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Lazarus JE, Gupta K. Recurrent UTI in Women-Risk Factors and Management. Infect Dis Clin North Am 2024; 38:325-341. [PMID: 38599896 DOI: 10.1016/j.idc.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Urinary tract infections (UTIs) are common in women; more than 50% of women will be diagnosed with a UTI in her lifetime. Many of these women will go on to develop recurrent UTI. Nevertheless, evidence-based prevention of recurrent UTI is under-utilized. Here, the authors provide detailed practical advice on UTI prevention with a thorough review of the evidence. Non-antibiotic prevention measures discussed include increased fluid intake, vaginal estrogen therapy, methenamine, and cranberry. Antibiotic prophyalxis for carefully selected patients is also discussed.
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Affiliation(s)
- Jacob E Lazarus
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, GRJ 512C, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Kalpana Gupta
- Harvard Medical School, Boston, MA, USA; Veterans Affairs Boston Healthcare System, 1400 VFW Parkway, Executive Suite, West Roxbury, MA 02132, USA; Boston University School of Medicine, Boston, MA, USA.
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2
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Naber KG, Alidjanov JF, Fünfstück R, Strohmaier WL, Kranz J, Cai T, Pilatz A, Wagenlehner FM. Therapeutic strategies for uncomplicated cystitis in women. GMS INFECTIOUS DISEASES 2024; 12:Doc01. [PMID: 38764941 PMCID: PMC11099625 DOI: 10.3205/id000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
Uncomplicated cystitis is affecting many women of all ages and has a great impact on the quality of life, especially in women suffering from recurrent, uncomplicated cystitis. By far the most frequent uropathogen, E. coli, may have acquired increasing resistance against a variety of oral antibiotics, which may differ between countries and regions. Therefore, local resistance data are important to be considered. On the other hand, non-antibiotic therapy has also become an option which should be discussed and offered to the patient. In patients suffering from recurrent uncomplicated cystitis, individual risk factors and possible behavioral changes should first be taken into account. Non-antimicrobial prophylactic strategies shown to be successful in well-designed clinical studies are the next options. Long term antibiotic prophylaxis, however, should only be considered as a last option. For some of those patients self-diagnosis and self-treatment may be suitable, e.g. by using a recognized questionnaire.
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Affiliation(s)
- Kurt G. Naber
- Department of Urology, Technical University of Munich, Germany
| | | | | | - Walter L. Strohmaier
- Medical School Regiomed, Coburg, Germany
- Julius Maximilian University, Wuerzburg, Germany
- University of Split, Croatia
| | - Jennifer Kranz
- Department of Urology and Pediatric Urology, University Medical Center RWTH Aachen, Germany
- Department of Urology and Kidney Transplantation, Martin Luther University, Halle (Saale), Germany
| | - Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
| | - Adrian Pilatz
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Germany
| | - Florian M. Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Germany
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3
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Jiang L, Wang H, Luo L, Pang X, Liu T, Sun L, Zhang G. Urogenital microbiota-driven virulence factor genes associated with recurrent urinary tract infection. Front Microbiol 2024; 15:1344716. [PMID: 38384270 PMCID: PMC10879396 DOI: 10.3389/fmicb.2024.1344716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/18/2024] [Indexed: 02/23/2024] Open
Abstract
Urinary tract infections (UTIs) are a common health issue affecting individuals worldwide. Recurrent urinary tract infections (rUTI) pose a significant clinical challenge, with limited understanding of the underlying mechanisms. Recent research suggests that the urobiome, the microbial community residing in the urinary tract, may play a crucial role in the development and recurrence of urinary tract infections. However, the specific virulence factor genes (VFGs) driven by urobiome contributing to infection recurrence remain poorly understood. Our study aimed to investigate the relationship between urobiome driven VFGs and recurrent urinary tract infections. By analyzing the VFGs composition of the urinary microbiome in patients with rUTI compared to a control group, we found higher alpha diversity in rUTI patients compared with healthy control. And then, we sought to identify specific VFGs features associated with infection recurrence. Specifically, we observed an increased abundance of certain VGFs in the recurrent infection group. We also associated VFGs and clinical data. We then developed a diagnostic model based on the levels of these VFGs using random forest and support vector machine analysis to distinguish healthy control and rUIT, rUTI relapse and rUTI remission. The diagnostic accuracy of the model was assessed using receiver operating characteristic curve analysis, and the area under the ROC curve were 0.83 and 0.75. These findings provide valuable insights into the complex interplay between the VFGs of urobiome and recurrent urinary tract infections, highlighting potential targets for therapeutic interventions to prevent infection recurrence.
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Affiliation(s)
| | | | | | | | | | - Lijiang Sun
- Department of Urology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guiming Zhang
- Department of Urology, Affiliated Hospital of Qingdao University, Qingdao, China
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Buzzi G, Antonello M, Scognamiglio F, De Simoni O, Spolverato G, Pilati P, Pucciarelli S, Angriman I, Scarpa M, Castagliuolo I. Predictors of urinary tract infection after lower gastrointestinal surgery. Langenbecks Arch Surg 2023; 408:342. [PMID: 37642738 DOI: 10.1007/s00423-023-03064-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Urinary tract infections (UTIs) cause postoperative morbidity in patients undergoing lower gastrointestinal (GI) surgery that can prolong postoperative hospital stays. In patients with a fever of unknown origin (FUO), clinicians ignore what to do while waiting for the results of the urine culture test. This study aimed to develop a nomogram predicting UTI in the case of postoperative FUO. METHODS This observational, retrospective study included all consecutive patients from 1 November 2020 to 1 November 2021 undergoing lower-GI surgery at the Chirurgia Generale 3, University Hospital of Padua, Italy. A nomogram was created and externally validated in 90 consecutive patients undergoing urine culture tests for FUO at the Chirurgia Oncologica Unit, Veneto Institute of Oncology. RESULTS In the development cohort, 109 (N = 109) patients performed a urine culture test for FUO, and 39 were diagnosed with UTI. In a multivariate analysis of patients who underwent urine culture tests for FUO, UTI was associated with female sex, older age, and duration of catheterization at the date of the urine culture test. We developed a nomogram to predict UTI in surgical patients with a C-index of 0.76. In the validation cohort, 90 consecutive patients, who had lower-GI surgery, underwent a urine culture test for FUO and were tested with this nomogram. In the validation cohort, the C-index of the nomogram for predicting a positive urine culture test was 0.71. CONCLUSIONS AND RELEVANCE UTIs are a common problem in patients undergoing lower-GI surgery. A nomogram including the major risk factors may help to reduce the inappropriate use of antibiotics during the period awaiting the result of the urine culture test.
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Affiliation(s)
- Gianluca Buzzi
- Chirurgia Generale 3, Padua University Hospital, Via Giustiniani 2, 35128, Padova, Italy
| | - Maria Antonello
- Department of Molecular Medicine, University of Padua and Microbiology Unit, Padua University Hospital, Padova, Italy
| | - Federico Scognamiglio
- Chirurgia Generale 3, Padua University Hospital, Via Giustiniani 2, 35128, Padova, Italy
| | - Ottavia De Simoni
- Chirurgia Oncologica Unit, Veneto Institute of Oncology, Castelfranco Hospital, Treviso, Italy
| | - Gaya Spolverato
- Chirurgia Generale 3, Padua University Hospital, Via Giustiniani 2, 35128, Padova, Italy
| | - Pierluigi Pilati
- Chirurgia Oncologica Unit, Veneto Institute of Oncology, Castelfranco Hospital, Treviso, Italy
| | - Salvatore Pucciarelli
- Chirurgia Generale 3, Padua University Hospital, Via Giustiniani 2, 35128, Padova, Italy
| | - Imerio Angriman
- Chirurgia Generale 3, Padua University Hospital, Via Giustiniani 2, 35128, Padova, Italy
| | - Marco Scarpa
- Chirurgia Generale 3, Padua University Hospital, Via Giustiniani 2, 35128, Padova, Italy.
| | - Ignazio Castagliuolo
- Department of Molecular Medicine, University of Padua and Microbiology Unit, Padua University Hospital, Padova, Italy
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Cai T, Anceschi U, Prata F, Collini L, Brugnolli A, Migno S, Rizzo M, Liguori G, Gallelli L, Wagenlehner FME, Johansen TEB, Montanari L, Palmieri A, Tascini C. Artificial Intelligence Can Guide Antibiotic Choice in Recurrent UTIs and Become an Important Aid to Improve Antimicrobial Stewardship. Antibiotics (Basel) 2023; 12:antibiotics12020375. [PMID: 36830285 PMCID: PMC9952599 DOI: 10.3390/antibiotics12020375] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND A correct approach to recurrent urinary tract infections (rUTIs) is an important pillar of antimicrobial stewardship. We aim to define an Artificial Neural Network (ANN) for predicting the clinical efficacy of the empiric antimicrobial treatment in women with rUTIs. METHODS We extracted clinical and microbiological data from 1043 women. We trained an ANN on 725 patients and validated it on 318. RESULTS The ANN showed a sensitivity of 87.8% and specificity of 97.3% in predicting the clinical efficacy of empirical therapy. The previous use of fluoroquinolones (HR = 4.23; p = 0.008) and cephalosporins (HR = 2.81; p = 0.003) as well as the presence of Escherichia coli with resistance against cotrimoxazole (HR = 3.54; p = 0.001) have been identified as the most important variables affecting the ANN output decision predicting the fluoroquinolones-based therapy failure. A previous isolation of Escherichia coli with resistance against fosfomycin (HR = 2.67; p = 0.001) and amoxicillin-clavulanic acid (HR = 1.94; p = 0.001) seems to be the most influential variable affecting the output decision predicting the cephalosporins- and cotrimoxazole-based therapy failure. The previously mentioned Escherichia coli with resistance against cotrimoxazole (HR = 2.35; p < 0.001) and amoxicillin-clavulanic acid (HR = 3.41; p = 0.007) seems to be the most influential variable affecting the output decision predicting the fosfomycin-based therapy failure. CONCLUSIONS ANNs seem to be an interesting tool to guide the antimicrobial choice in the management of rUTIs at the point of care.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, 38123 Trento, Italy
- Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway
- Correspondence:
| | - Umberto Anceschi
- IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Francesco Prata
- Department of Urology, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Lucia Collini
- Department of Microbiology, Santa Chiara Regional Hospital, 38123 Trento, Italy
| | - Anna Brugnolli
- Centre of Higher Education for Health Sciences, 38122 Trento, Italy
| | - Serena Migno
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, 38123 Trento, Italy
| | - Michele Rizzo
- Department of Urology, University of Trieste, 34127 Trieste, Italy
| | - Giovanni Liguori
- Department of Urology, University of Trieste, 34127 Trieste, Italy
| | - Luca Gallelli
- Department of Health Science, School of Medicine, University of Catanzaro, 88100 Catanzaro, Italy
| | - Florian M. E. Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University, 35390 Giessen, Germany
| | - Truls E. Bjerklund Johansen
- Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway
- Department of Urology, Oslo University Hospital, 0315 Oslo, Norway
- Institute of Clinical Medicine, University of Aarhus, 8000 Aarhus, Denmark
| | - Luca Montanari
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, 33100 Udine, Italy
| | - Alessandro Palmieri
- Department of Urology, University of Naples Federico II, 80138 Naples, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, 33100 Udine, Italy
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Recurrent UTI: Questions and Answers on Clinical Practice. URO 2022. [DOI: 10.3390/uro2040029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Recurrent urinary tract infection (rUTI) management is still a challenge due to the lack of a standard approach and due to the burden of diseases both on personal and societal aspects. Consultations for rUTIs in everyday clinical practice range from 1% to 6% of all medical visits with high social and personal associated costs, such as prescriptions, hospital expenses, days of sick leave due to the disease, and the treatment of related comorbidities. Recurrent UTIs are, then, associated with anxiety and depression due to treatment failures and symptomatic recurrences. Often urologists are asked to give practical recommendations to patients regarding the everyday management of recurrent UTIs. Here, we aim to give to the physicians managing UTI some helpful suggestions for their everyday clinical practice, on the basis of the recent evidence.
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Bonkat G, Cai T, Galeone C, Koves B, Bruyere F. Adherence to European Association of Urology Guidelines and State of the Art of Glycosaminoglycan Therapy for the Management of Urinary Tract Infections: A Narrative Review and Expert Meeting Report. EUR UROL SUPPL 2022; 44:37-45. [PMID: 36051173 PMCID: PMC9424561 DOI: 10.1016/j.euros.2022.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 11/29/2022] Open
Abstract
Context Urinary tract infections (UTIs) have a significant impact on patient's quality of life and society. Antibiotic therapy is the primary approach for the management of UTIs; however, it has major limits in the prevention of recurrent UTIs (rUTIs), also increasing the risk of development of multidrug-resistant micro-organisms. Objective The aim of this paper is to discuss the European Association of Urology guidelines for the management of UTIs/rUTIs, the level of adherence to these recommendations, and the available evidence on the use of glycosaminoglycans (GAGs) as a possible alternative treatment to prevent rUTIs. Evidence acquisition This narrative review and expert meeting report is based on a literature search concerning the currently available UTI guidelines, the results of a survey administered to 227 urologists, and the opinion of an expert panel in the field of UTIs. Evidence synthesis Results obtained from the literature search showed that adherence to guidelines is not optimal. The survey demonstrated that antibiotics remain one of the treatments of UTIs. However, most of the urologists are aware of the problem caused by the resistance to antibiotics and prefer alternative methods for the prophylaxis of UTIs. Considering the alternative methods, the authors concluded that GAG therapy is highly effective in preventing rUTIs. Conclusions Adherence to the international guidelines is important to align the clinical practice and avoid the spreading of antibiotic resistance. The survey outlines that the misuse and overuse of antibiotics are major problems; an analysis of clinical evidence confirms that GAG therapy is a valuable therapeutic approach to prevent the recurrence of episodes of UTIs and to limit the onset of antibiotic resistance. Patient summary Although antibiotic therapy is primarily used for the management of urinary tract infections (UTIs), misuse and overuse of antibiotics are of concern. Adherence to the international guidelines is important to prevent the spreading of antibiotic resistance. Clinical evidence confirms that the use of glycosaminoglycans is a valuable therapeutic approach to prevent UTI recurrence and limit the onset of antibiotic resistance.
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Affiliation(s)
- Gernot Bonkat
- Alta uro AG, Merian Iselin Klinik, Centre of Biomechanics & Calorimetry, University of Basel, Basel, Switzerland
| | - Tommaso Cai
- Department of Urology, Santa Chiara Hospital, Trento, Italy
| | - Carlotta Galeone
- Bicocca Applied Statistics Center (B-ASC), Università degli Studi di Milano-Bicocca, Milano, Italy.,Biostatistics & Outcome Research, Statinfo, Renate, Italy
| | - Bela Koves
- Department of Urology, University of Szeged, Szeged, Hungary
| | - Franck Bruyere
- Department of Urology, University of Tours, Tours, France
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Cai T, Tamanini I, Collini L, Brugnolli A, Migno S, Mereu L, Tateo S, Pilatz A, Rizzo M, Liguori G, Bonkat G, Wagenlehner FME, Bjerklund Johansen TE. Management of Recurrent Cystitis in Women: When Prompt Identification of Risk Factors Might Make a Difference. Eur Urol Focus 2022; 8:1476-1482. [PMID: 35135727 DOI: 10.1016/j.euf.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/19/2021] [Accepted: 01/20/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Management of recurrent urinary tract infection (rUTI) is still challenging. A better understanding of the natural history of rUTI could help us reduce antibiotic use and improve antibiotic stewardship. OBJECTIVE To describe the effect of risk identification, stratification, and counseling on the natural course of the disease in women with rUTI. DESIGN, SETTING, AND PARTICIPANTS A total of 373 women affected by recurrent cystitis were enrolled in this longitudinal cohort study between December 2014 and December 2019. A systematic and standardized identification of risk factors was performed. INTERVENTION As intervention, risk factors were treated or removed where possible. Patients with nonremovable risk factors were included in the control group. All patients were scheduled for follow-up visits every 6 mo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The main outcome measures were the rate of symptomatic recurrences and improvement in questionnaire results from baseline to the end of the follow-up period. Reduction of antibiotic usage was regarded as a secondary outcome measure. RESULTS AND LIMITATIONS Finally, 353 women were analyzed: 196 in the study group and 157 in the control group. At the end of the follow-up period, a statistically significant reduction in the symptomatic recurrence rate was found between the two groups (0.9 ± 0.2 and 2.6 ± 0.5; p < 0.001), as well as in quality of life and anxiety according to mean questionnaire results: quality of life (0.88 ± 0.06 and 0.63 ± 0.09; p < 0.001) and Spielberger State-Trait Anxiety Inventory-Form Y (32.7 ± 9.3 and 47.5 ± 14.3; p < 0.001). The use of antibiotics was significantly lower in the study group: 4410 versus 9821 (p < 0.001). A limitation to consider is the lack of a randomized design for the active approach in the high-risk group. CONCLUSIONS Identification, counseling, and removal of risk factors, where possible, are able to change the natural history of rUTI, by reducing the number of symptomatic episodes and antibiotic use and improving quality of life. PATIENT SUMMARY In this report, we analyzed a large cohort of women affected by recurrent urinary tract infections and followed for a long time period. We found that risk factor identification and counseling may change the natural history of recurrent urinary tract infections, concluding that this approach is able to reduce the number of symptomatic episodes, reduce antibiotic usage, and improve patients' quality of life.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Irene Tamanini
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
| | - Lucia Collini
- Department of Microbiology, Santa Chiara Regional Hospital, Trento, Italy
| | - Anna Brugnolli
- Centre of Higher Education for Health Sciences, Trento, Italy
| | - Serena Migno
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, Trento, Italy
| | - Liliana Mereu
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, Trento, Italy
| | - Saverio Tateo
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, Trento, Italy
| | - Adrian Pilatz
- Clinic for Urology, Pediatric Urology and Andrology, University Hospital Giessen and Marburg GmbH, Justus Liebig University, Giessen, Germany
| | - Michele Rizzo
- Department of Urology, University of Trieste, Trieste, Italy
| | | | - Gernot Bonkat
- alta uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University of Basel, Basel, Switzerland
| | - Florian M E Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, University Hospital Giessen and Marburg GmbH, Justus Liebig University, Giessen, Germany
| | - Truls E Bjerklund Johansen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Urology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Aarhus, Aarhus, Denmark
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Grigoryan L, Mulgirigama A, Powell M, Schmiemann G. The emotional impact of urinary tract infections in women: a qualitative analysis. BMC Womens Health 2022; 22:182. [PMID: 35585572 PMCID: PMC9118576 DOI: 10.1186/s12905-022-01757-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 05/05/2022] [Indexed: 11/21/2022] Open
Abstract
Background While many studies address the clinical management of participants with uncomplicated urinary tract infection (uUTI), the emotional impact of uUTIs has been investigated less often. The aim of this qualitative study was to understand the emotional experience of women with uUTIs. Methods This was a qualitative, exploratory, in-depth interview-based study conducted among women in the United States (US) and Germany. Women aged ≥ 18 years with at least one uUTI treated with antibiotics in the past year were recruited through a patient community panel and physician referrals. Participants were recruited using purposive sampling to include an equal split of those with 1 or ≥ 2 antibiotics, and an equal split of those treated for a single or recurrent uUTIs (≥ 2 uUTIs in the past year). A structured telephone interview included questions about symptoms, diagnosis, treatment, and retreatment (if any). Each participant was queried about her emotions and the impact of the uUTI on life activities. Thematic analysis of responses was carried out to identify common themes. Results A total of 65 participants completed the interview, 40 (61.5%) from the US and 25 (38.5%) from Germany. Major themes that emerged from the analyses included (1) a wide range of negative emotions were experienced due to uUTI symptoms, interference with activities of daily life, and effects on relationships and sleep; (2) varied emotions and understanding related to uUTI treatment and management approaches; (3) treatment failure caused frustration, worry, and anger; and (4) the prospect of recurrent uUTIs provoked dread and helplessness. Conclusion Our research uncovered emotions of helplessness and dread experienced by women in the context of uUTI clinical treatment failure and recurrent uUTIs. Knowing patients’ perspectives on UTI management will help guide the development of patient education and improve shared decision-making. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01757-3.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Aruni Mulgirigama
- Global Specialty and Primary Care, GlaxoSmithKline, Brentford, Middlesex, UK
| | - Marcy Powell
- Safety and Medical Governance, GlaxoSmithKline, Research Triangle, NC, USA
| | - Guido Schmiemann
- Department for Health Services Research, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
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10
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Naber KG, Tirán-Saucedo J, Wagenlehner FME. Psychosocial burden of recurrent uncomplicated urinary tract infections. GMS INFECTIOUS DISEASES 2022; 10:Doc01. [PMID: 35463815 PMCID: PMC9006425 DOI: 10.3205/id000078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: Urinary tract infections (UTI) are a leading cause of bacterial infections in women. Despite acute treatment, 30-50% of women who have a UTI will experience a recurrence within 6-12 months. In this review, the focus will be on the personal psychosocial impacts of recurrent UTI. Methods: A PubMed/MEDLINE literature search was carried out from 2000 to 2020 in order to identify any recent high-quality meta-analyses or systematic reviews on these topics. Results: One systematic review was found appropriate for this manuscript. Concerning impact on quality of life (QoL) and daily activities, a reduced quality of both intimate and social relationships, self-esteem, and capacity for work was found due to recurrent UTI. Social function was substantially more reduced than physical function. In one study, the greatest reduction overall was in mental role functioning, whereas in another study, mental health reductions were not substantially greater than those of physical health. About one third of women suffered from UTI very often or often after sexual intercourse, and more than half of the patients stated that sexual relations were negatively influenced by UTI. Data from the GESPRIT study suggest that prophylaxis for recurrent UTI is underutilized, because less than 40% of the study population were offered prophylaxis after experiencing three UTI per year, despite all surveyed participants being willing to undertake at least one of the prophylactic measures listed in the survey. Conclusions: Little data on the psychosocial impact of recurrent UTI are available. Therefore, future studies must also incorporate QoL assessments as key outcome measures.
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Affiliation(s)
- Kurt G. Naber
- Department of Urology, Technical University of Munich, Germany,*To whom correspondence should be addressed: Kurt G. Naber, Department of Urology, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Str. 22, 81675 Munich, Germany, E-mail:
| | - José Tirán-Saucedo
- IMIGO/Instituto Mexicano de Infectología Ginecología y Obstetricia, Obstetrics and Gynaecology/Infectious Diseases, Monterrey, México
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Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
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Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
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Zare M, Vehreschild MJGT, Wagenlehner F. Management of uncomplicated recurrent urinary tract infections. BJU Int 2021; 129:668-678. [PMID: 34741796 DOI: 10.1111/bju.15630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To discuss optimal management of recurrent urinary tract infections (UTIs) in women. About every second woman experiences at least one UTI in her lifetime, of those 30% experience another UTI, and 3% further recurrences. Especially young healthy women without underlying anatomical deficiencies suffer from recurrent UTIs (rUTI), which are associated with significant morbidity and reduction in quality of life. METHODS This is a narrative review, investigating publications dealing with recurrent UTI in women. Risk factors and options for management are discussed. RESULTS The increased susceptibility of women to rUTI is based on the female anatomy in addition to behavioural, genetic, and urological factors. However, why some women are more likely than others to develop and maintain rUTI remains to be clarified. Invasive characteristics of certain uropathogenic Escherichia coli that are able to form extra- and intracellular biofilms and may therefore cause delayed release of bacteria into the bladder, may play a role in this setting. Treatment recommendations for an acute episode of rUTI do not differ from those for isolated episodes. Given the nature of rUTI, different prophylactic approaches also play an important role. Women with rUTI should first be counselled to use non-antibiotic strategies including behavioural changes, anti-adhesive treatments, antiseptics, and immunomodulation, before antibiotic prophylaxis is considered. In addition to the traditional treatment and prophylactic therapies, new experimental strategies are emerging and show promising effects, such as faecal microbiota transfer (FMT), a treatment option that transfers microorganisms and metabolites of a healthy donor's faecal matter to patients using oral capsules, enemas, or endoscopy. Initial findings suggest that FMT might be a promising treatment approach to interrupt the cycle of rUTI. Furthermore, bacteriophages, infecting and replicating in bacteria, have been clinically trialled for UTIs. CONCLUSION Due to the limitation of available data, novel treatment options require further clinical research to objectify the potential in treating bacterial infections, particularly UTIs.
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Affiliation(s)
- Mary Zare
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Florian Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Giessen, Germany
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Alidjanov JF, Khudaybergenov UA, Ayubov BA, Pilatz A, Mohr S, Münst JC, Ziviello Yuen ON, Pilatz S, Christmann C, Dittmar F, Mirsaidov NM, Buch-Heberling M, Naber KG, Bjerklund Johansen TE, Wagenlehner FME. Linguistic and clinical validation of the acute cystitis symptom score in German-speaking Swiss women with acute cystitis. Int Urogynecol J 2021; 32:3275-3286. [PMID: 34170341 PMCID: PMC8227360 DOI: 10.1007/s00192-021-04864-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/19/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The Global Prevalence Study of Infections in Urinary tract in Community Setting (GPIU.COM) includes epidemiological aspects of acute cystitis (AC) in women in Germany and Switzerland. The primary study relates to the German version of the Acute Cystitis Symptom Score (ACSS), a self-reporting questionnaire for self-diagnosis and monitoring the symptomatic course of AC in women. The current study aimed to analyze the validity and reliability of the German ACSS in German-speaking female patients with AC in Switzerland. METHODS Anonymized patient data were collected and analyzed from women with AC at the first visit (diagnosis) and follow-up visits as baseline and controls, respectively. Data from 97 patients with a median age of 41 years underwent analysis. Psychometric and diagnostic characteristics of the ACSS were measured and statistically analyzed. RESULTS Average internal consistency of the ACSS resulted in a Cronbach's alpha (95% CI) of 0.86 (0.83; 0.89) and did not differ significantly between the Swiss and German cohorts. Diagnostic values of the ACSS for the Swiss cohort were relatively lower than for the German cohort, possible due to discrepancies between definitions of UTI in national guidelines. CONCLUSIONS The analysis showed that the German version of the ACSS is also suitable for use in the German-speaking female population of Switzerland. Minor differences in definitions of AC between German and Swiss guidelines explain the observed discrepancies in diagnostic values of the ACSS between cohorts.
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Affiliation(s)
- Jakhongir F Alidjanov
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, Rudolph-Buchheim str. 7, 35392, Giessen, Hessen, Germany.
| | | | - Bekhzod A Ayubov
- Department of Urological Surgery, Republican Specialized Scientific-Practical Medical Center of Urology, Tashkent, Uzbekistan
| | - Adrian Pilatz
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Giessen, Hessen, Germany
| | - Stefan Mohr
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Julia C Münst
- Department of Gynaecology, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | | | | | - Corina Christmann
- Department of Obstetrics and Gynecology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Florian Dittmar
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Giessen, Hessen, Germany
| | - Nodir M Mirsaidov
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Giessen, Hessen, Germany
| | - Mareike Buch-Heberling
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Giessen, Hessen, Germany
| | - Kurt G Naber
- Department of Urology, Technical University of Munich, Munich, Germany
| | - Truls E Bjerklund Johansen
- Department of Urology of Oslo University Hospital, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, University of Aarhus, Aarhus, Denmark
| | - Florian M E Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Giessen, Hessen, Germany
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Cai T. Recurrent uncomplicated urinary tract infections: definitions and risk factors. GMS INFECTIOUS DISEASES 2021; 9:Doc03. [PMID: 34113535 PMCID: PMC8167371 DOI: 10.3205/id000072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: Recurrent uncomplicated urinary tract infections (UTI) have a high impact on patients’ quality of life and high direct and indirect costs for public health. Therefore, optimal management should be of high priority. Methods: Current international guidelines were reviewed, and a systematic literature search was performed in Medline, Cochrane, and Embase. Results: Several risks factors have been identified and used in everyday clinical practice to plan the correct strategy for recurrence prevention. Among all factors, the most important are: sexual intercourse, spermicide use, having a new sex partner, having a mother with a history of UTI, having had UTI during childhood, and asymptomatic bacteriuria treatment. Moreover, other risk factors such as reduced fluid intake, habitual and post-coital delayed urination, wiping from back to front after defecation, douching and wearing occlusive underwear, as well as irregular bowel function should be taken into account. Conclusions: Recurrent UTI show a high impact on clinical practice. Risk factors are generally related to both virulence of pathogens and patient’s behavior or condition. A recently developed nomogram can assist in identifying women at high risk of symptomatic recurrence that can be suitable candidates for a prophylactic strategy.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Hospital, Trento, Italy
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15
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Gonzales Favoreto M, Pereira Gregorio E, Averbeck MA, de Almeida SHM. Independent validation of a predictive nomogram for risk of reinfection in women with recurrent non-complicated urinary tract infections. Ther Adv Urol 2020; 12:1756287220922423. [PMID: 32435277 PMCID: PMC7225790 DOI: 10.1177/1756287220922423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/30/2020] [Indexed: 12/29/2022] Open
Abstract
Aims: Independent external validation of a predictive nomogram for risk of reinfection in women with a history of non-complicated recurrent urinary tract infection (UTI). Methods: A retrospective longitudinal study was conducted to validate the LUTIRE nomogram in a Brazilian female cohort. The nomogram was applied to 81 women presenting non-complicated recurring UTI screened at a urological clinic. External validation was performed using the nomogram variables in patients followed up from January 2014 to December 2016 at a urological clinic. Accuracy of the nomogram was obtained by analyzing the predictive capacity observed in the area under the receiver operating characteristic (ROC) curve. A multivariate logistic regression model was used to assess the ability of the nomogram variables to predict the recurrence of UTI over 12 months. The time to recurrence of infection was calculated using a Kaplan–Meier curve and the log-rank test with calculation of the hazard ratio. Results: The mean age of the study population was 42.8 years; 57 women (70.37%) had recurrence. The independent variables with statistical significance in the multivariate analysis were gram-negative bacteria [odds ratio (OR) 18.38; p = 0.03897] and number of UTIs in the past 12 months (OR 25.11; p = 0.00006). The accuracy of the nomogram for discriminating patients who had UTI recurrence was 82.6% (95% CI = 72.5–90.1). Conclusion: The LUTIRE nomogram showed good accuracy among Brazilian women with recurrent UTI.
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Affiliation(s)
- Marcelo Gonzales Favoreto
- Postgraduation Program in Medicine and Health Sciences at State University of Londrina (UEL), Londrina, Brazil
| | | | - Marcio Augusto Averbeck
- Head of Neuro-Urology, Video-Urodynamics Unit, Moinhos de Vento Hospital, Rua Tiradentes, 333, 6th floor, Porto Alegre, RS 90560-030, Brazil
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Storme O, Tirán Saucedo J, Garcia-Mora A, Dehesa-Dávila M, Naber KG. Risk factors and predisposing conditions for urinary tract infection. Ther Adv Urol 2019; 11:1756287218814382. [PMID: 31105772 PMCID: PMC6502981 DOI: 10.1177/1756287218814382] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/27/2018] [Indexed: 12/16/2022] Open
Abstract
Understanding individual and population-specific risk factors associated with recurrent urinary tract infections (UTIs) can help physicians tailor prophylactic strategies. Frequent intercourse, vulvovaginal atrophy, change of the local bacterial flora, history of UTIs during premenopause or in childhood, family history, and a nonsecretor blood type are substantiated risk factors for recurrent uncomplicated UTIs. This is a narrative review based on relevant literature according to the experience and expertise of the authors. Asymptomatic bacteriuria is generally benign; however, during pregnancy it is more common and is associated with an increased likelihood of symptomatic infection, which may harm the mother or fetus. Screening of pregnant women and appropriate treatment with antimicrobials must be balanced with the potential for adverse treatment-related outcomes; appropriate prophylaxis should be considered where possible. High-quality data are currently lacking on risks related to asymptomatic bacteriuria in pregnancy and further data in this hard-to-study population should be a primary concern for researchers. Incomplete voiding represents the primary risk factor for UTIs associated with conditions such as urinary incontinence and prolapse. Correcting the presence of residual urine remains the most effective prophylaxis in these populations. Bladder function alters throughout life; however, changes in function may be particularly profound in clinical populations at high risk of UTIs. Patients with neurogenic bladder will also likely have other evolving medical issues which increase the risk of UTIs, such as repeated catheterization and increasing residual urine volume. More aggressive antimicrobial prophylactic strategies may be appropriate in these patients. Again, the paucity of data on prophylaxis in these high-risk patients requires the attention of the research community.
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Affiliation(s)
- Oscar Storme
- Padre Hurtado Hospital, Universidad del
Desarrollo, Calle Esperanza 2150, Paradero 28, Santa Rosa, San Ramón,
Chile
| | - José Tirán Saucedo
- Instituto Mexicano de Infectología, Ginecología
y Obstetrica, Universidad de Monterrey, Monterrey, Mexico
| | - Arturo Garcia-Mora
- Instituto Nacional de Ciencias Médicas y
Nutrición Salvador Zubirán, Mexico City, Mexico
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Flokas ME, Andreatos N, Alevizakos M, Kalbasi A, Onur P, Mylonakis E. Inappropriate Management of Asymptomatic Patients With Positive Urine Cultures: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2017; 4:ofx207. [PMID: 29226170 PMCID: PMC5714225 DOI: 10.1093/ofid/ofx207] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/22/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Mismanagement of asymptomatic patients with positive urine cultures (referred to as asymptomatic bacteriuria [ASB] in the literature) promotes antimicrobial resistance and results in unnecessary antimicrobial-related adverse events and increased health care costs. METHODS We conducted a systematic review and meta-analysis of studies that reported on the rate of inappropriate ASB treatment published from 2004 to August 2016. The appropriateness of antimicrobial administration was based on guidelines published by the Infectious Diseases Society of America. RESULTS A total of 2142 nonduplicate articles were identified, and among them 30 fulfilled our inclusion criteria. The pooled prevalence of antimicrobial treatment among 4129 cases who did not require treatment was 45% (95% CI, 39-50). Isolation of gram-negative pathogens (odds ratio [OR], 3.58; 95% CI, 2.12-6.06), pyuria (OR, 2.83; 95% CI, 1.9-4.22), nitrite positivity (OR, 3.83; 95% CI, 2.24-6.54), and female sex (OR, 2.11; 95% CI, 1.46-3.06) increased the odds of receiving treatment. The rates of treatment were higher in studies with ≥100 000 cfu/mL cutoff values compared with <10 000 cfu/mL for bacterial growth (P, .011). The implementation of educational and organizational interventions designed to eliminate the overtreatment of ASB resulted in a median absolute risk reduction of 33% (rangeARR, 16-36%, medianRRR, 53%; rangeRRR, 25-80%). CONCLUSION The mismanagement of ASB remains extremely frequent. Female sex and the overinterpretation of certain laboratory data (positive nitrites, pyuria, isolation of gram-negative bacteria and cultures with higher microbial count) are associated with overtreatment. Even simple stewardship interventions can be particularly effective, and antimicrobial stewardship programs should focus on the challenge of differentiating true urinary tract infection from ASB.
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Affiliation(s)
- Myrto Eleni Flokas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Nikolaos Andreatos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Michail Alevizakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Alireza Kalbasi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Pelin Onur
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
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Cai T, Bartoletti R. Reply to Fätkenheuer and Jung. Clin Infect Dis 2016; 62:1191. [PMID: 26908784 DOI: 10.1093/cid/ciw057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento
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Urological infections due to multidrug-resistant bacteria: what we need to know? Urologia 2016; 83:21-6. [PMID: 26166012 DOI: 10.5301/uro.5000123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Recent epidemiological data have confirmed the increasing problem of antimicrobial resistance not only for hospitalized, healthcare-associated patients, but also for outpatients. In particular, the progressive increase in resistance to broad-spectrum antibiotics, such as third-generation cephalosporins, fluoroquinolones or carbapenems in Enterobacteriaceae, is an alarming situation for all urologists and general practitioners. Here, we aimed to review the epidemiological data of multidrug-resistant bacteria in the urological setting, in order to summarize all diagnostic and therapeutic recommendations to use in everyday clinical practice. METHODS We collected all recent publications from Medline and Cochrane Library from January 2000 to December 2013. Moreover, data from the abstracts presented at the EAU and AUA Congresses during the last 5 years have also been analyzed. All papers were evaluated by an expert panel on urological infections on behalf of the Italian Urological Association (SIU). RESULTS Fluoroquinolone and other antibiotic-resistant bacteria prevalence is normally very high in the lower urinary tract infection patients. In particular, multidrug-resistant bacteria prevalence in urological practice contributes to infectious morbidity increasing the financial costs to healthcare system. The expert panel on urological infections on behalf of the Italian Urological Association formulated new diagnostic pathway and therapeutic protocol in patients affected by urological tract infections due to multidrug-resistant bacteria. CONCLUSIONS The recent emergence of multidrug-resistant pathogens is an alarming public health issue also in urological practice with socioeconomic importance. Our practice should be revised on the basis of these new acquisitions.
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Takahashi S. Editorial Comment from Dr Takahashi to Development and validation of a nomogram predicting recurrence risk in women with symptomatic urinary tract infection. Int J Urol 2014; 21:934-5. [DOI: 10.1111/iju.12478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Satoshi Takahashi
- Department of Urology; Sapporo Medical University School of Medicine; Sapporo Japan
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Yazawa S. Editorial Comment from Dr Yazawa to Development and validation of a nomogram predicting recurrence risk in women with symptomatic urinary tract infection. Int J Urol 2014; 21:935. [DOI: 10.1111/iju.12489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Satoshi Yazawa
- Department of Urology; Keio University School of Medicine; Tokyo Japan
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