Summary of the UAA-AAUS guidelines for urinary tract infections

Long non‑coding RNAs MALAT1, NEAT1 and DSCR4 can be serum biomarkers in predicting urosepsis occurrence and reflect disease severity

Sepsis commonly occurs in patients with serious infections. It severely threatens the health of patients and has very high mortality rates. Urosepsis is a type of sepsis in which the serious infection originates from the urinary system. Early diagnosis of the occurrence and severity of urogenital sepsis is crucial for improving patient prognosis. Long noncoding RNAs (LncRNAs) play important roles in the occurrence of a number of diseases, including sepsis, and can be potential biomarkers that predict disease development. The present study aimed to discover potential LncRNAs that can predict the occurrence of urosepsis. RNA-sequence data from patients with sepsis from the GEO database was analyzed and LncRNAs associated with sepsis were identified. The expression of LncRNAs associated with sepsis was tested in clinical urosepsis samples. Finally, the value of these LncRNAs in predicting urosepsis was verified using clinical samples. From the GEO database a total of nine LncRNAs (MALAT1, NEAT1, RMRP, LncIRX5, LINC01742, DSCR4, C22ORF34, LINC00381, and LINC01102) were identified that had expression changes corresponding with the occurrence of sepsis. Specifically, MALAT1, NEAT1 and DSCR4 revealed differential expression in patients with urosepsis. Moreover, MALAT1, and DSCR4 were shown to be significant risk indicators for urosepsis, and NEAT1 was shown to reflect disease severity. Therefore, the present study indicated that the LncRNAs, MALAT1, NEAT1 and DSCR4 can reflect the occurrence and severity of urosepsis and may act as potential biomarkers.

The risk factors, antimicrobial resistance patterns, and outcomes associated with extended-spectrum β-lactamases-Producing pathogens in pediatric urinary tract infection

BACKGROUND

Extended-spectrum β-lactamases-producing Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis (ESBL-producing-EKP) are an increasingly common cause of childhood urinary tract infection (UTI) worldwide. Recognizing the risk factors and antimicrobial resistance patterns may guide new management in this population.

METHODS

This is a retrospective cohort study of over 5 years in Taiwan (2017-2021). Inclusion criteria are hospitalized pediatric patients with the discharge diagnosis of UTI caused by E. coli, Klebsiella pneumoniae, or Proteus mirabilis. ESBL-producing-EKP and non-ESBL-producing-EKP UTI cases were reviewed for characteristics, urinary isolate antibiotics resistance, and clinical outcomes.

RESULTS

The incidence rate of ESBL-producing-EKP UTI increased over the study period (Overall incidence rate: 14.1 %, 46/327 patients). Recent antibiotic therapy in ≤6 months (X2 = 11.83, p < 0.01) and a preterm gestational history (X2 = 8.11, p < 0.05) were associated with an increased risk. The proportion of patients with these two risk factors for ESBL acquisition were 37.5 % (X2 = 9.08, p < 0.05). The co-resistance rate of ESBL-producing-EKP to other antimicrobial agents was 63.0 % for gentamicin, 56.5 % for trimethoprim-sulfamethoxazole, 52.2 % for ciprofloxacin, 4.3 % for amikacin, and 2.2 % for imipenem. The generalized linear model analysis identified a significantly longer length of stay (β: 2.85; 95 % confidence interval [CI]: 1.14-4.56; p < 0.01) and intensive care unit duration (β: 5.86; 95 % CI: 1.59-10.12; p < 0.01) among patients with ESBL-producing-EKP UTI.

CONCLUSION

Amikacin should be considered as an alternative antimicrobial choice beyond carbapenems for ESBL-producing-EKP UTI, especially in the context of carbapenem-resistant E. coli/Klebsiella pneumoniae (CRE/CRKP) emergence.

Therapeutic strategies for uncomplicated cystitis in women

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.

Stratifying Antenatal Hydronephrosis: Predicting High-Grade VUR Using Ultrasound and Scintigraphy

(1) Background: Antenatal hydronephrosis (AHN), detected in approximately one percent of prenatal ultrasounds, is caused by vesicoureteral reflux (VUR) in 15-21% of cases, a condition with significant risks such as urinary tract infections and renal scarring. Our study addresses the diagnostic challenges of VUR in AHN. Utilizing renal ultrasonography and scintigraphy, we developed a novel scoring system that accurately predicts high-grade VUR, optimizing diagnostic precision while minimizing the need for more invasive methods like voiding cystourethrogram (VCUG); (2) Methods: This retrospective study re-analyzed renal ultrasonography, scintigraphy, and VCUG images from infants admitted between 2003 and 2013, excluding cases with complex urinary anomalies; (3) Results: Our analysis included 124 patients (75% male), of whom 11% had high-grade VUR. The multivariate analysis identified visible ureter, reduced renal length, and decreased differential renal function (DRF) as primary predictors. Consequently, we established a three-tier risk score, classifying patients into low, intermediate, and high-risk groups for high-grade VUR, with corresponding prevalences of 2.3%, 22.2%, and 75.0%. The scoring system demonstrated 86% sensitivity and 79% specificity; (4) Conclusions: Our scoring system, focusing on objective parameters of the visible ureter, renal length, and DRF, effectively identifies high-grade VUR in AHN patients. This method enhances diagnostics in ANH by reducing reliance on VCUG and facilitating more tailored and less invasive patient care.

Association between antibiotic administration before discharge and emergency department length of stay for urinary tract infection: A retrospective analysis

BACKGROUND

Patients with urinary tract infections (UTIs) may have treatment initiated in the emergency department (ED) before discharge with an antibiotic prescription. The effect of a single antibiotic dose administered before discharge on ED length of stay (LOS) is unknown.

OBJECTIVES

The purpose of this study was to compare the LOS and the rate of revisits within 30 days among patients diagnosed as having UTIs other than pyelonephritis who received parenteral, oral, or no antibiotic during an ED visit.

METHODS

This was a retrospective cohort study of adult patients with a diagnosis of UTI who received an antibiotic prescription at discharge from a single community ED in the United States between 2019 and 2020. Patients were excluded if they were admitted to the hospital, were diagnosed as having pyelonephritis, or had an ED visit in the previous 30 days. ED LOS was compared using 3-factor analysis of variance. ED revisits at 72 hours and 30 days were compared using the chi-square test.

RESULTS

A total of 694 patients with an ED visit for UTI and an antibiotic prescription at discharge were included. The mean age of the study population was 58 years. Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours (5%, 5%, 2%; P = 0.17) or 30 days (15%, 16%, 17%: P = 0.98) among patients who received parenteral, oral, or no antibiotic before discharge.

CONCLUSIONS

A single dose of parenteral antibiotic before discharge was associated with an increased ED LOS compared with treatment with oral antibiotic or discharge without ED treatment. ED revisit rates were similar regardless of ED treatment.

Association Between Use of Fluoroquinolones and Risk of Mitral or Aortic Valve Regurgitation: A Nationwide Cohort Study

Biological plausibility suggests that fluoroquinolones may lead to mitral valve regurgitation or aortic valve regurgitation (MR/AR) through a collagen degradation pathway. However, available real-world studies were limited and yielded inconsistent findings. We estimated the risk of MR/AR associated with fluoroquinolones compared with other antibiotics with similar indications in a population-based cohort study. We identified adult patients who initiated fluoroquinolones or comparison antibiotics from the nationwide Taiwanese claims database. Patients were followed for up to 60 days after cohort entry. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of MR/AR comparing fluoroquinolones to comparison antibiotics after 1:1 propensity score (PS) matching. All analyses were conducted by type of fluoroquinolone (fluoroquinolones as a class, respiratory fluoroquinolones, and non-respiratory fluoroquinolones) and comparison antibiotic (amoxicillin/clavulanate or ampicillin/sulbactam, extended-spectrum cephalosporins). Among 6,649,284 eligible patients, the crude incidence rates of MR/AR ranged from 1.44 to 4.99 per 1,000 person-years across different types of fluoroquinolones and comparison antibiotics. However, fluoroquinolone use was not associated with an increased risk in each pairwise PS-matched comparison. HRs were 1.00 (95% CI, 0.89-1.11) for fluoroquinolones as a class, 0.96 (95% CI, 0.83-1.12) for respiratory fluoroquinolones, and 0.87 (95% CI, 0.75-1.01) for non-respiratory fluoroquinolones, compared with amoxicillin/clavulanate or ampicillin/sulbactam. Results were similar when fluoroquinolones were compared with extended-spectrum cephalosporins (HRs of 0.96, 95% CI, 0.82-1.12, HR, 1.05, 95% CI, 0.86-1.28, and HR, 0.88, 95% CI, 0.75-1.03, respectively). This large-scale cohort study did not find a higher risk of MR/AR with different types of fluoroquinolones in the adult population.

Modified Zhibai Dihuang pill alleviated urinary tract infection induced by extended-spectrum β-lactamase Escherichia coli in rats by regulating biofilm formation

CONTEXT

Zhibai Dihuang pill (ZD), a traditional Chinese medicine nourishes Yin and reduces internal heat, is believed to have therapeutic effects on urinary tract infections (UTIs).

OBJECTIVE

To explore the effects and mechanism of modified ZD (MZD) on UTI induced by extended-spectrum β-lactamase (ESBLs) Escherichia coli.

MATERIALS AND METHODS

Thirty Sprague-Dawley rats were randomly divided into control, model (0.5 mL 1.5 × 108 CFU/mL ESBLs E. coli), MZD (20 g/kg MZD), LVFX (0.025 g/kg LVFX), and MZD + LVFX groups (20 g/kg MZD + 0.025 g/kg LVFX), n = 6. After 14 days of treatment, serum biochemical indicators, renal function indicators, bladder and renal histopathology, and urine bacterial counts in rats were determined. Additionally, the effects of MZD on ESBLs E. coli biofilm formation and related gene expression were analyzed.

RESULTS

MZD significantly decreased the count of white blood cells (from 13.12 to 9.13), the proportion of neutrophils (from 43.53 to 23.18), C-reactive protein (from 13.21 to 9.71), serum creatinine (from 35.78 to 30.15), and urea nitrogen (from 12.56 to 10.15), relieved the inflammation and fibrosis of bladder and kidney tissues, and reduced the number of bacteria in urine (from 2174 to 559). In addition, MZD inhibited the formation of ESBLs E. coli biofilms (2.04-fold) and decreased the gene expressions of luxS, pfS and ompA (1.41-1.62-fold).

DISCUSSION AND CONCLUSION

MZD treated ESBLs E. coli-induced UTI inhibited biofilm formation, providing a theoretical basis for the clinical application of MZD. Further study on the clinical effect of MZD may provide a novel therapy option for UTI.

PIC cystography in occult vesicoureteral reflux: A systematic review highlighting its utility in children with recurrent urinary tract infections and normal VCUG

BACKGROUND

Vesicoureteral reflux (VUR) affects 1-2% of children, predisposing them to pyelonephritis, renal scarring, and reflux nephropathy. Treatment aims to prevent febrile urinary tract infections (f-UTI) and long-term sequelae. While guidelines differ, the current consensus proposes individual risk-stratification and subsequent management strategies. Here, we systematically analyzed the current literature on Positional Instillation of Contrast Cystography (PIC) for individualized diagnostics in patients with recurrent f-UTIs.

OBJECTIVE

We present a comprehensive qualitative and quantitative synthesis. Outcomes were: 1. the ability of PIC to predict VUR in patients with negative voiding cystographies (VCUG), 2. the ability of PIC to predict occult contralateral VUR, 3. the correlation of occult VUR in PIC with dimercaptosuccinic acid (DMSA) scan findings, and 4. the incidence of postoperative f-UTI in children treated for occult VUR picked up on PIC.

STUDY DESIGN

We conducted a systematic review following the PRISMA guidelines, applying the following inclusion criteria: Children with occult VUR in PIC with negative VCUG.

RESULTS

We included nine studies with 496 symptomatic patients with a mean age of 6.8 years, published between 2003 and 2021. PIC detected VUR in 73% of patients. Out of them, 81% had low-grade and 19% high-grade VUR. Occult contralateral VUR was present in 41% children. The presence of renal scars on DMSA scan was 1.39 times more likely with occult VUR on PIC. 85% of patients did not experience recurrent f-UTIs after PIC and subsequent treatment.

DISCUSSION

PIC can detect occult VUR in patients with recurrent f-UTIs in whom VCUG is negative. However, we recommend a cautious approach in the use of PIC in clinical practice until further prospective studies confirm the validity of our outcome measures.

CONCLUSION

Identification, risk stratification, and prompt action are central in managing VUR. PIC can be helpful in identifying VUR in patients with recurrent f-UTI.

Clinical Efficacy and Safety Evaluation of Ceftazidime-Avibactam in the Treatment of Klebsiella pneumoniae Infection: A Retrospective Analysis from a Hospital in China

Background

Ceftazidime-avibactam (CAZ-AVI) is a new cephalosporin/β-lactamase inhibitor combination that received clinical approval in China in 2019. This study aims to investigate the efficacy and safety of CAZ-AVI in the treatment of Klebsiella pneumoniae (KP) infection in a hospital, and differences in efficacy among various infection sites and between monotherapy and combination therapy, providing valuable insights for its further application.

Methods

Patients who used CAZ-AVI between January 2019 and April 2023 were identified through the hospital information system. Demographic information, details of the infection site, KP strain's drug sensitivity report, treatment duration, combination therapies, adverse drug reactions (ADR), and 28-day survival were recorded. Clinical and microbiological efficacies were analyzed using SPSS 23.0 software to compare different infection sites and combination therapies.

Results

The overall effective clinical response (CR) rate of CAZ-AVI against KP infection was 62.13%, with a favorable microbial response (MR) rate was 65.68% and a 28-day survival rate was 63.91%. No significant difference occurred in effective CR and 28-day survival rate among different infection sites (P = 0.709 and 0.862, respectively). The favorable MR rate for abdominal infections was slightly lower than that for other sites of infection (P = 0.021). No significant differences in effective CR, favorable MR, and 28-day survival between monotherapy and combination therapy were present (P values were 0.649, 0.123, and 0.280, respectively). The incidence of ADR was 1.78%, including increased creatinine, elevated transaminase, hematuria, and thrombocytopenia.

Conclusion

CAZ-AVI demonstrates good clinical efficacy and safety in the treatment of KP infections. The clinical efficacy of CAZ-AVI was similar across different infection sites, and combination therapy did not show an advantage over monotherapy. Further studies are warranted. It should be noted that CAZ-AVI may induce thrombocytopenia and hematuria.

Nitrofurantoin: what is the evidence for current UK guidance?

Three days of nitrofurantoin at 100 mg twice daily is recommended as first-line treatment for uncomplicated urinary tract infection (UTI) in evidence-based guidelines across the UK. A review of international guidelines shows that the evidence base has been interpreted in very different ways. UK guidelines are unusual in promoting short (3 day) courses, and we find little direct evidence to support this. Although 'short' courses of antibiotics for other agents may provide optimum balance between providing effective treatment whilst reducing selective pressure driving resistance amongst colonizing microbial flora, it remains unclear that course lengths can be extrapolated to nitrofurantoin. Three days of nitrofurantoin may indeed be a useful intervention in a large group of patients. However, without supporting evidence and because clinical response should be expected to vary widely, it is unclear that establishing and promoting an antibiotic duration for UTI is the best approach to optimizing prescribing in this important area.

Elevated UTI Biomarkers in Symptomatic Patients with Urine Microbial Densities of 10,000 CFU/mL Indicate a Lower Threshold for Diagnosing UTIs

The literature lacks consensus on the minimum microbial density required for diagnosing urinary tract infections (UTIs). This study categorized the microbial densities of urine specimens from symptomatic UTI patients aged ≥ 60 years and correlated them with detected levels of the immune response biomarkers neutrophil gelatinase-associated lipocalin (NGAL), interleukin-8 (IL-8), and interleukin-1-beta (IL-1β). The objective was to identify the microbial densities associated with significant elevation of these biomarkers in order to determine an optimal threshold for diagnosing symptomatic UTIs. Biobanked midstream voided urine samples were analyzed for microbial identification and quantification using standard urine culture (SUC) and multiplex-polymerase chain reaction (M-PCR) testing, while NGAL, IL-8, and IL-1β levels were measured via enzyme-linked immunosorbent assay (ELISA). NGAL, IL-8, and IL-1β levels were all significantly elevated at microbial densities ≥ 10,000 cells/mL when measured via M-PCR (p < 0.0069) or equivalent colony-forming units (CFUs)/mL via SUC (p < 0.0104) compared to samples with no detectable microbes. With both PCR and SUC, a consensus of two or more elevated biomarkers correlated well with microbial densities > 10,000 cells/mL or CFU/mL, respectively. The association between ≥10,000 cells and CFU per mL with elevated biomarkers in symptomatic patients suggests that this lower threshold may be more suitable than 100,000 CFU/mL for diagnosing UTIs.

Investigating the Role of Antibiotics on Induction, Inhibition and Eradication of Biofilms of Poultry Associated Escherichia coli Isolated from Retail Chicken Meat

Background: Widespread use of antibiotics as growth promoters and prophylactic agents has dramatic consequences for the development of antibiotic resistance. In this study, we investigated effects of selected antibiotics on bacterial biofilms and performed extensive antibiotic and VF profiling of poultry-meat associated E. coli strains. Methods: Antibiotic susceptibility was performed by a disc diffusion method, followed by molecular screening of resistance and virulence determinants. Further biofilm formation assays, MIC-p, MIC-b, MBIC and MBEC, were performed using standard tissue culture plate method. Results: In total, 83 (75%) samples were confirmed as E. coli from poultry sources, 26 different antibiotics were tested, and maximum numbers of the isolates were resistant to lincomycin (100%), while the least resistance was seen against cefotaxime (1%) and polymyxin B (1%). Overall, 48% of the isolates were ESBL producers and 40% showed carbapenemase activity; important virulence genes were detected in following percentages: fimH32 (39%), papC21 (25%), iutA34 (41%), kpsMT-II23 (28%), papEF9 (11%), papGII22 (27%) and fyuA13 (16%). Colistin showed remarkable anti-biofilm activity, while at sub-MIC levels, gentamicin, ceftriaxone and enrofloxin significantly (p < 0.01) inhibited the biofilms. A strong induction of bacterial biofilm, after exposure to sub-minimal levels of colistin clearly indicates risk of bacterial overgrowth in a farm environment, while use of colistin aggravates the risk of emergence of colistin resistant Enterobacteriaceae, a highly undesirable public health scenario.

The effect of fluoroquinolones and antioxidans on biofilm formation by Proteus mirabilis strains

Background

Fluoroquinolones are a group of antibiotics used in urinary tract infections. Unfortunately, resistance to this group of drugs is currently growing. The combined action of fluoroquinolones and other antibacterial and anti-biofilm substances may extend the use of this therapeutic option by clinicians. The aim of the study was to determine the effect of selected fluoroquinolones and therapeutic concentrations of ascorbic acid and rutoside on biofilm formation by Proteus mirabilis.

Materials and methods

The study included 15 strains of P. mirabilis isolated from urinary tract infections in patients of the University Hospital No. 1 dr A. Jurasz in Bydgoszcz (Poland). The metabolic activity of the biofilm treated with 0.4 mg/ml ascorbic acid, 0.02 µg/ml rutoside and chemotherapeutic agents (ciprofloxacin, norfloxacin) in the concentration range of 0.125–4.0 MIC (minimum inhibitory concentration) was assessed spectrophotometrically.

Results

Both ciprofloxacin and norfloxacin inhibited biofilm formation by the tested strains. The biofilm reduction rate was correlated with the increasing concentration of antibiotic used. No synergism in fluoroquinolones with ascorbic acid, rutoside or both was found. The ascorbic acid and rutoside combination, however, significantly decreased biofilm production.

Conclusions

Our research proves a beneficial impact of ascorbic acid with rutoside supplementation on biofilm of P. mirabilis strains causing urinary tract infections.

Association of sarcopenia with a higher risk of infection in patients with type 2 diabetes

AIMS

This study aimed to determine whether patients with type 2 diabetes and sarcopenia had a higher risk of infection.

STUDY DESIGNS

A cross-sectional study and a follow-up study were performed.

METHOD

A total of 2562 patients were enrolled and assessed for body composition and infection status. They were classified into four groups according to body fat (BF) and muscle mass index (ASMI): obese, sarcopenic, sarcopenic obese, and normal. Among these, 275 patients were followed for a median follow-up period of 1.84 years to evaluate the relationship of changes in skeletal muscle with infection status.

RESULTS

The sarcopenic and sarcopenic obese groups showed a higher risk of infection, an increase by 49.6% (OR = 1.496, 95% CI 1.102-2.031) and 42.4% (OR = 1.424, 95% CI 1.031-1.967) compared with the normal group, and also had a higher risk of respiratory infection, an increase by 56.0% (OR = 1.560, 95% CI 1.084-2.246) and 57.4% (OR = 1.574, 95% CI 1.080-2.293), respectively. Patients with the increased ASMI (OR = 0.079, 95% CI 0.021-0.298) represented a lower risk of infection than those with the decreased ASMI. Even a minor change (OR = 0.125, 95% CI 0.041-0.378) against age was beneficial to lowering the risk of infection. However, no association was found in the changes of body mass index and BF with infection status.

CONCLUSIONS

Sarcopenia, especially in patients with diabetes who are also obese, increases the risk of infection. Maintaining or improving muscle mass is expected to reduce infections.

Recurrent Urinary Tract Infections and Asymptomatic Bacteriuria in Adults

Purpose of review

Our goal was to summarize recent evidence regarding recurrent urinary tract infections and asymptomatic bacteriuria in different adult populations.

Recent findings

Several research groups are focused on the description of resident bacterial flora in the bladder and urinary dysbiosis in the microbiome era. Even the definitions might change in light of these discoveries. However, the role of urinary microbiome and bacterial interference has still to be determined.

Summary

Systematic treatment of asymptomatic bacteriuria is not recommended and even classic indications such as asymptomatic bacteriuria in pregnant women are controversial. In fact, its treatment is associated with a higher probability of symptomatic UTI and a higher prevalence of antibiotic-resistant bacteria. Improving the diagnosis of asymptomatic bacteriuria and optimizing the management of recurrent urinary tract infections, especially through non-antibiotics measures, are needed in order to minimise antimicrobial resistance.

Risk factors for urinary infection after retrograde upper urinary lithotripsy: Implication for nursing

ABSTRACT

There are needs to evaluate the risk factors for urinary infection after retrograde upper urinary lithotripsy, to provide insights into the management and nursing care of patients with retrograde upper urinary lithotripsy.Patients who received retrograde upper urinary lithotripsy with a Foley 20 urinary tube insertion from June 1, 2019 to December 31, 2020 in our hospital were selected. Patients were grouped urinary infection and no infection group according to the culture results of urine, and the clinical data of the 2 groups of patients were collected and compared. Single factor and logistic regression analysis were used to analyze the risk factors of urinary tract infection after retrograde upper urinary lithotripsy.Four hundred ten patients with retrograde upper urinary lithotripsy were included, of whom 62 patients had the urinary tract infection, the incidence of urinary tract infection was 15.12%. There were significant differences in the gender, age, diabetes, stone diameter, duration of urinary tube insertion and duration of surgery between infection and no-infection group (all P < .05). The Escherichia coli (62.90%) was the most commonly seen bacterial in patients with urinary tract infection. Female (odds ratio [OR]: 1.602, 95% confidence interval 95% [CI]: 1.132∼2.472), age >50 years (OR: 2.247, 95% CI: 1.346∼3.244), diabetes (OR: 2.228, 95% CI: 1.033∼3.451), stone diameter ≥2 cm (OR: 2.152, 95% CI: 1.395∼3.099), duration of urinary tube insertion ≥3 days (OR: 1.942, 95% CI:1.158∼2.632), duration of surgery ≥90 minutes (OR: 2.128, 95% CI: 1.104∼3.846) were the independent risk factors for the postoperative urinary tract infection in patients with retrograde upper urinary lithotripsy (all P < .05).The incidence of urinary tract infection in patients undergoing retrograde upper urinary lithotripsy was high, counteractive measures targeted on those risk factors are needed to prevent and reduce the postoperative urinary infection in clinical settings.

The feasibility and advantages of immediate removal of urinary catheter after lobectomy: A prospective randomized trial

Aim

This study aims to evaluate the feasibility and advantages of immediate urinary catheter removal compared with prolonged indwelling catheterization in lung cancer lobectomy.

Design

This study was designed as a prospective, single‐centre, randomized and open‐label clinical study.

Methods

People with lung cancer undergoing lobectomy/pneumonectomy were recruited and randomly allocated to two groups. One group had their urinary catheter removed immediately while the other group had it removed 48 hr after surgery.

Results

No significant difference in the incidence of postoperative urinary retention (POUR) was observed between the two groups. However, the incidence of postoperative catheter‐associated urinary tract infection (CAUTI) in the immediate removal group (6.7%) was lower than the control group (17.2%) (p = .030). Furthermore, the incidence of catheter‐associated emergence agitation (CAEA) in the control group (25.3%) was higher than the immediate removal group (8.9%) (p = .007). The average length of hospital stay of the immediate removal group [6.51(4–11) days] was shorter than the control group [7.20(5–12) days] (p = .002). Immediate removal of urinary catheter appeared to have fewer complications and shorter hospital stay than delayed removal.

High Prevalence of Extended-Spectrum Beta-Lactamases in Escherichia coli Strains Collected From Strictly Defined Community-Acquired Urinary Tract Infections in Adults in China: A Multicenter Prospective Clinical Microbiological and Molecular Study

Objective

The objective of the study was to investigate the antimicrobial susceptibility and extended-spectrum beta-lactamase (ESBL) positive rates of Escherichia coli from community-acquired urinary tract infections (CA-UTIs) in Chinese hospitals.

Materials and Methods

A total of 809 E. coli isolates from CA-UTIs in 10 hospitals (5 tertiary and 5 secondary hospitals) from different regions in China were collected during the period 2016–2017 according to the strict inclusion criteria. Antimicrobial susceptibility testing was carried out by standard broth microdilution method. Isolates were categorized as ESBL-positive, ESBL-negative, and ESBL-uncertain groups according to the CLSI recommended phenotypic screening method. ESBL and AmpC genes were amplified and sequenced on ESBL-positive and ESBL-uncertain isolates.

Results

The antimicrobial agents with susceptibility rates of greater than 95% included imipenem (99.9%), colistin (99.6%), ertapenem (98.9%), amikacin (98.3%), cefmetazole (97.9%), nitrofurantoin (96%), and fosfomycin (95.4%). However, susceptibilities to cephalosporins (varying from 58.6% to 74.9%) and levofloxacin (48.8%) were relatively low. In the phenotypic detection of ESBLs, ESBL-positive isolates made up 38.07% of E. coli strains isolated from CA-UTIs, while 2.97% were ESBL-uncertain. Antimicrobial susceptibilities of imipenem, cefmetazole, colistin, ertapenem, amikacin, and nitrofurantoin against ESBL-producing E. coli strains were greater than 90%. The percentage of ESBL-producing strains was higher in male (53.6%) than in female patients (35.2%) (p < 0.001). CTX-M-14 (31.8%) was the major CTX-M variant in the ESBL-producing E. coli, followed by CTX-M-55 (23.4%), CTX-M-15 (17.5%), and CTX-M-27 (13.3%). The prevalence of carbapenem-resistant E. coli among CA-UTI isolates was 0.25% (2/809).

Conclusion

Our study indicated high prevalence of ESBL in E. coli strains from strictly defined community-acquired urinary tract infections in adults in China. Imipenem, colistin, ertapenem, amikacin, and nitrofurantoin were the most active antimicrobials against ESBL-positive E. coli isolates. bla_CTX–M–14 is the predominant esbl gene in ESBL-producing and ESBL-uncertain strains. Our study indicated that the use of cephalosporins and fluoroquinolone needs to be restricted for empirical treatment of CA-UTIs in China.

Complicated urinary tract infections with diabetes mellitus

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

Klebsiella pneumoniae infection secondary to spontaneous renal rupture that presents only as fever: A case report

BACKGROUND

Spontaneous renal rupture is a rare disease in the clinic. The causes of spontaneous renal rupture include extrarenal factors, intrarenal factors, and idiopathic factors. Reports on infection secondary to spontaneous renal rupture and the complications of spontaneous renal rupture are scarce. Furthermore, there are few patients with spontaneous renal rupture who present only with fever.

CASE SUMMARY

We present the case of a 52-year-old female patient who was admitted to our hospital. She presented only with fever, and the cause of the disease was unclear. She underwent a contrast-enhanced computed tomography (CT) scan, which showed that the left renal capsule had a crescent-shaped, low-density shadow; the perirenal fat was blurred, and exudation was visible with no sign of calculi, malignancies, instrumentation, or trauma. Under ultrasound guidance, a pigtail catheter was inserted into the hematoma, and fluid was drained and used for the bacterial test, which proved the presence of Klebsiella pneumoniae. Two months later, abdominal CT showed that the hematoma was absorbed, so the drainage tube was removed. The abdominal CT was normal after 4 mo.

CONCLUSION

Spontaneous renal rupture due to intrarenal factors causes a higher proportion of shock and is more likely to cause anemia.

Levofloxacin Versus Ciprofloxacin in the Treatment of Urinary Tract Infections: Evidence-Based Analysis

Urinary tract infections (UTIs) are one of the most common bacterial infections acquired both in community and hospital. Fluoroquinolones, represented by levofloxacin and ciprofloxacin, are widely used for treatment of UTIs. However, it remains controversial for the comparison between the 2 drugs, which propelled us to conduct the first evidence-based research on this topic. To establish their relative efficacy and safety, we searched Pubmed, embase, and Web of Science for randomized controlled trials (RCTs) for UTIs. A total of 5 RCTs were finally included, involving 2,352 patients and a systematic review and meta-analysis were performed to compare the end-of-therapy and posttherapy clinical success rate, microbial eradication rate and adverse event rate. Jadad score and Review Manager 5.3.0 version were applied respectively to evaluate the study quality and heterogeneity. There was no significant difference between levofloxacin and ciprofloxacin group in end-of-therapy or posttherapy clinical success rate and microbial eradication rate (p > 0.05). As for adverse event rate, the 2 drugs were comparable and both safe for clinical use. Based on one included trial and pharmacological research, we raised hypothesis that levofloxacin was superior to ciprofloxacin for treatment of E. coli-induced chronic bacterial prostatitis (CBP) and it required a further study to prove it.

Antimicrobial pharmacokinetics and preclinical in vitro models to support optimized treatment approaches for uncomplicated lower urinary tract infections

INTRODUCTION

Urinary tract infections (UTIs) are extremely common. Millions of people, particularly healthy women, are affected worldwide every year. One-in-two women will have a recurrence within 12-months of an initial UTI. Inadequate treatment risks worsening infection leading to acute pyelonephritis, bacteremia and sepsis. In an era of increasing antimicrobial resistance, it is critical to provide optimized antimicrobial treatment.

AREAS COVERED

Literature was searched using PubMed and Google Scholar (up to 06/2020), examining the etiology, diagnosis and oral antimicrobial therapy for uncomplicated UTIs, with emphasis on urinary antimicrobial pharmacokinetics (PK) and the application of dynamic in vitro models for the pharmacodynamic (PD) profiling of pathogen response.

EXPERT OPINION

The majority of antimicrobial agents included in international guidelines were developed decades ago without well-described dose-response relationships. Microbiology laboratories still apply standard diagnostic methodology that has essentially remained unchanged for decades. Furthermore, it is uncertain how relevant standard in vitro susceptibility is for predicting antimicrobial efficacy in urine. In order to optimize UTI treatments, clinicians must exploit the urine-specific PK of antimicrobial agents. Dynamic in vitro models are valuable tools to examine the PK/PD and urodynamic variables associated with UTIs, while informing uropathogen susceptibility reporting, optimized dosing schedules, clinical trials and treatment guidelines.

Urolithiasis Is a Risk Factor for Uroseptic Shock and Acute Kidney Injury in Patients With Urinary Tract Infection

Urinary tract infection (UTI) is a common complication in patients with urolithiasis. This study aimed to compare clinical manifestations and treatment outcomes among UTI patients with or without urolithiasis. It also focused on identifying relationships among urolithiasis, uroseptic shock, and acute kidney injury (AKI). This retrospective study enrolled hospitalized UTI patients who underwent imaging in an acute care setting from January 2006 to March 2015. Of 662 participants enrolled, 113 (17.1%) had urolithiasis, 107 (16.2%) developed uroseptic shock, and 184 (27.8%) developed AKI. A multivariate logistic regression analysis showed that in UTI patients, urolithiasis is associated with an increased risk of uroseptic shock (OR 1.80, 95% CI: 1.08-3.02, P = 0.025), AKI (OR 1.95, 95% CI: 1.22-3.12, P = 0.005), and bacteremia (OR 1.68, 95% CI: 1.08-2.64, P = 0.022). Urolithiasis is common in UTI patients and is associated with an increased risk of uroseptic shock and AKI.

Systematic review: bacterial colonisation of conduits and neobladders-when to test, watch, and treat

BACKGROUND

Urinary diversion procedures frequently result in bacterial colonisation. There is an increased incidence of developing urinary tract infections (UTIs) in this patient population. Current guidelines, however, recommend against treating this colonisation. This systematic review aimed to determine when and how to test, monitor, and treat bacteriuria in patients with urinary diversion.

METHODS

A systematic search strategy was conducted based on keywords "urinary diversion" and "bacteriuria", on MEDLINE, Embase, and Google Scholar. Articles were screened and included only if they reported on (i) testing methods for bacteriuria, (ii) surveillance of bacteriuria over time, or (iii) when and how to treat bacteriuria. Results were summarised and reported using a narrative synthesis.

RESULTS

Altogether, 26 studies were included in this review. Inconsistencies were noted in the definitions of bacteriuria, with most studies reporting bacteriuria as > 10⁴ cfu/mL (8/17 studies). Bacteriuria prevalence varied greatly (range 9.1-100%). Monitoring bacteriuria over time may help detect a reduction in bacteriuria, as demonstrated in three studies (follow-up range 5-18 months; sample size 18-56). The link between preceding bacteriuria and subsequent UTIs has not been fully explored yet. Short-term antimicrobial therapy may be useful in the immediate post-operative setting; however, long-term prophylactic treatment is ineffective in preventing bacteriuria.

CONCLUSIONS

We recommend consistent reporting of bacteriuria definitions, the benefits of monitoring bacteriuria over time, and use of short-term antimicrobial therapy; bacteriuria should not be treated with long-term therapy.

Latin American consensus on uncomplicated recurrent urinary tract infection-2018

An estimated 20-30% of adult women who experience an initial urinary tract infection (UTI) will have recurrent infection. In these patients, prophylaxis may be considered to improve their quality of life and control overuse of antibiotics. Despite this need, there is currently no Latin American consensus on the treatment and prophylaxis of recurrent UTIs. This consensus, signed by a panel of regional and international experts on UTI management, aims to address this need and is the first step toward a Latin American consensus on a number of urogynecological conditions. The panel agrees that antibiotics should be considered the primary treatment option for symptomatic UTI, taking into account local pathogen resistance patterns. Regarding prophylaxis, immunoactive therapy with the bacterial lysate OM-89 received a grade A recommendation and local estrogen in postmenopausal women grade B recommendation. Lower-grade recommendations include behavior modification and D-mannose; probiotics (Lactobacilli), cranberries, and hyaluronic acid (and derivatives) received limited recommendations; their use should be discussed with the patient. Though considered effective and receiving grade A recommendation, antimicrobial prophylaxis should be considered only following prophylaxis with effective non-antimicrobial measures that were not successful and chosen based on the frequency of sexual intercourse and local pathogen resistance patterns.

A Survey of the FDA's Adverse Event Reporting System Database Concerning Urogenital Tract Infections and Sodium Glucose Cotransporter-2 Inhibitor Use

INTRODUCTION

We tested the possible association between sodium glucose cotransporter-2 inhibitor (SGLT-2i) use and urogenital tract infection (UTI) occurrences by assessing the publicly available US Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

Disproportionality analysis and Bayesian analysis were used to mine FAERS for suspected UTI data for SGLT-2i use from the first quarter of 2004 to the second quarter of 2018.

RESULTS

On the basis of 37,100 reports, 1628 reports (4.39% of total adverse drug reactions, ADRs) were associated with UTIs; among them, the number of UTIs reported for the top four was as follows: canagliflozin, 858 (52.74%); dapagliflozin, 324 (19.91%); empagliflozin, 189 (11.62%); and empagliflozin/metformin, 183 (11.25%). Although the number of ADRs reported for these drugs is different, their risk of causing UTIs is determined. Of the reports of SGLT-2i adverse events related to UTIs, 61.73% occurred in women, which was a much higher proportion than that in men (28.50%).

CONCLUSION

FAERS data were consistent with clinical studies on a strong association between SGLT-2i use and UTIs. The results strongly suggest that female patients are more likely than male patients to experience UTIs when using SGLT-2i.

Urinary tract infections (UTIs) or genital tract infections (GTIs)? It's the diagnostics that count

Urinary tract infections (UTIs) and genital tract infections (GTIs) are both very common infectious diseases. Thus, accuracy and rapidity in recognition and treatment of sexually transmitted urogenital tract infections (ST-UGTIs) is a major concern in global public health systems. The application of reliable, accurate diagnostic tools is the key to definite detection, identification and treatment. This literature review focused on different characteristics of UGTIs in patients and the importance of diagnostic methodologies.

The articles published and indexed from 1980 through October 2018 in the databases of PubMed and MEDLINE, as well as the Google Scholar web search engine, were collected and studied. MeSH keywords of “Sexual intercourse”, “Urinary Tract Infections”, “Genital Tract Infections” and “Toll-Like Receptors” were used for searching articles. Then, the proper articles (original and review articles) were subjected to a very rigorous selection process.

The clinical symptoms and signs or asymptomatic properties of UTIs and GTIs are similar and often overlap. In many cases, the lack of suitable diagnostic techniques leads to misdiagnosed/undignosed GTIs and overdiagnosed UTIs. The outcome of poor diagnostics is failure of definite identification and treatment.

The application of advanced techniques comprising PCR, microarray and next-generation sequencing promises to be more effective, together with the use of the microbial pattern of the individual’s UGT to provide reliable detection, identification and definite treatment. This will be an option in the near future.

Transurethral Resection of the Prostate: are We Following the Guidelines? - Outcomes from the Global Prevalence of Infections in Urology (GPIU) Study

Transurethral resection of the prostate (TURP) is one of the most common urological procedures. With the increasing rate of multiresistant infections including urosepsis, it is essential for all surgeons to adhere to the relevant international guidelines to prevent infectious complications. The aim of this prospective, multinational, multicentre study was to evaluate compliance with recommended infection control measures regarding TURP procedures. The study was performed as a side questionnaire to the annual Global Prevalence Study of Infections in Urology (GPIU) between 2006 and 2009. Patients that had undergone TURP were eligible. Baseline data about hospitals and patients were collected. The questionnaire contained questions regarding preoperative microbiological investigations, catheter care and performance of perioperative antibiotic prophylaxis. A total of 825 men were included from 138 participating centres from Africa, Asia, Europe and South America. Only 50.1% of the patients received perioperative antibiotic prophylaxis with a median duration of 3 days (interquartile range [IQR] = 1-7 days). Preoperative urine culture was taken in 59.2%. The catheter was replaced in 1 week prior to the surgery only in 38.3% of cases. Compliance with the recommended infection control measures regarding TURP were only moderate, despite high grade recommendations in relevant international Guidelines. Stronger guideline adherence is necessary to improve patient care decrease antibiotic consumption in line with antibiotic stewardship in surgical practices.

Influence of beta-blocker therapy on the risk of infections and death in patients at high risk for stroke induced immunodepression

Background

Stroke-induced immunodepression is a well characterized complication of acute ischemic stroke. In experimental studies beta-blocker therapy reversed stroke-induced immunodepression, reduced infection rates and mortality. Recent, heterogeneous studies in stroke patients could not provide evidence of a protective effect of beta-blocker therapy. Aim of this study is to investigate the potential preventive effect of beta-blockers in subgroups of patients at high risk for stroke-induced immunodepression.

Methods

Data from a prospectively derived registry of major stroke patients receiving endovascular therapy between 2011–2017 in a tertiary stroke center (University Medical Center Göttingen. Germany) was used. The effect of beta-blocker therapy on pneumonia, urinary tract infection, sepsis and mortality was assessed using multivariate logistic regression analysis.

Results

Three hundred six patients with a mean age of 72 ± 13 years and a median NIHSS of 16 (IQR 10.75–20) were included. 158 patients (51.6%) had pre-stroke- and continued beta-blocker therapy. Beta-blocker therapy did not reduce the incidence of pneumonia (OR 0.78, 95% CI 0.31–1.92, p = 0.584), urinary tract infections (OR 1.51, 0.88–2.60, p = 0.135), sepsis (OR 0.57, 0.18–1.80, p = 0.334) or mortality (OR 0.59, 0.16–2.17, p = 0.429). Strokes involving the insula and anterio-medial cortex increased the risk for pneumonia (OR 4.55, 2.41–8.56, p<0.001) and sepsis (OR 4.13, 1.81–9.43, p = 0.001), while right hemispheric strokes increased the risk for pneumonia (OR 1.60, 0.92–2.77, p = 0.096). There was a non-significantly increased risk for urinary tract infections in patients with beta-blocker therapy and insula/anterio-medial cortex strokes (OR 3.12, 95% CI 0.88–11.05, p = 0.077) with no effect of beta-blocker therapy on pneumonia, sepsis or mortality in both subgroups.

Conclusions

In major ischemic stroke patients, beta-blocker therapy did not lower post-stroke infection rates and was associated with urinary tract infections in a subgroup with insula/anterio-medial strokes.