

This study is a comparison of the microbiological and clinical efficacy of single-dose fosfomycin trometamol therapy and a 5 day course of trimethoprim in the treatment of uncomplicated urinary tract infection in female patients. Urine dip-slide samples were obtained from 547 female patients aged 18-65 by 22 General Practitioners (GPs) participating in the study from 21 centres in the UK. All patients were diagnosed as having a urinary tract infection by their GP on the basis of history and clinical examination. Patients were randomised to receive either single dose fosfomycin trometamol or a 5 day course of trimethoprim in a 2:1 ratio. Patients who had significant bacteriuria (> or = 10(5) c.f.u/ml) at the first visit (300) were included in the microbiological analysis. The two commonest urinary pathogens isolated were Escherichia coli and Staphylococcus saprophyticus. Trimethoprim resistance was more frequent amongst E. coli isolates whereas fosfomycin trometamol resistance was more common amongst S. saprophyticus isolates. Microbiological cure was demonstrated in 83.3% of the trimethoprim treated group and 83% of the fosfomycin trometamol treated group. Persistence of the infecting bacteria was seen in 17% of each treatment arm.

Community-acquired urinary tract infection in adults: a hospital viewpoint

The clinical and epidemiologic spectrum of 175 cases of community-acquired urinary tract infection (UTI) were evaluated at a university hospital. Patients were grouped in five different categories of which complicated UTI was the most common (39%). Bacteraemia was detected in eight patients (18%) of this group and in five (12%) with acute uncomplicated pyelonephritis. A single organism was isolated in 166 cases (95%). The rate of Escherichia coli bacteriuria ranged from 60% (asymptomatic bacteriuria) to 94% (uncomplicated cystitis). Of the 184 isolates, 92% were susceptible to ciprofloxacin and significantly high rates of resistance were found for ampicillin, cefazolin, cefuroxime, and co-trimoxazole. Isolates causing uncomplicated UTI had significantly high rates of resistance to ampicillin, amoxycillin-clavulanate and co-trimoxazole and those causing complicated UTI, had significantly high rates of resistance to most oral antibiotics tested, except quinolones and nitrofurantoine. Community-acquired UTI requiring hospital evaluation occurs in a complex group of patients, and current patterns of antibiotic resistance make it difficult to suggest empiric oral treatments in this setting.

Diagnosis and treatment of uncomplicated urinary tract infection

Acute uncomplicated urinary tract infection 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. Review of the published data suggests that a 3-day regimen is more effective than a single-dose regimen for all antimicrobials tested. Regimens with trimethoprim-sulfamethoxazole seem to be more effective than those with beta lactams, regardless of the duration. Because of increasing resistance to trimethoprim-sulfamethoxazole, an alternative regimen such as nitrofurantoin (in a 7-day regimen), a fluoroquinolone, or an oral third-generation cephalosporin may be a better empiric choice in some areas. Acute pyelonephritis caused by highly virulent uropathogens in an otherwise healthy woman may be considered an uncomplicated infection. The optimal treatment duration for acute uncomplicated pyelonephritis has not been established, but 10- to 14-day regimens are recommended. We prefer to use antimicrobials that attain high renal tissue levels, such as a fluoroquinolone, trimethoprim-sulfamethoxazole, or an aminoglycoside, for pyelonephritis. Acute uncomplicated cystitis or pyelonephritis in healthy adult men is uncommon but is generally caused by the same spectrum of uropathogens with the same antimicrobial susceptibility profile as that seen in women.

Utility of urine and blood cultures in pyelonephritis

OBJECTIVE

To determine how often the results of urine and blood cultures led to changes in antibiotic therapy for patients discharged from the hospital with the diagnosis of pyelonephritis.

METHODS

A retrospective chart review was performed of consecutively admitted patients, 10-90 years old, with an ICD-9 discharge diagnosis of acute pyelonephritis. All patients were admitted to a university-based, tertiary care center and a large HMO medical center from 1993 to 1994. The association of urine and blood culture results with a change in antibiotic therapy was assessed.

RESULTS

Of the 194 patients who met inclusion criteria, 189 (97%) had urine cultures obtained at the time of admission and 139 (71%) had blood cultures obtained. Ampicillin, gentamicin, or both were given as initial antibiotics 81% of the time, and isolated organisms from urine or blood were sensitive to the empiric antibiotics 95% of the time. Most (171/189; 90%) urine cultures were positive, but only 9 (5%) of these led to a change in antibiotic therapy. 80% of the urinary pathogens were Escherichia coli, 5% Enterococcus, 5% Proteus, and 4% Klebsiella. Only 40 (29%) of the 139 blood cultures were positive; none prompted a change in antibiotics. There were no cases in which blood and urine cultures grew different pathogens.

CONCLUSIONS

Urine cultures are useful in directing antibiotic therapy in patients with the discharge diagnosis of acute pyelonephritis and support a change in therapy in 5% of cases. Among the patients in this study, blood cultures results did not lead to changes in antibiotic therapy. These findings warrant prospective, multicenter evaluation.

Urinary tract infections

Urinary tract infections (UTIs) are still the precipitating cause for 7 million patient visits per year with total costs exceeding one billion dollars. Diagnostic modalities have become more "friendly" for the smaller laboratory with "dip stick" culture tests providing a rapid method of isolation of pathogens. In many cases, empiric therapy is more cost effective than culture in uncomplicated UTIs in women. The etiologic organisms implicated in UTIs have not changed dramatically over the past two decades, with E. coli still accounting for the majority of cases. Antibiotic susceptibility patterns have changed dramatically, with ampicillin losing utility die to the emergence of resistance. Quinolones, which have been exceedingly active against gram-negative enteric pathogens, are no longer universally active and more pathogenic organisms, such as pseudomonas, may be resistant. The emergence of other highly resistant organisms, such as Enterococcus faecium, must be watched for.

Improving the prescribing of antibiotics for urinary tract infection

BACKGROUND

In recent years there have been changes in the recommended antibiotic treatment for urinary tract infections (UTIs). In particular, the use of amoxycillin or co-trimoxazole is now discouraged, with amoxycillin-potassium clavulanate, cephalexin and trimethoprim becoming first-line agents for uncomplicated lower UTIs.

AIM

To examine whether academic detailing, performed by a pharmacist, could modify prescribing practices for antibiotics used in the treatment of UTI in the community setting.

METHODS

The intervention was conducted in Southern Tasmania, using the remainder of the State as a control area. The target group of general practitioners was sent educational material designed to assist in the appropriate prescribing of antibiotics in the treatment of UTI. A pharmacist then visited each general practitioner and discussed the rational use of antibiotics for UTIs directly with him/her. Outcomes were measured using evaluation feedback from the general practitioners and pharmacoepidemiological data, which were not linked to diagnosis. The key variable examined was the total defined daily doses (DDDs) dispensed for the recommended first-line agents (amoxycillin-potassium clavulanate, cephalexin and trimethoprim) compared with amoxycillin (3 g single-dose form) and co-trimoxazole.

RESULTS

The educational programme was very well received by the general practitioners. Changes in the prescribing of antibiotics commonly used for UTIs were evident in both study regions over the course of the study, but the improvements were significantly greater in the intervention area.

CONCLUSION

Educational programmes utilizing academic detailing by pharmacists can modify prescribing practices within the community setting.

Urinary tract infection in persons with spinal cord injury

Persons with spinal cord injury (SCI) have an increased risk of developing urinary tract infections. Certain structural and physiological factors, such as bladder over-distention, vesicoureteral reflux, high-pressure voiding, large post-void residuals, stones in the urinary tract, and outlet obstruction increase the risk of infection. The method of bladder drainage also influences the risk of urinary tract infection, and most persons with SCI on indwelling or intermittent catheterization develop urinary tract infection. The association of behavioral and demographic factors with the risk of urinary tract infection are less well understood. The method of specimen collection must be considered when determining the significance of bacteria. A national consensus conference sponsored by the National Institute on Disability and Rehabilitation Research defined significant bacteriuria as: > or = 10(2) colony forming units (cfu) of uropathogens per milliliter of urine in catheter specimens from persons on intermittent catheterization; > or = 10(4)cfu/mL in clean-voided specimens from catheter-free males using condom catheters; and any detectable concentration of uropathogens in indwelling catheter or suprapubic aspirate specimens. Symptomatic urinary tract infection warrants therapy, but the diagnosis is complicated by the poor sensitivity and specificity of symptoms and signs. Pyuria is generally present in persons with symptomatic urinary tract infection, although it is a nonspecific test, and its absence generally indicates the absence of symptomatic urinary tract infection. Treatment of asymptomatic bacteriuria has not been shown to be beneficial and increases the risk of development of antimicrobial-resistant uropathogens. Antibiotic prophylaxis is generally not recommended because of its unproven benefit in several studies and its association with emergence of antimicrobial resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

Uncomplicated E coli urinary tract infection in college women: a retrospective study of E coli sensitivities to commonly prescribed antibiotics

To determine the sensitivity of Escherichia coli organisms to various antibiotics, the authors conducted a 4-month retrospective chart study of 95 patients with urinary tract infection (UTI). They found great variation in sensitivity of E coli to the different antibiotics and concluded that amoxicillin and the cephalosporins are no longer effective first-line UTI treatments. Of the antibiotics evaluated, ciprofloxacin was the best choice, but both nitrofurantoin and TMP/SMX are less expensive and are effective for about 90% of uncomplicated UTIs.

Management of bacterial urinary tract infections in adults

OBJECTIVE

To provide a comprehensive review of the diagnosis and therapeutic management considerations in patients with urinary tract infections (UTIs).

DATA SOURCES

A MEDLINE search was used to identify pertinent English language literature, including reviews. Infectious disease textbooks were used for background information.

STUDY SELECTION

Clinical trials evaluating drug therapy in a variety of patient populations with UTIs were reviewed.

DATA EXTRACTION

Background information was obtained from comprehensive reviews. Drug dosing strategies and efficacy comparisons were extracted from the investigations in this area.

DATA SYNTHESIS

Information was processed to provide general guidelines and resources for practitioners to use in managing UTIs.

CONCLUSIONS

There are a number of useful antibiotics for the management of UTIs. The distinctions between infection severity and underlying risk factors within a given population influence the appropriateness of drug selection and duration of treatment.

Management of lower urinary tract infections

Most urinary tract infections (UTIs) present as bacterial cystitis in healthy women in the sexually active age group. The commonest pathogen is Escherichia coli and most of the remainder are due to Staphylococcus saprophyticus. Many women are prone to recurrent UTIs and these are invariably due to a reinfection with a different organism. After diagnosis, a curative course of treatment should be given, but the approach should be different if the infection is uncomplicated (normal urinary tract and normal renal function) as opposed to complicated (male patient, abnormal urinary tract, impaired host defence mechanisms, impaired renal function, infection with a virulent organism). It is believed that traditional dosage regimens for uncomplicated UTIs are extravagant. There is no convincing evidence that a long course of medication is more effective than a short one; in fact, the use of single dose therapy for uncomplicated UTIs is gaining support. Trimethoprim 600mg, cotrimoxazole (trimethoprim/sulfamethoxazole) 1.92g, fosfomycin trometamol 3g and the 4-quinolones are the preferred agents for single dose treatment. Failure of single dose therapy is a simple guide for the need for further urinary tract investigation or more intensive therapy. If UTIs recur, it may be necessary to consider long term, low dose prophylaxis. The most effective drugs for this type of treatment include nitrofurantoin 50mg, trimethoprim 100mg and norfloxacin 200mg, given at night. More recent studies show that a dose administered on alternate nights, 3 nights a week or after intercourse is just as effective.

London after Tomlinson. Care in the capital: what needs to be done

One of the aims of the Tomlinson report is to shift more care from the secondary to the primary sector in London. But the primary sector is already underresourced and overloaded. The capital has a heterogeneous population which often makes inappropriate demands on general practitioners. Many premises are inadequate and there are insufficient support staff. David Metcalfe emphasises that London is special and that the shift will not become a reality unless these problems are tackled. He suggests the establishment of different models of practice centres which could treat some of the patients who now go to accident and emergency departments. Some would be the night emergency service base, some would have primary care beds, and each would have a different mix of specialist support.

Diagnosis and management of urinary tract infection in adults

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Urinary tract infections in the 90s: pathogenesis and management

Urinary tract infections are one of the most common types of infection encountered in the practice of medicine. Recent discussions have focused on our current knowledge of natural host defenses that function during normal physiologic conditions in an attempt to prevent urinary infections. However, increased susceptibility to these infections may result from intrinsic risk factors that alter host defenses, or from extrinsic risk factors. Advances in the treatment of urinary infections have focused on short course therapy for women with uncomplicated lower tract infections, and on oral therapy in women with mild acute uncomplicated pyelonephritis. Also, in the area of prevention, reasonable candidates for antimicrobial prophylaxis have been identified. Even so, further studies are needed to define more clearly our understanding of the pathogenesis, treatment, and prevention of infections of the urinary tract.