Diagnosis, Treatment, and Prevention of Urinary Tract Infection

Distinct Escherichia coli transcriptional profiles in the guts of recurrent UTI sufferers revealed by pangenome hybrid selection

Low-abundance members of microbial communities are difficult to study in their native habitats. This includes Escherichia coli, a minor, but common inhabitant of the gastrointestinal tract and opportunistic pathogen, including of the urinary tract, where it is the primary pathogen. While multi-omic analyses have detailed critical interactions between uropathogenic Escherichia coli (UPEC) and the bladder that mediate UTI outcome, comparatively little is known about UPEC in its pre-infection reservoir, partly due to its low abundance there (<1% relative abundance). To accurately and sensitively explore the genomes and transcriptomes of diverse E. coli in gastrointestinal communities, we developed E. coli PanSelect which uses a set of probes designed to specifically recognize and capture E. coli's broad pangenome from sequencing libraries. We demonstrated the ability of E. coli PanSelect to enrich, by orders of magnitude, sequencing data from diverse E. coli using a mock community and a set of human stool samples collected as part of a cohort study investigating drivers of recurrent urinary tract infections (rUTI). Comparisons of genomes and transcriptomes between E. coli residing in the gastrointestinal tracts of women with and without a history of rUTI suggest that rUTI gut E. coli are responding to increased levels of oxygen and nitrate, suggestive of mucosal inflammation, which may have implications for recurrent disease. E. coli PanSelect is well suited for investigations of native in vivo biology of E. coli in other environments where it is at low relative abundance, and the framework described here has broad applicability to other highly diverse, low abundance organisms.

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Prevalence of Urinary Tract Infections and Antibiogram of Bacteria Isolated From Children With Sickle Cell Disease in Tanzania

Introduction Individuals with sickle cell disease (SCD) are particularly vulnerable to urinary tract infections (UTIs) due to immunological deficits and renal abnormalities associated with the disorder. These infections can exacerbate underlying health issues and lead to severe complications if not managed promptly and effectively. Due to the heightened risk and potential consequences of UTIs in this population, this study aimed to determine their prevalence and explore the resistance patterns of causative pathogens among children attending the SCD Clinic at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania. Focusing on this demographic group, we sought to provide targeted insights to inform better clinical protocols and intervention strategies in regions heavily affected by SCD. Materials and methods This prospective cross-sectional study was conducted at the MNH, Dar es Salaam, Tanzania, with an enrollment over two months from 19th March to 21st May 2015. We diagnosed UTIs in children with SCD using dipstick and culture methods. Antibiotic susceptibility was assessed using the Kirby-Bauer disc diffusion method, evaluating resistance patterns to antibiotics such as ampicillin, cloxacillin, erythromycin, chloramphenicol, ceftriaxone, and trimethoprim-sulfamethoxazole. The diagnostic accuracy of the dipstick and culture methods was validated to ensure reliability in detecting UTIs. Statistical analysis was conducted using Statistical Product and Service Solutions (SPSS) software (Released 2019; IBM Corp., Armonk, New York, United States). Results Among the 250 children, 56 (22.4%) were UTI-positive according to the culture method and 62 (24.8%) were UTI-positive according to the dipstick test. Girls were more likely to be UTI-positive than boys (29.1% and 13.6%, respectively; p-value = 0.011). Escherichia coli was the most common uropathogen, followed by Klebsiella, Staphylococcus, Proteus, and Pseudomonas (44.2%, 26.9%, 21.2%, 3.8%, and 1.9%, respectively). All isolates were resistant to ampiclox. Resistance rates to ampicillin, erythromycin, cotrimoxazole, chloramphenicol, and ceftriaxone were 94.2%, 76.9%, 59.6%, 46.2%, and 21.2%, respectively. Conclusion This study indicated that dipsticks diagnosed more UTIs. The prevalence was higher in girls than in boys. Escherichia coli was the most commonly isolated antibiotic-resistant organism. High resistance levels were observed against the combination of ampicillin and cloxacillin. However, the isolates were less resistant to ceftriaxone. These results call for increased surveillance of resistant uropathogens in the pediatric population with SCD.

An update on alternative therapy for Escherichia coli causing urinary tract infections; a narrative review

BACKGROUND

Urinary tract infections (UTIs) are the most common type of nosocomial infection and severe health issues because of the difficulties and frequent recurrence. Today, alternative methods such as sonodynamic therapy (SDT), photodynamic therapy (PDT) and herbal materials use for treating infections like UTI in many countries.

METHOD

We conducted searches of the biomedical databases (Google Scholar, Scopus, PubMed, and Web of sciences) to identify related studies from 2008 to 2023.

RESULT

SDT aims to use ultrasound to activate a sonosensitizer, which causes a biological effect by raising reactive oxygen species (ROS). When bacteria are exposed to ROS, several important effects occur: oxidative damage, DNA damage, protein dysfunction etc. SDT with herbal medicine significantly reduced the number of colony-forming units and bactericidal activity for Klebsiella pneumonia and E. coli. PDT is a promising treatment for cancer and microbial infections, combining a photosensitiser, light and tissue molecular oxygen. It involves a photosensitizer, light source, and oxygen, with variations affecting microbial binding and bactericidal activity. Factors affecting antibacterial properties include plant type, growing conditions, harvesting, and processing. This review highlights the recent advancements in sonodynamic, photodynamic, herbal, and bio-material-based approaches in the treatment of E. coli infections.

CONCLUSIONS

These alternative therapies offer exciting prospects for addressing UTIs, especially in cases where traditional antibiotic treatments may be less effective. Further research and clinical studies are warranted to fully explore the potential of these innovative treatment modalities in combating UTIs and improving patient outcomes.

Causality between allergic diseases and kidney diseases: a two-sample Mendelian randomization study

Background

Evidence from observational studies and clinical trials suggests that the allergic diseases (ADs) are associated with kidney diseases (KDs). However, the causal association between them remains to be determined. We used bidirectional two-sample Mendelian randomization (MR) analysis to evaluate the potential causality between them.

Methods

Mendelian randomization (MR) was performed using publicly available genome-wide association study (GWAS) summary datasets. Inverse variance weighted (IVW), weighted median, MR-Egger regression, simple mode, and weighted mode methods are used to evaluate the causality between ADs and KDs. Sensitivity and heterogeneity analyses were used to ensure the stability of the results.

Results

The MR results indicated that genetic susceptibility to ADs was associated with a higher risk of CKD [odds ratio (OR) = 1.124, 95% CI = 1.020-1.239, p = 0.019] and unspecified kidney failure (OR = 1.170, 95% CI = 1.004-1.363, p = 0.045) but not with kidney stone, ureter stone or bladder stone (OR = 1.001, 95% CI = 1.000-1.002, p = 0.216), other renal or kidney problem (OR = 1.000, 95% CI = 1.000-1.001, p = 0.339), urinary tract or kidney infection (OR = 1.000, 95% CI = 0.999-1.001, p = 0.604), kidney volume (OR = 0.996, 95% CI = 0.960-1.033, p = 0.812) and cyst of kidney (OR = 0.914, 95% CI = 0.756-1.105, p = 0.354). No causal evidence of KDs on ADs was found in present study.

Conclusion

Results from MR analysis indicate a causal association between ADs and CKD and unspecified kidney failure. These findings partly suggest that early monitoring of CKD risk in patients with ADs is intentional.

Urinary Tract Infection in Children: A Narrative Review

This study investigates the susceptibility of different age groups and genders to urinary tract infections (UTIs) in pediatric populations, focusing on anatomical and behavioural factors. A systematic review of clinical data explores manifestations, accurate diagnosis methods, and antibiotic treatment regimens. Escherichia coli is a prevalent uropathogen, and the study addresses concerns about antibiotic resistance. The research aims to close knowledge gaps, influence guidelines, and enhance public health initiatives. Factors influencing UTI prevalence, such as age, gender, and structural abnormalities, are discussed. The review follows a robust search methodology, presenting a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. The included studies cover a wide range of topics related to pediatric UTIs, including aetiology, treatment, prevention, and diagnostic approaches. The study emphasizes the importance of understanding and addressing pediatric UTIs for effective management and prevention.

Cranberry, but not D-mannose and ibuprofen, prevents against uropathogenic Escherichia coli-induced cell damage and cell death in MDCK cells

Introduction

The main function of the urinary tract is to form an impermeable barrier against urinary solutes and bacteria. However, this barrier can be compromised by urinary tract infections, most commonly caused by uropathogenic Escherichia coli (UPEC). This can result in damage to the epithelial barrier, leading to decreased epithelial thickness, loss of tight junctions, loss of epithelial integrity, and apoptosis. Due to the rise in antimicrobial resistance, there is worldwide interest in exploring non-antibiotic agents as alternative therapy.

Methods

Using the Madin-Darby canine kidney (MDCK) cell line, a widely accepted epithelial cell model for the urinary tract, and the UPEC strain UTI89, this paper aimed to investigate the impact of UPEC on cell integrity, permeability, and barrier functions, and determine whether cranberry, D-mannose and ibuprofen could counteract the effects induced by UPEC. Furthermore, the study examined the protective potential of these agents against UPEC-induced increase in reactive oxygen species (ROS) production and programmed death-ligand 1 (PD-L1) expression.

Results

The results demonstrated that UTI89 caused a marked reduction in cell viability and monolayer integrity. Cranberry (3 mg/mL) was protective against these changes. In addition, cranberry exhibited protective effects against UPEC-induced damage to cell barrier integrity, escalation of oxidative stress, and UPEC/TNFα-triggered PD-L1 expression. However, no effect was observed for D-mannose and ibuprofen in alleviating UPEC-induced cell damage and changes in ROS and PD-L1 levels.

Conclusion

Overall, cranberry, but not D-mannose or ibuprofen, has a protective influence against UPEC associated damage in urinary epithelial cells.

Antibiotics susceptibility patterns of uropathogenic bacteria: a cross-sectional analytic study at Kanifing General Hospital, The Gambia

BACKGROUND

Antimicrobial resistance poses a public health threat for the treatment of community-acquired urinary tract infections. This study determined the susceptibility patterns of uropathogens and associated risk factors among outpatients diagnosed with urinary tract infections at the Kanifing General Hospital in the Gambia.

METHODS

A cross-sectional analytic study was conducted among patients with suspected urinary tract infections at Kanifing General Hospital from March to May 2021. Data on socio-demographic and other risk factors were collected from the study participants using a structured pre-tested questionnaire. Mid-stream urine samples were collected, and bacteria identification and antimicrobial susceptibility testing done using standard microbiological methods. Descriptive and inferential statistical analysis were done to determine factors associated with urinary tract infection at 95% confidence level and a p -value < 0.05.

RESULTS

A total of 422 patients were enrolled with 82.5% (348/422) being females. The prevalence of community acquired urinary tract infection was 12.8% (54/422). Escherichia coli was the most prevalent isolate (74.1%, 40/54), followed by Klebsiella spp (8.5%, 10/54). Antimicrobial resistance was highest for Ampicillin (87.0%, 47/54), Trimethoprim/Sulfamethoxazole (77.8%, 42/54) and Tetracycline (75.9%, 41/54). Uropathogens sensitivity was 77.8% (42/54) for Nitrofurantoin and 75.9% (41/54) for Ceftazidime. Being female (aOR 5.90 95% CI = 1.48-23.67), previous history of urinary tract infection (aOR 2.34, 95% CI = 1.06-5.14), use of unprescribed antibiotics (aOR 2.0, 95% CI = 1.05-3.62) and having no formal education (aOR 8.02, 95% CI = 1.04-62.0) were significant factors associated for having uropathogenic bacterial infection.

CONCLUSION

E. coli was the most prevalent uropathogen isolated. Ciprofloxacin, Nitrofurantoin and Ceftazidime were the most sensitive antibiotics. Routine surveillance of susceptibility of uropathogenic bacteria would be helpful to update clinicians on the choice of antibiotics.

Diagnostic work-up of urinary tract infections in pregnancy: study protocol of a prospective cohort study

INTRODUCTION

Symptoms of urinary tract infections in pregnant women are often less specific, in contrast to non-pregnant women where typical clinical symptoms of a urinary tract infection are sufficient to diagnose urinary tract infections. Moreover, symptoms of a urinary tract infection can mimic pregnancy-related symptoms, or symptoms of a threatened preterm birth, such as contractions. In order to diagnose or rule out a urinary tract infection, additional diagnostic testing is required.The diagnostic accuracy of urine dipstick analysis and urine sediment in the diagnosis of urinary tract infections in pregnant women has not been ascertained nor validated.

METHODS AND ANALYSIS

In this single-centre prospective cohort study, pregnant women (≥16 years old) with a suspected urinary tract infection will be included. The women will be asked to complete a short questionnaire regarding complaints, risk factors for urinary tract infections and baseline characteristics. Their urine will be tested with a urine dipstick, urine sediment and urine culture. The different sensitivities and specificities per test will be assessed. Our aim is to evaluate and compare the diagnostic accuracy of urine dipstick analysis and urine sediment in comparison with urine culture (reference test) in pregnant women. In addition, we will compare these tests to a predefined 'true urinary tract infection', to distinguish between a urinary tract infection and asymptomatic bacteriuria.

ETHICS AND DISSEMINATION

Approval was requested from the Medical Ethics Review Committee of the Academic Medical Centre; an official approval of this study by the committee was not required. The outcomes of this study will be published in a peer-reviewed journal.

Plasmid-mediated quinolone resistance determinants in fluoroquinolone-nonsusceptible Escherichia coli isolated from patients with urinary tract infections in a university hospital, 2009-2010 and 2020: PMQR in UTI E. coli

OBJECTIVES

This study aimed to characterize the plasmid-mediated quinolone resistance (PMQR) in fluoroquinolone non-susceptible E. coli (FQNSEC) isolated from patients with urinary tract infections (UTIs) in 2019-2010 and 2020.

METHODS

A total of 844 E. coli isolates were collected from UTI patients at National Cheng Kung University Hospital (NCKUH). The antimicrobial susceptibility of E. coli isolates to 21 antibiotics was determined by disk diffusion tests. The distribution of phylogenetic groups, virulence factor, and PMQR genes, was determined by PCR. Conjugation assays were performed to investigate the transferrability of qnr genes from FQNSEC isolates to E. coli C600.

RESULTS

We found 211 (41.9%) and 152 (44.7%) E. coli isolates were FQNSEC in 2009-2010 and 2020, respectively. Phylogenetic group B2 was dominant in FQNSEC isolates (52.34%), followed by group F (10.47%), group B1 (9.64%), and group D (9.64%). FQNSEC isolates were more resistant to 17 of 19 tested antimicrobial agents, compared to the FQ susceptible E. coli. PMQR screening results showed that 34, 22, and 10 FQNSEC isolates containing aac(6')-Ib-cr, qnr genes, and efflux pump genes (qepA or oqxAB), respectively. PMQR E. coli isolates were more non-susceptible to gentamicin, amoxicillin, ampicillin/sulbactam, imipenem, cefazolin, cefuroxime, cefmetazole, ceftriaxone, ceftazidime, and cefepime, compared to non-PMQR FQNSEC. Moreover, 16 of 22 qnr-carrying plasmids were transferrable to the recipient C600.

CONCLUSION

Here, we reported the high prevalence of MDR- and XDR-E. coli in FQNSEC isolates. Moreover, qnr-carrying plasmids were highly transferable and lead to the resistance to other classes of antibiotics in the transconjugants.

Management of urinary tract infections and antibiotic susceptibility patterns of bacterial isolates

AIM OF STUDY

Urinary tract infections (UTIs) are among the most common infections affecting individuals of different ages worldwide. Antimicrobial agents are usually the first-line treatment for UTIs, and the use of the prescribed antibiotic is escalating, resulting in increased rates of bacterial resistance and UTI recurrence. The current study aimed to identify the causative bacteria in Jordan, to explore their resistance pattern to antibiotics and to describe drug-related problems (DRPs) associated with UTI management.

METHODS

This prospective, descriptive study was conducted in two major health institutions in two cities in Jordan over a period of six months. The study population included inpatients and outpatients diagnosed with UTIs. Patients' data were collected directly from patients using data collection sheet and from patients' charts.

RESULTS

A total of 273 patients were included, of whom 56.4% were women. Urine cultures were obtained from 81% of the patients. Escherichia coli was the most common causative pathogen (50.6%), followed by Klebsiella pneumonia (10.8%). Extended spectrum beta-lactamase (ESBL) producing E. coli was the most commonly detected organism across all types of UTIs. Ceftriaxone and imipenem/cilastatin were most commonly administered to hospitalised patients, whilst ciprofloxacin and co-triamzaxole were the most commonly prescribed in outpatient clinics. The susceptibility results for parenteral antibiotics showed high rates of resistance to cefazolin and ticarcillin. Additionally, high rates of resistance to fluoroquinolones were identified. Further, several DRPs were identified. High rates of resistance to commonly prescribed antibiotics were detected. DRPs (ie, inappropriate antibiotic dosage, unnecessary antibiotic prescribing, inappropriate duration of therapy and prescribing of ineffective antibiotics) were relatively common.

CONCLUSION

The present study highlights the need for clinical pharmacists to manage the high level of drug related problems by providing updated information about proper drug selection, rational drug use and patient education and counselling.

Womens' self-management skills for prevention and treatment of recurring urinary tract infection

BACKGROUND

The guideline on urinary tract infections (UTI) of the Dutch College of General Practitioners provides recommendations on patient-initiated treatment and prevention of recurring UTI.

AIM

To study familiarity with self-management skills for prevention of recurring UTI amongst adult women.

DESIGN AND SETTINGS

An online questionnaire was developed, based on the UTI guideline and interviews with women having recurring UTI. Pharmacists in a postgraduate education programme (N = 76) aimed to invite 10 adult women with a recurring UTI prescription to complete the questionnaire. Women were asked for informed consent to link medication record data to questionnaire data.

METHOD

We calculated proportions of the scores for self-management skills and analysed differences between age groups with chi-square test.

RESULTS

Complete questionnaires were available for 719 women (mean age 55.1 ± 18.5 years). The proportions of women 18-50 years and women 51 years or older were 36.4% and 63.6%, respectively. Education levels of women 18-50 years were significantly higher than those of women 51 years and older. Before consulting a general practitioner (GP) for symptoms, 32.1% of all women increased fluid intake; additionally, 15.0% used analgesics and increased fluid intake. Of all women, 33.9% searched internet for information on self-management and 18% occasionally received a prescription for patient-initiated treatment, half of these prescriptions for use during vacation. Cranberry was used by 47%, d-mannose by 5% and vitamin C by 29% of all women. Awareness of different preventive behavioural measures (eg, fluid intake, washing without soap and emptying bladder after sexual intercourse) varied between 20% and 90%.

CONCLUSION

Almost half of all women applied self-management (increased fluid intake, analgesics) before consulting a GP for recurring UTI. Awareness of preventive behavioural measures for recurring UTI varied considerably. Thus, education of women about the use of analgesics and behavioural measures deserves attention.

A Natural Alternative Treatment for Urinary Tract Infections: Itxasol©, the Importance of the Formulation

Genito-urinary tract infections have a high incidence in the general population, being more prevalent among women than men. These diseases are usually treated with antibiotics, but very frequently, they are recurrent and lead to the creation of resistance and are associated with increased morbidity and mortality. For this reason, it is necessary to develop new compounds for their treatment. In this work, our objective is to review the characteristics of the compounds of a new formulation called Itxasol© that is prescribed as an adjuvant for the treatment of UTIs and composed of β-arbutin, umbelliferon and n-acetyl cysteine. This formulation, based on biomimetic principles, makes Itxasol© a broad-spectrum antibiotic with bactericidal, bacteriostatic and antifungal properties that is capable of destroying the biofilm and stopping its formation. It also acts as an anti-inflammatory agent, without the adverse effects associated with the recurrent use of antibiotics that leads to renal nephrotoxicity and other side effects. All these characteristics make Itxasol© an ideal candidate for the treatment of UTIs since it behaves like an antibiotic and with better characteristics than other adjuvants, such as D-mannose and cranberry extracts.

Bioinformatics and experimental findings reveal the therapeutic actions and targets of pachymic acid against cystitis glandularis

Pachymic acid (PA), a bioactive ingredient isolated from Poria cocos Wolf, is reported with potential benefits of anti-inflammatory, anti-oxidative actions. It is reasoned that PA may play the potential benefits against cystitis glandularis (CG), an inflammation of the bladder tissue. In this study, we aimed to apply the network pharmacology and molecular docking analyses to reveal concrete anti-CG targets and mechanisms of PA, and then the bioinformatic findings were verified by using clinical and animal samples. The methodological data from network pharmacology approach showed that 303 and 243 reporting targets of CG and PA, and other 31 shared targets of CG and PA were identified. Subsequently, all top targets of PA against CG were screened out, including cyclooxygenase-2, epidermal growth factor receptor, tumor antigen p53 (TP53), tumor necrosis factor-alpha (TNF), interleukin-1 (IL-1) beta, proto-oncogene c-jun. Molecular docking data demonstrated that PA exerted potent bonding capacities with TNF, TP53 proteins in CG. In human study, the findings suggested that overactivated TNF-α expression and suppressed TP53 activation were detected in CG samples. In animal study, PA-treated mice showed reduced intravesical IL-1, IL-6 levels, and lactate dehydrogenase content, downregulated TNF-α and upregulated TP53 proteins in bladder samples. Taken together, our bioinformatics and experimental findings identify the key anti-CG biotargets and mechanisms of PA. More markedly, these pivotal pharmacological targets of PA against CG have been screened out and verified by using computational and experimental analyses.

Manual treatment for kidney mobility and symptoms in women with nonspecific low back pain and urinary infections

CONTEXT

Recent studies have suggested a connection between low back pain (LBP) and urinary tract infections (UTI). These disturbances could be triggered via visceral-somatic pathways, and there is evidence that kidney mobility is reduced in patients suffering from nonspecific LBP. Manual treatment of the perinephric fascia could improve both kidney mobility and LBP related symptoms.

OBJECTIVES

To assess whether manual treatment relieves UTI and reduces pain in patients with nonspecific LBP through improvement in kidney mobility.

METHODS

Records from all patients treated at a single physical therapy center in 2019 were retrospectively reviewed. Patients were included if they were 18 years of age or older, had nonspecific LBP, and experienced at least one UTI episode in the 3 months before presentation. Patients were excluded if they had undergone manipulative treatment in the 6 months before presentation, if they had one of several medical conditions, if they had a history of chronic pain medication use, and more. Patient records were divided into two groups for analysis: those who were treated with manipulative techniques of the fascia with thrust movement (Group A) vs those who were treated without thrust movement (Group B). Kidney Mobility Scores (KMS) were analyzed using high resolution ultrasound. Symptoms as reported at patients' 1 month follow up visits were also used to assess outcomes; these included UTI relapse, lumbar spine mobility assessed with a modified Schober test, and lumbar spine pain.

RESULTS

Of 126 available records, 20 patients were included in this retrospective study (10 in Group A and 10 in Group B), all of whom who completed treatment and attended their 1 month follow up visit. Treatments took place in a single session for all patients and all underwent ultrasound of the right kidney before and after treatment. The mean (± standard deviation) KMS (1.9 ± 1.1), mobility when bending (22.7 ± 1.2), and LBP scores (1.2 ± 2.6) of the patients in Group A improved significantly in comparison with the patients in Group B (mean KMS, 1.1 ± 0.8; mobility when bending, 21.9 ± 1.1; and LBP, 3.9 ± 2.7) KMS, p<0.001; mobility when bending, p=0.003; and LBP, p=0.007). At the 1 month follow up visit, no significant statistical changes were observed in UTI recurrence (secondary outcome) in Group A (-16.5 ± 4.3) compared with Group B (-20.4 ± 7) (p=0.152).

CONCLUSIONS

Manual treatments for nonspecific LBP associated with UTI resulted in improved mobility and symptoms for patients in this retrospective study, including a significant increase in kidney mobility.

Epidemiology and Antimicrobial Susceptibility Pattern of Uropathogens in Patients with the Community- and Hospital-Acquired Urinary Tract Infections at a Tertiary Hospital in Somalia

Background: Urinary tract infections (UTIs) are the most common infections in the community and in hospitalized patients. Objectives: To investigate the epidemiology and antimicrobial susceptibility pattern of uropathogens and determine the appropriate empirical antibiotics to treat UTIs in the community and hospitalized patients. Methods: A total of 2,485 urine cultures were performed at Mogadishu Somali Turkish Training and Research Hospital. Through the standard Kirby-Bauer disk diffusion method and commercial disks, antimicrobial sensitivity and resistance were studied based on the Clinical and Laboratory Standards Institute (CLSI) system using Mueller-Hinton agar. The identification of the microorganisms was done using eosin methylene blue agar and blood agar. Results: Escherichia coli was the most predominant pathogen (63.4%) in all age groups, both genders, and in the community and hospital-acquired UTIs, followed by Klebsiella pneumonia (13.3%). Ceftriaxone, trimethoprim/sulfamethoxazole, ampicillin, cefuroxime, and cefixime revealed the highest resistance level (82-100%) against uropathogens. Ciprofloxacin (67.7%) and levofloxacin (54.2%) showed increasing resistance rates against uropathogens. Tigecycline, colimycin, vancomycin, and teicoplanin exhibited the most powerful sensitivity rate (100%). Moreover, fosfomycin, nitrofurantoin, and amikacin manifested a significant sensitivity rate ranging from 86% - 95%. Acinetobacter baumannii was the most prevalent pathogen that belonged to multidrug- and extensively drug-resistant patterns in 69.1% of the samples. Escherichia coli and K. pneumonia showed similar multidrug-resistant patterns in 35.2% of the cases. Conclusions: The results indicated increased trends of antimicrobial resistance rate in trimethoprim/sulfamethoxazole (85.1%) and fluoroquinolones (61%) against E. coli that was higher than the recommended local resistance rate for empirical therapy (< 20% and < 10%, respectively). According to the results, using fosfomycin and nitrofurantoin are suggested for UTI empiric treatment, and other antibiotics should be prescribed carefully.

Outpatient antimicrobial stewardship: Targets for urinary tract infections

BACKGROUND

Urinary tract infections (UTIs) are common. Outpatient antimicrobial stewardship programs are emerging and a focused approach to UTIs is needed to help guide programs.

METHODS

Data were collected by retrospective chart review of outpatients using encounters from January 2005 to March 2018. Antibiotic therapy was indicated if at least one UTI symptom was present. Antibiotic therapy was appropriate if consistent with guidelines and culture results. Factors that differed significantly (P <.05) between the comparator groups were built into a multivariable logistic regression model to determine factors associated with inappropriate prescribing.

RESULTS

A total of 607 outpatients were included, of which approximately 68% were treated inappropriately. Inappropriate regimens consisted of 50.9% (n = 309) incorrect durations, 35.1% (n = 213) incorrect choice of antibiotic, and 12.4% (n = 75) incorrect doses. Ten percent of patients developed a reinfection within 30 days. Recurrence of UTI with the same pathogen within 30 days occurred in 5.1%. Catheter use and advanced age are both risk factors for recurrence and inappropriate treatment.

CONCLUSIONS

Outpatient antibiotic prescribing for UTIs is suboptimal. Stewardship programs should focus on patients with catheters and of advanced age as they are often inappropriately treated.

Microbial Resistance in Urinary Tract Infections

Objective

To determine the pattern of microbes responsible for urinary tract infections and their susceptibility to antimicrobial agents.

Methods

This was a prospective, observational study conducted at Benazir Bhutto Hospital, Rawalpindi, Pakistan. The urine samples of 440 patients were collected and sent for culture and sensitivity analysis. The results were recorded on a proforma. The data were analyzed using IBM Statistical Package for Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY). Descriptive statistics were used to describe the data. Chi-square test was applied to determine the significance of the difference between gender and microorganisms as well as microorganism and antimicrobial sensitivity. P-value of less than 0.05 was considered significant.

Results

Out of 440 urine samples, 144 culture-positive samples had been obtained from male participants and 296 culture-positive samples had been obtained from female participants. The most common organism on analysis was Escherichia coli. There were more rates of resistance in males. The organisms were most susceptible to fosfomycin and imipenem (p = 0.01). The organisms were resistant to ceftazidime (p = 0.01).

Conclusion

In Pakistan, most patients with resistance present with mild symptoms instead of severe clinical manifestations. Therefore, there is a need to reduce the over-prescription of antibiotics for urinary tract infections, especially in cases when other non-antimicrobial agents can be used.

The standardized herbal combination BNO 2103 contained in Canephron® N alleviates inflammatory pain in experimental cystitis and prostatitis

BACKGROUND

Urinary tract infections are among the most common types of infections and give rise to inflammation with pain as one of the main symptoms. The herbal medicinal product Canephron^® N contains BNO 2103, a defined mixture of pulverized rosemary leaves, centaury herb, and lovage root, and has been used in the treatment of urinary tract infections for more than 25 years.

PURPOSE

To test the hypothesis that BNO 2103 reduces pain in cystitis and prostatitis by virtue of anti-inflammatory properties, and to reveal potential mechanisms underlying the anti-inflammatory features.

STUDY DESIGN

BNO 2103 was studied for anti-inflammatory and analgesic properties in three animal models in vivo, and the mode of action underlying the anti-inflammatory features was investigated in human leukocytes and cell-free assays in vitro.

METHODS

To assess the anti-inflammatory and analgesic efficacy of BNO 2103 we employed cyclophosphamide-induced cystitis and carrageenan-induced prostatitis in rats, and zymosan-induced peritonitis in mice. Human neutrophils and monocytes as well as isolated human 5-lipoxygenase and microsomal prostaglandin E₂ synthase-1-containing microsomes were utilized to assess inhibition of leukotriene and/or prostaglandin E₂ production by HPLC and/or ELISA.

RESULTS

When given orally, BNO 2103 reduced inflammation and hyperalgesia in experimental cystitis in rats, while individual components of BNO 2103 also reduced hyperalgesia. Furthermore, BNO 2103 reduced hyperalgesia in rats with carrageenan-induced prostatitis. Cell-based and cell-free studies implicate inhibition of prostaglandin E₂ and leukotriene B₄ biosynthesis as potential mechanisms underlying the analgesic and anti-inflammatory effects.

CONCLUSION

Our data support the hypothesis that BNO 2103 reduces pain by virtue of its anti-inflammatory properties, possibly related to suppression of prostaglandin E₂ and leukotriene B₄ formation, and suggest that this combination has the potential to treat clinical symptoms such as inflammatory pain. Thus BNO 2103 may represent an alternative to reduce the use of antibiotics in urinary tract infections.

Features of urinary Escherichia coli isolated from children with complicated and uncomplicated urinary tract infections in Mexico

The Hospital Infantil de México Federico Gómez (HIMFG) is a tertiary care hospital in Mexico City where Escherichia coli is frequently isolated from the urine samples of pediatric patients with urinary tract infections. A collection of 178 urinary Escherichia coli (UEc) isolates associated with complicated and uncomplicated urinary tract infections were evaluated in this study. The patterns of resistance to 9 antibiotic classes showed that 60.7% of the UEc isolates had a highly multidrug-resistant (MDR) profile. Genetic diversity analyses of the UEc isolates showed a high variability and revealed 16 clusters associated with four phylogenetic groups, namely, groups A, B1, B2, and D. Phylogenetic group B2 was widely associated with the 16 clusters as well as with virulence and fitness genes. The virulence and fitness genes in the UEc isolates, which included fimbriae-, siderophore-, toxin-, and mobility-associated genes, were grouped as occurring at a low, variable, or high frequency. Interestingly, only the papF gene could be amplified from some UEc isolates, and the sequence analysis of the pap operon identified an insertion sequence (IS) element and gene loss. These data suggested pathoadaptability and the development of immune system evasion, which was confirmed by the loss of P fimbriae-associated agglutination in the UEc isolates. E. coli clone O25-ST131 had a prevalence of 20.2% among the UEc isolates; these isolates displayed both a highly MDR profile and the presence of the papGII, fimH, papGIII, iutD, sat, hlyA, and motA genes. In conclusion, the UEc isolates from complicated urinary tract infection (cUTI) were characterized as being MDR, highly genetically diverse, and associated with phylogenetic group B2 and many virulence and fitness genes. Additionally, gene loss and IS elements were identified in some UEc isolates identified as clone O25-ST131.

Direct disk testing versus isolation and antimicrobial susceptibility testing of urine from urinary tract infection

BACKGROUND AND OBJECTIVES

Urinary tract infections are common infections that can be caused by many bacterial pathogens. The susceptibility of such pathogens to antimicrobial agents is identified by different methods including disk diffusion test, direct sensitivity testing and determination minimum inhibitory concentration. The present study was conducted to isolate and identify bacteria cultured from urine samples and compare the results of direct sensitivity test (DST) against Kirby-Bauer's disk diffusion antimicrobial sensitivity (AST) with respect to reliability, time and cost.

MATERIALS AND METHODS

Midstream urine samples were inoculated on blood and MacConkey agar plates; growth was evaluated after colony counting. We identified isolates based on their cultural and biochemical properties, and Vitek^® 2 system. Both DST and AST were performed on Mueller-Hinton agar using 10 antimicrobial agents. Error rate was calculated between the DST and AST as the proportion of comparisons between DST and AST test results. The comparisons represented as "very major error", "major error", or "minor error" and "agreement" (i.e, no error).

RESULTS

We tested 373 urine samples, of them 257 (68.9%) were from females and 116 (31.1%) from males. Primary cultivation detected growth (>10⁵ cfu/mL) from 206 (55.23%) samples; Gram-negative isolates were the most common isolates; these included Escherichia coli (111, 51.87%), and Klebsiella pneumoniae (19, 8.88%), while Staphylococcus aureus (14, 6.54%) was the main Gram-positive isolate. From the 1940 individual comparisons of DST and AST of single (pure) bacterial isolates, 12 comparisons (0.6%) represented very major errors, 9 (0.5%) major errors, 36 (1.8%) minor errors, and 1883 comparisons (97.1%) were in agreement.

CONCLUSION

E. coli was the most common isolate. Cefixime and cefpodoxime were found to be the most ineffective antimicrobial agents, while meropenem and nitrofurantoin were the most effective agents against all isolated urinary pathogens. DST and AST almost give the same results in pure cultures, and direct antimicrobial susceptibility for urine specimens can safely replace standard antimicrobial susceptibility in urinary tract infection.

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

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