Urinary tract infection: traditional pharmacologic therapies

Comprehensive insights into UTIs: from pathophysiology to precision diagnosis and management

Urinary tract infections (UTIs) are the second most common infectious disease, predominantly impacting women with 150 million individuals affected globally. It increases the socio-economic burden of society and is mainly caused by Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter spp., and Staphylococcus spp. The severity of the infection correlates with the host factors varying from acute to chronic infections. Even with a high incidence rate, the diagnosis is mainly based on the symptoms, dipstick analysis, and culture analysis, which are time-consuming, labour-intensive, and lacking sensitivity and specificity. During this period, medical professionals prescribe empirical antibiotics, which may increase the antimicrobial resistance rate. Timely and precise UTI diagnosis is essential for addressing antibiotic resistance and improving overall quality of life. In response to these challenges, new techniques are emerging. The review provides a comprehensive overview of the global burden of UTIs, associated risk factors, implicated organisms, traditional and innovative diagnostic methods, and approaches to UTI treatment and prevention.

The Prevalence of Urinary Tract Infections and Antibiotic Prescription Treatments Across Three Countries: A Retrospective Study Using an Electronic Medical Record

Introduction The Clinical Rotation Evaluation and Documentation Organizer (CREDO) is an electronic medical record (EMR) system created by the Edward Via College of Osteopathic Medicine (VCOM). International healthcare providers who partner with VCOM can gain access to CREDO and input their patient data. The objective of this study was to determine the frequency of urinary tract infection (UTI) diagnoses and prescription use over a one-year period in three Latin American countries. Methods Researchers analyzed the frequency of UTI diagnosis with corresponding prescription recommendations over a 12-month period in three Latin American countries (i.e., Dominican Republic, El Salvador, and Honduras) that utilize the CREDO system. For each month between May 2021 and May 2022, the total number of UTI diagnosis codes and prescription codes were summed, graphed, and analyzed. Results In El Salvador, there were 142 UTIs and 126 corresponding prescriptions written for UTIs reported from May 2021 to May 2022 but diagnoses were not consistent each month. Ciprofloxacin was prescribed most frequently at a rate of 43.7% in El Salvador. In Honduras, there were 68 UTIs and 68 corresponding prescriptions written for the UTIs reported from May 2021 until May 2022 with Ciprofloxacin being prescribed most frequently at a rate of 39.7%. Again, diagnosis frequency was not consistent each month. In the Dominican Republic, there were 42 UTIs and 14 corresponding prescriptions written for those UTIs reported, however, data only reflected two months' worth of UTI diagnoses from May 2021 to May 2022. Fosfomycin was prescribed most frequently at a rate of 61.5%.  Conclusion: The findings above suggest that there are inconsistent UTI reports throughout the year with a varied use of antibiotics prescriptions for UTIs. The discovered discrepancies in disease reporting, or lack thereof of reporting, and prescription recommendation suggest inconsistent reporting in CREDO. In the future, focused education or revision on CREDO reporting and uniform coding practices could be implemented to reduce these inconsistencies.

In Vitro Killing of Canine Urinary Tract Infection Pathogens by Ampicillin, Cephalexin, Marbofloxacin, Pradofloxacin, and Trimethoprim/Sulfamethoxazole

Urinary tract infections are common in dogs, necessitating antimicrobial therapy. We determined the speed and extent of in vitro killing of canine urinary tract infection pathogens by five antimicrobial agents (ampicillin, cephalexin, marbofloxacin, pradofloxacin, and trimethoprim/sulfamethoxazole) following the first 3 h of drug exposure. Minimum inhibitory and mutant prevention drug concentrations were determined for each strain. In vitro killing was determined by exposing bacteria to clinically relevant drug concentrations and recording the log10 reduction and percent kill in viable cells at timed intervals. Marbofloxacin and pradofloxacin killed more bacterial cells, and faster than other agents, depending on the time of sampling and drug concentration. Significant differences were seen between drugs for killing Escherichia coli, Proteus mirabilis, Enterococcus faecalis, and Staphylococcus pseudintermedius strains. At the maximum urine drug concentrations, significantly more E. coli cells were killed by marbofloxacin than by ampicillin (p < 0.0001), cephalexin (p < 0.0001), and TMP/SMX (p < 0.0001) and by pradofloxacin than by cephalexin (p < 0.0001) and TMP/SMX (p < 0.0001), following 5 min of drug exposure. Rapid killing of bacteria should inform thinking on drug selection for short course therapy for uncomplicated UTIs, without compromising patient care, and is consistent with appropriate antimicrobial use and stewardship principles.

Differences between Risk Factors for Sepsis and Septic Shock in Obstructive Urolithiasis

BACKGROUND

Complicated acute pyelonephritis (APN) is a life-threatening condition that requires immediate intervention. This study examined the characteristics of APN occurring as a complication of ureteral stone.

METHODS

We retrospectively reviewed 85 patients diagnosed with APN complicated by ureteral stone between December 2006 and July 2017 at our institution. Patients with concomitant renal stone, multiple ureteral stones, ureteral strictures, ureteral cancer, and urogenital anomalies, including vesicoureteral reflux were excluded. Clinical characteristics including age, sex, underlying disease, medical history, stone characteristics, initial laboratory data, and the procedure used to correct urinary obstruction were summarized, and the risk factors associated with sepsis and septic shock were analyzed.

RESULTS

Sepsis was diagnosed at initial presentation in 62 patients, 17 of whom suffered from septic shock. Disease-related death did not occur in any patient. Previous history of stone (P = 0.015), leukocytosis (P < 0.001), elevated C-reactive protein levels (P = 0.006), and low albumin (P = 0.038) were significant risk factors for progression to sepsis. The absence of hypertension (P = 0.047), thrombocytopenia (P = 0.006), decreased erythrocyte sedimentation rate (ESR) (P = 0.003), elevated blood urea nitrogen (P = 0.016), and positive blood culture (P = 0.018) were significant predictors for progression to septic shock. Multivariate analysis revealed that previous history of stone (P = 0.015) was an independent risk factor for sepsis, while the absence of hypertension (P = 0.047), thrombocytopenia (P = 0.013), and decreased ESR (P = 0.009) were risk factors for shock.

CONCLUSION

The risk factors associated with the progression from APN to sepsis differed from those associated with the progression from sepsis to septic shock. Various factors should be considered while selecting treatment options based on the severity of APN associated with ureteral stone. It should be managed with aggressive treatment and close observation, especially in the presence of risk factors.

A rapid, point-of-care antibiotic susceptibility test for urinary tract infections

Introduction. The alarming rise in urinary tract infection (UTI) antimicrobial resistance has resulted from a combination of high prevalence, low specificity and the lack of a rapid, point-of-care (POC) antibiotic susceptibility test (AST), which has led to the overuse/inappropriate use of antibiotics.Aim. This study aimed to evaluate the performance of a rapid POC phenotypic AST device in reporting susceptibility information within 2 h.Methodology. Instrument calibration was performed with model bacteria and fluorescent microbeads to determine the dynamic range and limit of detection for quantifying concentrations of bacteria and demonstrate the ability to rapidly differentiate susceptible and resistant model bacteria. We then evaluated 30 presumptive UTI-positive patient urine samples in a clinical pilot study using a panel of 5 common UTI antibiotics plus a growth control and compared our results to the hospital standard of care AST.Results. Our device was able to robustly detect and quantify bacteria concentrations from 50 to 105 colony-forming units (c.f.u.) ml-1. The high sensitivity of this measurement technique enabled the device to differentiate between susceptible and resistant model bacteria with 100 % specificity over a 2 h growth period. In the clinical pilot study, an overall categorical agreement (CA) of 90.7 % was observed (sensitivity=91.4 %, specificity=88.9 %, n=97) with performance for individual drugs ranging from 85 % CA (ceftazidime) to 100 % (nitrofurantoin).Conclusions. By reducing the typical timeframe for susceptibility testing from 2-3 days to 2 h, our POC phenotypic AST can provide critical information to clinicians prior to the administration of antibiotic therapy.

Uropathogens and Gestational Outcomes of Urinary Tract Infections in Pregnancies that Necessitate Hospitalization

BACKGROUND AND OBJECTIVES

Our aim is to identify uropathogens that cause urinary tract infections (UTIs) that necessitate hospitalization, and analyze outcomes of gestational UTIs.

METHODS

This study consisted of 30 pregnant women who necessitate hospitalization because of UTI (7.8% of gestational UTIs during the same period of time). UTI that necessitates hospitalization is defined as clinical complaints, urination problems, urine analysis and culture positivity, fever and uterine discomfort. Patients with at least two positive cultures (≥ 100,000 cfu/ml) were included to this study. Antimicrobial susceptibility tests were obtained in all cases in order to determine antimicrobial resistance and to choose the ideal antibiotics for treatment.

RESULTS

In our study, we have found that Escherichia coli is the most common microorganism (56.7%). Enterococcus faecalis (13.3%) and Klebsiella pneumonia (10%) were other frequently observed microorganisms. In this series, mean gestational week at birth was 35 weeks 5 days (range 23-40 weeks). Mean birthweight was 2,656 g (range 500-3,700 g). Twenty-three cases (76.7%) were hospitalized before 37th gestational week and preterm delivery rate was 56.3%. Maternal risk factors and coexisting diseases were detected in 11 (36.7%) patients as follows: diabetes mellitus in 4, thrombophilia in 3, thyroid disorders in 3 and hydroureteronephrosis in 1 case. Cesarean section rate was 65.2%.

CONCLUSIONS

Knowing uropathogens of patient population is beneficial in the management of patients and better planning of future medical treatments. Preterm labor seems to be an important complication in pregnancies with UTIs going together with fever and urination problems.

Genetic redundancy and persistence of plasmid-mediated trimethoprim/sulfamethoxazole resistant effluent and stream water Escherichia coli

Antibiotic resistant bacteria may persist in effluent receiving surface water in the presence of low (sub-inhibitory) antibiotic concentrations if the bacteria possess multiple genes encoding resistance to the same antibiotic. This redundancy of antibiotic resistance genes may occur in plasmids harboring conjugation and mobilization (mob) and integrase (intI) genes. Plasmids extracted from 76 sulfamethoxazole-trimethoprim resistant Escherichia coli originally isolated from effluent and an effluent-receiving stream were used as DNA template to identify sulfamethoxazole (sul) and trimethoprim (dfr) resistances genes plus detect the presence of intI and mob genes using PCR. Sulfamethoxazole and trimethoprim resistance was plasmid-mediated with three sul (sul1, sul2 and sul3 genes) and four dfr genes (dfrA12, dfrA8, dfrA17, and dfrA1 gene) the most prevalently detected. Approximately half of the plasmids carried class 1 and/or 2 integron and, although unrelated, half were also transmissible. Sampling site in relationship to effluent input significantly affected the number of intI and mob but not the number of sul and dfr genes. In the presence of low (sub-inhibitory) sulfamethoxazole concentration, isolates persisted regardless of integron and mobilization gene designation, whereas in the presence of trimethoprim, the presence of both integron and mobilization genes made isolates less persistent than in the absence of both or the presence of a gene from either group individually. Regardless, isolates persisted in large concentrations throughout the experiment. Treated effluent containing antibiotic resistant bacteria may be an important source of integrase and mobilization genes into the stream environment. Sulfamethoxazole-trimethoprim resistant bacteria may have a high degree of genetic redundancy and diversity carrying resistance to each antibiotic, although the role of integrase and mobilization genes towards persistence is unclear.

ANTIMICROBIAL RESISTANCE OF ESCHERICHIA COLI STRAINS ISOLATED FROM URINE AT OUTPATIENT POPULATION: A SINGLE LABORATORY EXPERIENCE

Objectives:

The aim of this study was to examine antimicrobial resistance of Escherichia coli strains isolated from urine in outpatient population.

Material and methods:

We performed a retrospective study for tree months period, between January 1^st and March 31^st, 2015, at the Department of Microbiology and Parasitology, Faculty of Medicine, University of Sarajevo. We determined the E. coli antimicrobial resistance in 556 first urine samples from outpatient population of Hrasno community in Sarajevo, Bosnia and Herzegovina. E. coli is the most frequent agent causing urinary tract infections in outpatients as well. The standard methods of descriptive statistics were performed for data analysis.

Results:

We observed the highest antimicrobial resistance of E. coli for ampicillin (82,79%), followed by trimethoprim-sulfamethoxazole (40,86%), nalidixic acid (19,35%), cephazolin (7,52%), nitrofurantoin (5,37%), gentamicin (2,15%) and ciprofloxacin (4,30%).

Conclusions:

The results of study showed that E. coli has the highest resistance to ampicillin and trimethoprim-sulfamethoxazole in outpatient population of Hrasno community.

Origin and Dissemination of Antimicrobial Resistance among Uropathogenic Escherichia coli

Antimicrobial agents of various types have important bearing on the outcomes of microbial infections. These agents may be bacteriostatic or –cidal, exert their impact via various means, originate from a living organism or a laboratory, and appropriately be used in or on living tissue or not. Though the primary focus of this chapter is on resistance to the antimicrobial agents used to treat uropathogenic Escherichia coli (UPEC)-caused urinary tract infections (UTIs), some attention will be given to UPEC’s resistance to silver-containing antiseptics, which may be incorporated into catheters to prevent foreign body-associated UTIs.

UV-Vis spectroscopic study and DFT calculation on the solvent effect of trimethoprim in neat solvents and aqueous mixtures

The solvatochromic behavior of trimethoprim (TMP) was analyzed using UV-Vis spectroscopy and DFT methods in neat and binary aqueous solvent mixtures. The effects of solvent dipolarity/polarizability and solvent-solute hydrogen bonding interactions on the absorption maxima were evaluated by means of the linear solvation energy relationship concept of Kamlet and Taft. This analysis indicated that both interactions play an important role in the position of the absorption maxima in neat solvents. The simulated absorption spectra of TMP and TMP:(solvent)n complexes in ACN and H2O using TD-DFT methods were in agreement with the experimental ones. Binary aqueous mixtures containing as co-solvents DMSO, ACN and EtOH were studied. Preferential solvation was detected as a nonideal behavior of the wavenumber curve respective to the analytical mole fraction of co-solvent in all binary systems. TMP molecules were preferentially solvated by the organic solvent over the whole composition range. Index of preferential solvation, as well as the influence of solvent parameters were calculated as a function of solvent composition.

Short- and long-term cure rates of short-duration trimethoprim-sulfamethoxazole treatment in female dogs with uncomplicated bacterial cystitis

Background

Long‐duration beta‐lactam antibiotics are used for empirical treatment in female dogs with uncomplicated bacterial cystitis. However, women with bacterial cystitis are treated with short‐duration potentiated sulfonamides because longer courses of beta‐lactams result in lower cure and higher recurrence rates.

Hypothesis/Objectives

Short‐duration potentiated sulfonamide treatment is more efficacious than long‐duration beta‐lactam treatment in achieving clinical and microbiological cures in female dogs with uncomplicated bacterial cystitis.

Animals

Thirty‐eight client‐owned female dogs.

Methods

Randomized, double‐blinded, placebo‐controlled clinical trial. Dogs were treated with TMP‐SMX (15 mg/kg PO q12h for 3 days followed by a placebo capsule PO q12h for 7 days; Group SDS; n = 20) or cephalexin (20 mg/kg PO q12h for 10 days; Group LDBL; n = 18). Dogs were monitored for clinical and microbiological cure during treatment and at short‐ and long‐term follow‐up.

Results

No statistically significant differences were found between treatment groups in clinical cure rates after 3 days of treatment (89% SDS, 94% LDBL; P = 1.00) and 4 days (85% SDS, 72% LDBL; P = .44) or >30 days (50% SDS, 65% LDBL; P = .50) after conclusion of treatment or in microbiological cure rates 4 days (59% SDS, 36% LDBL; P = .44) or >30 days (44% SDS, 20% LDBL; P = .40) after conclusion of treatment.

Conclusions and Clinical Importance

We did not identify a difference in cure rates between short‐duration sulfonamide and long‐duration beta‐lactam treatments in female dogs with uncomplicated cystitis. Long‐term cure rates in both treatment groups were low. In some female dogs, “uncomplicated” bacterial cystitis may be more complicated than previously recognized.

Application of probabilistic and fuzzy cognitive approaches in semantic web framework for medical decision support

This study aimed to focus on medical knowledge representation and reasoning using the probabilistic and fuzzy influence processes, implemented in the semantic web, for decision support tasks. Bayesian belief networks (BBNs) and fuzzy cognitive maps (FCMs), as dynamic influence graphs, were applied to handle the task of medical knowledge formalization for decision support. In order to perform reasoning on these knowledge models, a general purpose reasoning engine, EYE, with the necessary plug-ins was developed in the semantic web. The two formal approaches constitute the proposed decision support system (DSS) aiming to recognize the appropriate guidelines of a medical problem, and to propose easily understandable course of actions to guide the practitioners. The urinary tract infection (UTI) problem was selected as the proof-of-concept example to examine the proposed formalization techniques implemented in the semantic web. The medical guidelines for UTI treatment were formalized into BBN and FCM knowledge models. To assess the formal models' performance, 55 patient cases were extracted from a database and analyzed. The results showed that the suggested approaches formalized medical knowledge efficiently in the semantic web, and gave a front-end decision on antibiotics' suggestion for UTI.

Fuzzy cognitive map software tool for treatment management of uncomplicated urinary tract infection

Uncomplicated urinary tract infection (uUTI) is a bacterial infection that affects individuals with normal urinary tracts from both structural and functional perspective. The appropriate antibiotics and treatment suggestions to individuals suffer of uUTI is an important and complex task that demands a special attention. How to decrease the unsafely use of antibiotics and their consumption is an important issue in medical treatment. Aiming to model medical decision making for uUTI treatment, an innovative and flexible approach called fuzzy cognitive maps (FCMs) is proposed to handle with uncertainty and missing information. The FCM is a promising technique for modeling knowledge and/or medical guidelines/treatment suggestions and reasoning with it. A software tool, namely FCM-uUTI DSS, is investigated in this work to produce a decision support module for uUTI treatment management. The software tool was tested (evaluated) in a number of 38 patient cases, showing its functionality and demonstrating that the use of the FCMs as dynamic models is reliable and good. The results have shown that the suggested FCM-uUTI tool gives a front-end decision on antibiotics' suggestion for uUTI treatment and are considered as helpful references for physicians and patients. Due to its easy graphical representation and simulation process the proposed FCM formalization could be used to make the medical knowledge widely available through computer consultation systems.

Prevalence of antimicrobial resistance and integrons in Escherichia coli from Punjab, Pakistan

Antimicrobial resistance was studied in Escherichia coli strains isolated from urine samples of 457 patients suffering from urinary tract infection. High prevalence of class 1 integrons (43.56%), sulfamethoxazole resistance genes sul1 (45.54%) and sul2 (51.48%) along with occurrence of quinolone resistance genes was detected in multi drug resistance isolates.

Symptomatic therapy and neurorehabilitation in multiple sclerosis

Multiple sclerosis (MS) is associated with a variety of symptoms and functional deficits that result in a range of progressive impairments and handicap. Symptoms that contribute to loss of independence and restrictions in social activities lead to continuing decline in quality of life. Our aim is to give an updated overview on the management of symptoms and rehabilitation measures in MS. Appropriate use of these treatment options might help to reduce long-term consequences of MS in daily life. First, we review treatment of the main symptoms of MS: fatigue, bladder and bowel disturbances, sexual dysfunction, cognitive and affective disorders, and spasticity. Even though these symptomatic therapies have benefits, their use is limited by possible side-effects. Moreover, many common disabling symptoms, such as weakness, are not amenable to drug treatment. However, neurorehabilitation has been shown to ease the burden of these symptoms by improving self-performance and independence. Second, we discuss comprehensive multidisciplinary rehabilitation and specific treatment options. Even though rehabilitation has no direct influence on disease progression, studies to date have shown that this type of intervention improves personal activities and ability to participate in social activities, thereby improving quality of life. Treatment should be adapted depending on: the individual patient's needs, demands of their surrounding environment, type and degree of disability, and treatment goals. Improvement commonly persists for several months beyond the treatment period, mostly as a result of reconditioning and adaptation and appropriate use of medical and social support at home. These findings suggest that quality of life is determined by disability and handicap more than by functional deficits and disease progression.

Piperitone fromMentha longifolia var.chorodictya Rech F. reduces the nitrofurantoin resistance of strains of enterobacteriaceae

The diluted essential oil of Mentha longifolia (L.) var. chlorodictya Rech F. foliage enhanced the bactericidal activity of nitrofurantoin decreasing the minimum inhibitory concentration (MIC) of nitrofurantoin for nitrofurantoin-resistant strains of Enterobacteriaceae. Thin-layer chromatography (TLC) analysis of the essential oil detected a fraction (R(f) = 0.35, UV lambda(max) of 232.5), which was the most effective in enhancement of nitrofurantoin activity. Using gas liquid chromatography and known standards, the active fraction was identified as piperitone. 1 microl of the piperitone fraction decreased the MIC of nitrofurantoin 3-20 fold for the different strains of Enterobacteriaceae tested.