Gram negative bacteria related urinary tract infections: spectrum of antimicrobial resistance over 9 years in a University tertiary referral Hospital

Objective

Overuse of antibiotics has led to an increase in antimicrobial resistance (AMR) worldwide, with a negative impact on the healthcare system and the patients. In this context, our study aims to assess the current AMR patterns of urinary tract infections (UTIs) associated to Gram-negative bacteria. Thus, we provide useful information for doctors dealing with prophylactic and therapeutic empiric therapies.

Materials and methods

We retrospectively analysed more than 650,000 urine cultures collected in the Microbiology Department of a referral University Hospital of Southern England from January 2014 to December 2022.

Results

AMR spectra for 164,059 Gram-negative associated (UTIs) were analysed. The lowest percentage of resistance was found for Amikacin (2.30%), Gentamicin (5.89%) and Co-Amoxiclav (10.49%). Over a 9-year time, there was no significant change in resistance to Amikacin (2.04% in 2014 compared to 2.18% in 2022; p = 0.602) and to Fosfomycin (11.50% in 2014 versus 16.65% in 2022; p = 0.577). Overall, the trend of AMR significantly rose for Cefalexin (17.96-18.42%; p < 0.0001), Co-amoxiclav (9.46-12.69%; p < 0.0001), Nitrofurantoin (10.20-14.18%; p < 0.0001) and Piperacillin/Tazobactam (14.52-18.96%; p < 0.0001). Gram-negative resistance spectrum towards Ciprofloxacin (11.83-9.01%; p < 0.0001), Gentamicin (6.29-5.26%; p < 0.0001), Pivmecillinam (26.88-11.02%; p < 0.0001), Trimethoprim (36.72-29.23%; p < 0.0001) and Ampicillin/Amoxicillin (65.20-57.99%; p < 0.0001) significantly decreased.

Conclusion

Despite the application of national and international guidelines for prophylaxis and treatment of UTIs, the spectrum of resistance for the most common antibiotics is still changing. Clinicians in primary and secondary care must keep that in mind when prescribing antibiotics for suspected UTI and sepsis associated with Gram-negative infections Up-to-date therapeutic strategies can help implement treatment of UTI, reducing selection of multi-resistant pathogens and providing more accurate care for patients. Future studies will be required to help clinicians and keep the guidelines updated.

Outcomes of Elective Ureteroscopy for Ureteric Stones in Patients with Prior Urosepsis and Emergency Drainage: Prospective Study over 5 yr from a Tertiary Endourology Centre

BACKGROUND

Elective treatment of ureteric stones is needed after emergency drainage of urosepsis.

OBJECTIVE

We wanted to look at the outcomes of elective ureteroscopic stone treatment in patients with prior sepsis and emergency drainage via retrograde ureteric stent (RUS) or percutaneous nephrostomy (PCN).

DESIGN, SETTING, AND PARTICIPANTS

Data of all patients who underwent elective ureteroscopy (URS) for stone disease over 5 yr (March 2012-December 2016) were prospectively collected.

INTERVENTION

Elective URS following previous emergency RUS or PCN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcomes were collated for consecutive patients who underwent emergency drainage for urosepsis secondary to stone disease, followed by elective URS. Data was collected regarding patient demographics, stone parameters, and clinical outcomes. Statistical analysis was performed using SPSS version 24.

RESULTS AND LIMITATIONS

In total, 76 patients underwent 82 elective procedures (six underwent bilateral URS) with a male to female ratio of 1:2 and a mean age of 57 yr. Emergency decompression was achieved via RUS in 63 (83%) and PCN in 13 (17%) patients. A positive urine culture on presentation was obtained in 26 (34%) patients, and 27 (36%) patients were admitted to the intensive care unit (ICU). The mean single and overall stone size was 8.6 (2-23) and 10.8 (2-32) mm, respectively. The mean operating time was 42 (5-129) min with stone-free rate (SFR) of 97% (n=74). There were three (4%) complications in total, of which two patients developed urinary tract infection needing intravenous antibiotics (Clavien II) and a third developed sepsis (Clavien IV) needing ICU admission. There was no difference in ureteroscopic lithotripsy outcomes (operative time, complications, or SFR) on comparing initial RUS or PCN, admission to ICU or ward, positive or negative urine culture result, presence of single or multiple stones, and between American Society of Anaesthesiologists (ASA) grade of patients. The ASA grade of patients was a significant predictor of day case procedures (p=0.001).

CONCLUSIONS

Elective URS achieved excellent outcomes in patients who previously presented with obstructing calculi and sepsis needing emergency decompression. Overnight inpatient admission was needed in some patients with a higher ASA grade.

PATIENT SUMMARY

In this report, we look at the outcomes of planned ureteroscopy procedures for stone disease in patients with previous urosepsis. These patients with previous emergency drainage for urosepsis had excellent outcomes from their planned ureteroscopic surgery. This information will help in preoperative patient optimisation and counselling.