Fewer bacterial relapses after oral treatment with norfloxacin than with ceftibuten in acute pyelonephritis initially treated with intravenous cefuroxime

Cephalosporins for the treatment of uncomplicated pyelonephritis: A systematic review

BACKGROUND

The 2011 Infectious Diseases Society of America and European Society of Clinical Microbiology and Infectious Diseases guidelines recommend ciprofloxacin or sulfamethoxazole-trimethoprim (SMX-TMP) as first-line agents to treat uncomplicated acute pyelonephritis (APN).

OBJECTIVE

With increasing antimicrobial resistance rates and recent changes in practice patterns, the objective of this systematic review was to describe the effectiveness of cephalosporins for uncomplicated APN in more recently published literature.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for reporting. We searched PubMed, Embase, and Scopus for publications between January 2010 and September 2022. Eligible articles detailed patients with uncomplicated APN, treated with first- to fourth-generation cephalosporins, and identified a clinical, microbiological, or health care utilization outcome. Studies with more than 30% of complicated APN patients, non-English-language studies, case reports, case series, pharmacodynamic or pharmacokinetic studies, and in vitro laboratory or animal studies were excluded. Screening, review, and extraction were performed independently by 2 researchers, plus a third for conflict resolution. Critical appraisal of studies was performed using Joanna Briggs Institute checklists.

RESULTS

Eight studies met inclusion, including 5 cohort studies (62.5%), 2 randomized controlled trials (25%), and 1 nonrandomized experimental study (12.5%). Cephalosporins most used across the studies included cefazolin, cephalexin, cefuroxime, cefotaxime, cefdinir, cefditoren, and ceftriaxone. Outcomes assessed were diverse, including clinical or microbiological success and time to defervescence or symptom resolution. Cephalosporins displayed effectiveness for the treatment of acute uncomplicated APN regardless of study design or the presence of a comparison group. No trials reported inferiority of clinical treatment outcomes compared with a fluoroquinolone or SMX-TMP.

CONCLUSION

Cephalosporins may be viable treatment options for the management of uncomplicated APN.

Oral β-lactams vs fluoroquinolones and trimethoprim/sulfamethoxazole for step-down therapy for Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae bacteremia

PURPOSE

To compare rates of treatment failure for patients with bloodstream infections (BSIs) due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis who received oral step-down antibiotic therapy with either a fluoroquinolone (FQ) or trimethoprim/sulfamethoxazole (SXT) to rates for those who received an oral β-lactam (BL).

METHODS

This retrospective, multicenter, cohort study included 397 unique adult hospitalized patients with a BSI due to E. coli, K. pneumoniae, or P. mirabilis at 6 hospitals in central Texas between July 11, 2016, and July 11, 2018. The primary outcome was a composite of treatment failure comprising 30-day readmission due to recurrence, 30-day all-cause mortality, and change in oral antibiotic. Secondary outcomes included 90-day development of Clostridioides difficile infection, 90-day colonization with a multidrug-resistant organism, 90-day all-cause readmission, hospital length of stay, and the individual components of the primary outcome.

RESULTS

Of the 397 patients included, 200 received oral step-down therapy with a BL while 197 received an FQ or SXT. Most patients had an infection due to E. coli (82.8%) and a urinary source of infection (85%). Median total duration of therapy was 14 days in both groups. No difference in treatment failure was identified between the groups treated with a BL and FQ/SXT (7% vs 5.8%, P = 0.561). Median hospital length of stay was the only secondary endpoint in which there was an observed difference (6 vs 5 days, P = 0.04).

CONCLUSION

We observed no difference in treatment failure rates for patients receiving an oral BL compared to an oral FQ or SXT for step-down therapy of BSIs due to E. coli, K. pneumoniae, and P. mirabilis.

The Problem of Occult Pyelonephritis: Acute Pyelonephritis in Patients Presenting Only with Lower Urinary Tract Symptoms

Pyelonephritis is a prevalent diagnosis of emergency department visits. It commonly presents as flank pain and costovertebral tenderness with urinary symptoms. However, some cases occur without typical symptoms. Our study highlights the dubious presentation of pyelonephritis with lower urinary tract symptoms (LUTS) only. This study was conducted at a tertiary care hospital, where charts and files were reviewed from January 11, 2018 to February 28, 2019 for all the patients with a diagnosis of acute pyelonephritis from medical records. In our study, 521 patients were included and 492 (94%) of the participants were suffering from pyelonephritis. Approximately 22.8% of the patients showed the absence of both flank pain and costovertebral tenderness but were diagnosed with pyelonephritis based on computed tomography (CT) and magnetic resonance imaging (MRI). Moreover, 27% of the patients reported upper urinary tract symptoms only and were diagnosed by CT or MRI findings. Out of that only 24% and 16% of the patients reported flank pain and costovertebral tenderness, respectively. Insignificant associations with pyelonephritis were found for age, gender and other comorbidities. Our study showed a significant number of patients with pyelonephritis without any upper urinary tract symptoms. Patients with LUTS should be evaluated further by imaging if they belong to the high-risk population.

A retrospective review of oral cephalosporins versus fluoroquinolones for the treatment of pyelonephritis

Background

The current Infectious Diseases Society of America guidelines for the treatment of acute uncomplicated pyelonephritis (AUP) advise caution when using oral beta-lactams due to concern for potentially inferior efficacy compared to fluoroquinolones (FQs) and trimethoprim-sulfamethoxazole; however, studies specifically evaluating the efficacy of oral cephalosporins (CPs) in AUP are limited.

Objective

To assess the safety and efficacy of oral CPs versus FQs for the treatment of AUP.

Design, setting and participants

This is a retrospective, chart review study conducted at a single-center, tertiary care hospital.

Measurements

The primary endpoint was treatment failure within 30 days, defined as a change in antibiotic or return to ED or clinic due to persistent symptoms. Secondary endpoints included adverse drug reactions (ADRs) and C. difficile infection (CDI) within 30 days.

Results

Of the 343 patients included in the study, treatment failure occurred in 54/338 (16.0%) patients and was similar between oral CPs and FQs (35/229 [15.3%] vs. 19/109 [17.4%]). A higher percentage of treatment failures were observed for third generation (3GC) and first generation (1GC) CPs compared to second generation CPs (2GC) (3GC: 15/65 [23.4%]; 1GC: 11/49 [22.4%]; 2GC: 9/115 [7.8%]). Documented ADRs were low (6/343 [1.7%]) and no cases of CDI were documented.

Conclusions

Oral CPs appear to be as safe and effective as FQs for the treatment of AUP. Fewer treatment failures were noted with 2GCs as compared to 3GCs and 1GCs.

The efficacy of pivmecillinam in oral step-down treatment in hospitalised patients with E. coli bacteremic urinary tract infection; a single-arm, uncontrolled treatment study

BACKGROUND

The role of oral beta-lactam antibiotics in treating febrile urinary tract infections (UTI) is not yet definite. Today, fluoroquinolones together with trimethoprim-sulfamethoxazole (TMP-MTX) are considered standard of care and often the only available evidence-based oral treatment for febrile UTI. This study clarifies the efficacy and safety of pivmecillinam (PIV) used as step-down therapy for bacteremic urinary tract infection (UTI).

METHODS

A single-arm, uncontrolled treatment trial was conducted in the period September 2017-March 2020. Candidates for inclusion were men and women suffering from E. coli bacteremia due to UTI and were consecutively included in a Norwegian hospital. Exclusion criteria were among others: other ongoing bacterial infection, septic shock, pyonephrosis/abscess and pregnancy. After 3 days of parenteral antibiotic, the treatment was converted to the study drug; oral PIV 400 mg QID for 1 week. Primary endpoint was a combination of three elements; afebrility, no need for retreatment and improvement in self-reported health status. Test Of Cure (TOC) was 1 week post-treatment. Secondary endpoints included among others microbiological efficacy and CRP value < 30 mg/L.

RESULTS

Of 476 screened subjects, 53 patients were included. Median age was 67 years, 28 (56%) were women. 50 patients were evaluated for per-protocol analysis. 44 of 50 patients (88%) (95% CI [75.7-95.5]) reached the primary endpoint on TOC. 14 of 48 patients (29.2%) had significant growth (> 103 CFU/mL) of E.coli on TOC. CRP-level was strongly associated to treatment outcome, (OR 0.006 [95% CI 0.00-0.11], p < 0.001).

CONCLUSIONS

This trial documents that PIV 400 mg QID given for 1 week following 3 days of parenteral antibiotics, is a suitable treatment option in patients suffering from bacteremic UTI due to E. coli. Randomised clinical trials studying the efficacy of PIV vs standard of care of febrile UTI are warranted. Trial registration The trial was registered at ClinicalTrials.gov under the identifier: NCT03282006 13/09/2017 and approved by The Regional Committees for Medical Research Ethics South East Norway (2015/2384/REK sør-øst) and the Norwegian Medicines Agency (SLV; reference No 16/06018-09; EudraCT No 2016-000984-18) before initiation.

Is Piperacillin-Tazobactam Effective for the Treatment of Pyelonephritis Caused by Extended-Spectrum β-Lactamase-Producing Organisms?

BACKGROUND

Limited data exist regarding the efficacy of piperacillin-tazobactam (TZP) for the management of nonbacteremic pyelonephritis caused by extended-spectrum β-lactamase (ESBL)-producing organisms.

METHODS

We conducted a multicenter observational study comparing clinical outcomes of adults hospitalized with ESBL-producing pyelonephritis who were receiving TZP versus carbapenems, using an inverse probability of treatment weighted propensity score analysis. Patients were eligible for inclusion if all of the following criteria were met: (1) urine cultures growing Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, or Proteus mirabilis at ≥50 000 colony-forming units/mL; (2) identification of an ESBL gene; (3) pyuria (≥10 white blood cells per high powered field in the urine); and (4) dysuria and fever plus at least 1 of the following symptoms: emesis, rigors, hypotension, or flank pain.

RESULTS

There were 186 patients included in the propensity score-weighted cohort; 45 (24%) received TZP and 141 (76%) received a carbapenem. Of these 186 patients, 27% were admitted to the intensive care unit, 48% were immunocompromised, and 45% had underlying urologic abnormalities. There were no differences between the 2 groups in the proportion of patients (20% vs 25%) with recurrent cystitis or pyelonephritis with the same ESBL-producing organism within 30 days (odds ratio, 0.75; 95% confidence interval, .31-1.81; P = .52). There were no differences in the resolution of clinical symptoms by Day 7 or in 30-day mortality. There was 1 (2%) patient in the TZP arm and 11 (8%) patients in the carbapenem arm who had incident carbapenem-resistant organisms isolated within 30 days (P = .09).

CONCLUSIONS

TZP may be a reasonable alternative to carbapenems for the management of ESBL-producing pyelonephritis and may mitigate the risk of emergence of carbapenem-resistant organisms, compared with carbapenem therapy.

Comparative Effectiveness of Antibiotic Treatment Duration in Children With Pyelonephritis

IMPORTANCE

National guidelines recommend treating children with pyelonephritis for 7 to 14 days of antibiotic therapy, yet data are lacking to suggest a more precise treatment duration.

OBJECTIVE

To compare the clinical outcomes of children receiving a short-course vs a prolonged-course of antibiotic treatment for pyelonephritis.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective observational study using inverse probability of treatment weighted propensity score analysis of data from 5 hospitals in Maryland between July 1, 2016, and October 1, 2018. Participants were children aged 6 months to 18 years with a urine culture growing Escherichia coli, Klebsiella species, or Proteus mirabilis with laboratory and clinical criteria for pyelonephritis.

EXPOSURES

Treatment of pyelonephritis with a short-course (6 to 9 days) vs a prolonged-course (10 or more days) of antibiotics.

MAIN OUTCOMES AND MEASURES

Composite outcome of treatment failure within 30 days of completing antibiotic therapy: (a) unanticipated emergency department or outpatient visits related to urinary tract infection symptoms, (b) hospital readmission related to UTI symptoms, (c) prolongation of the planned, initial antibiotic treatment course, or (d) death. A subsequent urinary tract infection caused by a drug-resistant bacteria within 30 days was a secondary outcome.

RESULTS

Of 791 children who met study eligibility criteria (mean [SD] age 9.2 [6.3] years; 672 [85.0%]) were girls, 297 patients (37.5%) were prescribed a short-course and 494 patients (62.5%) were prescribed a prolonged-course of antibiotics. The median duration of short-course therapy was 8 days (interquartile range, 7-8 days), and the median duration of prolonged-course therapy was 11 days (interquartile range, 11-12 days). Baseline characteristics were similar between the groups in the inverse probability of treatment weighted cohort. There were 79 children (10.1%) who experienced treatment failure. The odds of treatment failure were similar for patients prescribed a short-course vs a prolonged-course of antibiotics (11.2% vs 9.4%; odds ratio, 1.22; 95% CI, 0.75-1.98). There was no significant difference in the odds of a drug-resistant uropathogen for patients with a subsequent urinary tract infection within 30 days when prescribed a short-courses vs prolonged-course of antibiotics (40% vs 64%; odds ratio, 0.36; 95% CI, 0.09-1.43).

CONCLUSIONS AND RELEVANCE

The study findings suggest that short-course antibiotic therapy may be as effective as prolonged-courses for children with pyelonephritis, and may mitigate the risk of future drug-resistant urinary tract infections. Additional studies are needed to confirm these findings.

Evaluation and Management of Urinary Tract Infection in the Emergency Department

Urinary tract infection (UTI) affects patients of all ages and is a diagnosis that emergency physicians might make multiple times per shift. This article reviews the evaluation and management of patients with infections of the urinary tract. Definitions of asymptomatic bacteriuria, uncomplicated UTI, and complicated UTI are presented, as well as techniques for distinguishing them. The pathophysiology and clinical and laboratory diagnoses of UTI are described. Treatment of UTI is reviewed, with attention to bacteriuria and special populations, including pregnant, elderly/geriatric, and spinal cord injury patients.

Pyelonephritis treatment in the community emergency department: Cephalosporins vs. first-line agents

OBJECTIVE

The purpose of this study was to assess treatment with a fluoroquinolone or trimethoprim-sulfamethoxazole versus cephalosporins for pyelonephritis in discharged patients from a community hospital setting.

METHODS

A retrospective chart review was completed for adult female patients who received a prescription for a cephalosporin, fluoroquinolone or trimethoprim-sulfamethoxazole for the treatment of pyelonephritis within the network of a large healthcare system. The primary endpoint evaluated the failure rate of each treatment group. The secondary endpoint evaluated the difference between rates of resistance on culture and sensitivity reports for treatment groups.

RESULTS

A total of 55 patients in the cephalosporin group and 43 patients in the fluoroquinolone and trimethoprim-sulfamethoxazole group were reviewed. The primary endpoint occurred in 0% of the patients in the cephalosporin group and in 23% of the patients in the fluoroquinolone and trimethoprim-sulfamethoxazole group, p < 0.001. Of the 98 urine samples collected, 71 samples were positive for pathogen growth. Upon evaluation of these isolates, 6% were resistant to cephalexin, 1% was resistant to cefdinir, 3% were resistant to ciprofloxacin and 23% were resistant to trimethoprim-sulfamethoxazole. Trimethoprim-sulfamethoxazole showed statistical significance for more bacterial resistance compared to the other agents, p < 0.01.

CONCLUSION

Failure of therapy for pyelonephritis occurred more often in the fluoroquinolone and trimethoprim-sulfamethoxazole group than in the cephalosporin group. The findings in this study are most applicable to patients who are treated on an outpatient basis. A prospective, randomized clinical trial is necessary to confirm these results.

Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections

Urinary tract infections (UTIs) are infectious diseases that commonly occur in communities. Although several international guidelines for the management of UTIs have been available, clinical characteristics, etiology and antimicrobial susceptibility patterns may differ from country to country. This work represents an update of the 2011 Korean guideline for UTIs. The current guideline was developed by the update and adaptation method. This clinical practice guideline provides recommendations for the diagnosis and management of UTIs, including asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. This guideline targets community-acquired UTIs occurring among adult patients. Healthcare-associated UTIs, catheter-associated UTIs, and infections in immunocompromised patients were not included in this guideline.

Clostridium difficile infection following systemic antibiotic administration in randomised controlled trials: a systematic review and meta-analysis

Antibiotics have been the most important risk factor for Clostridium difficile infection (CDI). However, only data from non-randomised studies have been reviewed. We sought to evaluate the risk for development of CDI associated with the major antibiotic classes by analysing data from randomised controlled trials (RCTs). The PubMed, Cochrane and Scopus databases were searched and the references of selected RCTs were also hand-searched. Eligible studies should have compared only one antibiotic versus another administered systemically. Inclusion of studies comparing combinations of antibiotics was allowed only if the second antibiotic was the same or from the same class or if it was administered in a subset of the enrolled patients who were equally distributed in the two arms. Only a minority of the selected RCTs (79/1332; 5.9%) reported CDI episodes. Carbapenems were associated with more CDI episodes than fluoroquinolones [risk ratio (RR) = 2.44, 95% confidence interval (CI) 1.32-4.49] and cephalosporins (RR = 2.24, 95% CI 1.46-3.42), but not penicillins (RR = 2.53, 95% CI 0.87-7.41). Cephalosporins were associated with more CDIs than penicillins (RR = 2.36, 95% CI 1.32-4.23) and fluoroquinolones (RR = 2.84, 95% CI 1.60-5.06). There was no difference in CDI frequency between fluoroquinolones and penicillins (RR = 1.34, 95% CI 0.55-3.25). Finally, clindamycin was associated with more CDI episodes than cephalosporins and penicillins (RR = 3.92, 95% CI 1.15-13.43). In conclusion, data from RCTs showed that clindamycin and carbapenems were associated with more CDIs than other antibiotics.

Resistance Patterns of Escherichia coli in Women with Uncomplicated Urinary Tract Infection Do Not Correlate with Emergency Department Antibiogram

BACKGROUND

Urine cultures are not always performed for female Emergency Department (ED) patients with uncomplicated urinary tract infection (UTI). Accordingly, hospital, and even ED-specific, antibiograms might be skewed toward elderly patients with many comorbidities and relatively high rates of antimicrobial resistance, and thus do not accurately reflect otherwise healthy women. Our ED antibiogram indicates Escherichia coli resistance rates for ciprofloxacin, levofloxacin, and trimethoprim-sulfamethoxazole (TMP-SMX) of 42%, 26%, and 33%, respectively.

OBJECTIVES

This study aims to compare resistance rates of urinary E. coli from otherwise healthy women with uncomplicated UTI and pyelonephritis in the ED to rates in our ED antibiogram.

METHODS

Females > 18 years old with acute onset of urinary frequency, urgency, or dysuria with pyuria identified on urinalysis (white blood cell count > 10/high-power field) were prospectively enrolled in the ED of an urban, academic medical center. Exclusion criteria indicating a complicated UTI were consistent with Infectious Diseases Society of America guidelines. Susceptibility patterns of E. coli to ciprofloxacin, levofloxacin, and TMP-SMX in the study group were compared to our ED antibiogram.

RESULTS

Forty-five patients grew E. coli. Pyelonephritis was suspected in nine (20%) subjects. Compared with the ED antibiogram, significantly lower rates of resistance to ciprofloxacin (2% vs. 42%, p < 0.001), levofloxacin (2% vs. 26%, p < 0.001), and TMP-SMX (16% vs. 33%, p = 0.016) were observed. Six patients grew non-E. coli uropathogens. All were susceptible to both levofloxacin and TMP-SMX.

CONCLUSIONS

ED antibiograms may overestimate resistance rates for uropathogens causing uncomplicated UTIs. In cases where nitrofurantoin cannot be used, fluoroquinolones and possibly TMP-SMX may remain viable options for treatment of uncomplicated UTI and pyelonephritis in women.

Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial

BACKGROUND

Acute pyelonephritis is a common infection in adult women, but there is a paucity of controlled trials of its treatment and the optimum duration of antibiotic treatment has not been properly defined. We compared the efficacy of ciprofloxacin for 7 days and 14 days in women with community-acquired acute pyelonephritis.

METHODS

In a prospective, non-inferiority trial undertaken at 21 centres of infectious diseases in Sweden, women (aged ≥18 years) who were not pregnant and had a presumptive diagnosis of acute pyelonephritis were randomly assigned to oral treatment with ciprofloxacin 500 mg twice daily for 7 days or 14 days. The first week was open label. A computer-generated randomisation list in block sizes of two was used for treatment allocation in a 1:1 ratio. The study was double-blind and placebo-controlled during the second week of treatment, which was either continuation of ciprofloxacin 500 mg or placebo tablets twice daily according to the randomisation code. Patients, carers, site investigators, and trial coordinating centre staff were masked to group assignment. The primary endpoint was the clinical and bacteriological outcome 10-14 days after completion of treatment with active drug. Analysis was by per protocol. This trial is registered with EudraCT, number 2005-004992-39, and ClinicalTrials.gov, number ISRCTN73338924.

FINDINGS

126 of 248 patients were randomly assigned to 7 days and 122 to 14 days of ciprofloxacin. 73 and 83 patients, respectively, were analysed. Short-term clinical cure occurred in 71 (97%) patients treated with ciprofloxacin for 7 days and 80 (96%) treated for 14 days (difference -0·9%; 90% CI -6·5 to 4·8; p=0·004; non-inferiority test). Cumulative efficacy at long-term follow-up was 93% in each group (68 of 73 vs 78 of 84; -0·3%; -7·4 to 7·2; p=0·015). Both regimens were well tolerated. Two patients discontinued ciprofloxacin because of myalgia with 7 days of treatment and itching exanthema with 14 days. Four (5%) of 86 patients assigned to 7 days of treatment who complied with study criteria and six (6%) of 93 assigned to 14 days reported an adverse event after the first week of treatment that was possibly or probably related to the study drug. In those assigned to 7 days, no patient had mucosal candida infection after the first week versus five treated for 14 days (p=0·036).

INTERPRETATION

Our results show that acute pyelonephritis in women, including older women and those with a more severe infection, can be treated successfully and safely with oral ciprofloxacin for 7 days. Short courses of antibiotics should be favoured in an era of increasing resistance.

FUNDING

Swedish Strategic Programme against Antibiotic Resistance (Strama).

Treatment duration of febrile urinary tract infections

Although febrile urinary tract infections (UTIs) are relatively common in adults, data on optimal treatment duration are limited. Randomized controlled trials specifically addressing the elderly and patients with comorbidities have not been performed. This review highlights current available evidence. Premenopausal, non-pregnant women without comorbidities can be treated with a 5–7 day regimen of fluoroquinolones in countries with low levels of fluoroquinolone resistance, or, if proven susceptible, with 14 days of trimethoprim-sulfamethoxazole. Oral β-lactams are less effective compared with fluoroquinolones and trimethoprim-sulfamethoxazole. In men with mild to moderate febrile UTI, a 2-week regimen of an oral fluoroquinolone is likely sufficient. Although data are limited, this possibly holds even in the elderly patients with comorbidities or bacteremia.

Antibiotic treatment of uncomplicated urinary tract infection in premenopausal women

Uncomplicated urinary tract infections (UTIs) in otherwise healthy premenopausal women are one of the most frequent infections in the community. Therefore any improvement in management will have a high impact not only on the quality of life of the individual patient but also on the health system. In placebo-controlled studies antimicrobial treatment was significantly more effective than placebo, but on the other hand showed more adverse events. The choice of antibiotic depends on the spectrum and susceptibility patterns of the uropathogens, its effectiveness for this indication, its tolerability, its collateral effects and cost. After a systematic literature search, recommendations for empiric treatment of acute uncomplicated cystitis and acute uncomplicated pyelonephritis and for follow-up strategies were developed.

International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases–Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

An update on uncomplicated urinary tract infections in women

PURPOSE OF REVIEW

Urinary tract infections (UTIs) in women comprise uncomplicated and complicated UTIs. Uncomplicated UTIs, such as acute uncomplicated cystitis and pyelonephritis, are very common infections in otherwise healthy women, with a high tendency to recur. Although severe complications are rare, their high prevalence causes remarkable costs in the healthcare systems.

RECENT FINDINGS

As most scientific evidence has been gathered in uncomplicated UTI, this study focuses on recent developments in epidemiology, pathogenesis, cause, diagnosis, treatment and prevention of uncomplicated UTI and recurrent UTI in women.

SUMMARY

A remarkable increase of antibiotic resistance is also noted in uncomplicated UTI. Therefore, prudent use of antibiotic substances in uncomplicated UTI is increasingly important.

Ceftibuten versus trimethoprim-sulfamethoxazole for oral treatment of febrile urinary tract infection in children

A randomized, open, coordinated multi-center trial compared the bacteriological and clinical efficacy and safety of orally administered ceftibuten and trimethoprim-sulfamethoxazole (TMP-SMX) in children with febrile urinary tract infection (UTI). Children aged 1 month to 12 years presenting with presumptive first-time febrile UTI were eligible for enrollment. A 2:1 assignment to treatment with ceftibuten 9 mg/kg once daily (n = 368) or TMP-SMX (3 mg + 15 mg)/kg twice daily (n = 179) for 10 days was performed. Escherichia coli was recovered in 96% of the cases. Among the E. coli isolates, 14% were resistant to TMP-SMX but none to ceftibuten. In the modified intention-to-treat population, the bacteriological elimination rates at follow-up did not differ significantly between patients treated with ceftibuten and those treated with TMP-SMX [91 vs. 95%, with a 95% confidence interval (CI) for difference of -9.7 to 1.0]. However, the clinical cure rate was significantly higher among those treated with ceftibuten (93 vs. 83%, with a 95% CI for difference of 2.4 to 17.0). Adverse events were similar for both regimens and consisted mainly of gastrointestinal disturbances. In conclusion, ceftibuten is a safe and effective drug for the empirical treatment of febrile UTI in young children.

The clinical spectrum of acute 'uncomplicated' pyelonephritis from an emergency medicine perspective

Acute uncomplicated pyelonephritis (APN) is a complex clinical entity, which is defined differently based on clinical or imaging criteria. The aim of this study was to describe the clinical and radiological presentation of APN-upper urinary tract infection (UTI) cases observed between May 2005 and June 2006 and hospitalised in the Emergency Medicine ward of San Luigi Hospital, Orbassano, Turin, Italy. All patients underwent imaging scans and were differentiated on the basis of parenchymal involvement. Of around 45000 patient visits to the emergency room between May 2005 and June 2006, 23 patients were diagnosed as having uncomplicated upper UTI (all female, age 15-57 years). Renal parenchymal involvement was confirmed by imaging in 16 cases (69.6%). The imaging spectrum ranged from a small single lesion to large multiple defects; on admission, 2 cases had no pain and 2 had no fever; lower urinary tract symptoms were present in only 13 patients (7 with parenchymal involvement). All patients with parenchymal involvement had at least one sign of systemic inflammation-infection. Most patients (15) had taken antibiotics before hospitalisation; consequently, urine cultures were negative in 21 cases (14 cases with positive imaging (87.5%)). The data from patients with and without parenchymal involvement overlapped, the only difference being a higher prevalence of high CRP levels in cases with parenchymal involvement.

Antibiotic treatment for acute 'uncomplicated' or 'primary' pyelonephritis: a systematic, 'semantic revision'

The definition of acute pyelonephritis is controversial. There are two contrasting approaches: (1) acute pyelonephritis is a severe infectious disease involving the kidney parenchyma, and specific imaging techniques are required for diagnosis; (2) acute pyelonephritis is a urinary tract infection, and diagnosis and therapy follow simplified clinical and laboratory pathways. In this study, recent randomized controlled trials (RCTs) were systematically reviewed and the diagnostic and therapeutic approaches to acute 'uncomplicated' pyelonephritis were analysed. Medline, Embase, Cochrane Central Register of Controlled Trials (CCTR) and Chinal were searched employing Mesh, Emtree and free terms on 'pyelonephritis'. Limits included human, period (1995-2004), and trials-reviews (where available). In total, 904 references and 175 full-text were retrieved; 29 were pertinent RCTs. Seven RCTs were added from reference lists (indexed on urinary tract infections). Imaging examinations were performed in 11 of 14 studies on children (diagnostic requisite in two) and in two studies on adults; scarring was not analysed in adults. Clinical definitions varied widely (fever >37.8 to >39 degrees C, culture titres 10(4) >10(5)). Studies on adults were limited to short-term end-points (microbiological sterilization, clinical improvement). Duration of therapy was 4-20 days. The trend was towards shorter periods of therapy, mainly on an outpatient basis; intravenous therapy, if performed, was usually limited to the first 1-3 days. For acute uncomplicated pyelonephritis, the tendency is towards 2 weeks of mainly oral antibiotic therapy. However, the recent literature on adults does not discriminate among different upper urinary tract infections nor does it provide data on renal scarring. While cost constraints point towards short-term therapies, further studies are needed to assess the prevalence and long-term effect of kidney scars.

Ciprofloxacin for 2 or 4 weeks in the treatment of febrile urinary tract infection in men: a randomized trial with a 1 year follow-up

In an open, prospective, single-centre study, 114 men with a presumptive diagnosis of febrile urinary tract infection (UTI) were randomized to oral treatment with ciprofloxacin 500 mg twice daily for 2 or 4 weeks. 72 patients were assessable for efficacy according to the protocol, 65 of whom had prostatic involvement by the infection, as measured by transient increases in serum prostate-specific antigen and prostate volume. All patients responded successfully with resolution of fever and symptoms during treatment. There were no significant differences in short-term bacteriological and clinical cure rates between the 2 treatment regimens [89 vs 97%, 95%, confidence interval (95% CI) for difference in proportions -3 to 19%; and 92 vs 97%, 95% CI -5 to 15%, respectively]. The lower cure rates among those allocated to the 2 week regimen may be explained by a higher frequency of urinary tract abnormalities requiring surgical intervention. After 1 y, 21 patients had experienced recurrences, which comprised asymptomatic bacteriuria (n = 10), symptomatic lower UTI (n = 5) and another episode of febrile UTI (n = 6). The results suggest that a 2 week course of ciprofloxacin may be adequate for febrile UTI in men.

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.