Best pharmacological practice: urinary tract infections

Efficacy and safety of NI-0101, an anti-toll-like receptor 4 monoclonal antibody, in patients with rheumatoid arthritis after inadequate response to methotrexate: a phase II study

OBJECTIVES

Anti-citrullinated protein antibodies (ACPAs) form immune complexes with citrullinated proteins binding toll-like receptor (TLR) 4, which has been proposed as a mediator of rheumatoid arthritis (RA). NI-0101 is a first-in-class humanised monoclonal antibody blocking TLR4, as confirmed by inhibition of in vivo lipopolysaccharide-induced cytokine release in healthy volunteers. This study was design to confirm preclinical investigations supporting a biomarker-driven approach for treatment of patients with RA who present positive for these immune complexes.

METHODS

Placebo-controlled, double-blind, randomised (2:1) trial of the tolerability and efficacy of NI-0101 (5 mg/kg, every 2 weeks for 12 weeks) versus placebo in ACPA-positive RA patients with inadequate response to methotrexate. Efficacy measures included Disease Activity Score (28-joint count) with C reactive protein (DAS28-CRP), European League Against Rheumatism (EULAR) good and moderate responses, and American College of Rheumatology (ACR) 20, ACR50 and ACR70 responses. Subgroup analyses defined on biomarkers were conducted. Pharmacokinetics, pharmacodynamics and safety were reported.

RESULTS

90 patients were randomised (NI-0101 (61) and placebo (29)); 86 completed the study. No significant between-group difference was observed for any of the efficacy endpoints. Subgroup analyses using baseline parameters as covariants did not reveal any population responding to NI-0101. Treatment-emergent adverse events occurred in 51.7% of patients who received placebo versus 52.5% for NI-0101.

CONCLUSIONS

We demonstrate for the first time that in RA, a human immune-mediated inflammatory disease, blocking the TLR4 pathway alone does not improve disease parameters. Successful targeting of innate immune pathways in RA may require broader and/or earlier inhibitory approaches.

Retrospective evaluation of nitrofurantoin and pivmecillinam for the treatment of lower urinary tract infections in men

OBJECTIVES

This study aimed to retrospectively assess the clinical outcome with nitrofurantoin and pivmecillinam for lower urinary tract infections (UTI) in men. Patients treated with trimethoprim were also included for comparison.

METHODS

All prescriptions of the study antibiotics to adult men in Uppsala County, Sweden, during 2012 were extracted. Data on patient characteristics, therapy, clinical outcome and microbiological results were obtained from the electronic medical records. The relative impact of antibiotic therapy, patient factors and pathogens on clinical outcome was assessed with univariate logistic regression using a 95% confidence interval (CI).

RESULTS

832 prescriptions were identified, and 171 patients treated with nitrofurantoin (n = 69), pivmecillinam (n = 57) and trimethoprim (n = 45) met the inclusion criteria. Treatment failure occurred in one patient treated with nitrofurantoin and in four patients treated with pivmecillinam. New prescriptions of UTI antibiotics and relapse within 3 months after completion of therapy were more frequent with nitrofurantoin (34% and 15%) and pivmecillinam (30% and 17%) than trimethoprim (22 and 7%). However, these differences were not statistically significant and substantial heterogeneity was noted between the treatment groups. Urinary tract catheterization was associated with a higher risk for new antibiotic prescriptions (OR 2.34, 95% CI 1.14-4.80; P = 0.022) and prostate cancer was associated with a higher incidence of relapse (OR 3.01, 95% CI 1.09-8.29; P = 0.042).

CONCLUSIONS

The clinical outcome with nitrofurantoin and pivmecillinam was acceptable in comparison with the results of previous studies. These antibiotics are suitable for empirical treatment of lower UTI in men considering their high activity against Escherichia coli and limited impact on the intestinal microbiota.

Comparative effectiveness of antibiotics for uncomplicated urinary tract infections: network meta-analysis of randomized trials

BACKGROUND

The efficacies and adverse effects of different antibiotics for uncomplicated urinary tract infections (UTIs) have been studied by standard meta-analytic methods using pairwise direct comparisons of antimicrobial treatments: the effects of one treatment are compared to those of either another treatment or placebo. However, for clinical decisions, we need to know the effectiveness of each possible treatment in comparison with all relevant alternatives, not with just one.

OBJECTIVES

To compare the efficacies and adverse effects of all relevant antibiotics for UTI treatment simultaneously by performing a network meta-analysis using direct and indirect treatment comparisons.

METHODS

Using logistic regression analysis, we performed a network meta-analysis of randomized controlled trials (RCTs) published after 1999 that compared different oral antibiotic or placebo regimens for UTI treatment in general practice or outpatient settings. We looked at five binary outcomes: early clinical, early bacteriological, late clinical and late bacteriological outcomes, as well as adverse effects. Consequently, a ranking of the antibiotic regimens could be composed.

RESULTS

Using a network structure, we could compare and rank nine treatments from 10 studies. Overall, ciprofloxacin and gatifloxacin appeared the most effective treatments, and amoxicillin-clavulanate appeared the least effective treatment. In terms of adverse effects, there were no significant differences.

DISCUSSION

Network meta-analysis shows some clear efficacy differences between different antibiotic treatments for UTI in women. It provides a useful tool for clinical decision making in everyday practice. Moreover, the method can be used for meta-analyses of RCTs across primary care and beyond.

The clinical and imaging presentation of acute "non complicated" pyelonephritis: a new profile for an ancient disease

BACKGROUND

Acute pyelonephritis (APN) is differently defined according to imaging or clinical criteria. In adults information on the relationship between imaging and clinical data is lacking.Our study was aimed at analysing the relationship between the clinical and imaging presentation of APN, defined according to imaging criteria (parenchymal involvement at MR or CT scan).

METHODS

All consecutive patients hospitalized for "non-complicated" APN were considered (June 2005-December 2009). Clinical, biochemical and imaging data at hospitalization were analyzed by univariate and logistic regression analysis.

RESULTS

There were 119 patients, all females, median age 32 years (15-72). At hospitalization, inflammatory markers were elevated (CRP median: 12.1 mg/dL, normal < 0.8). Incomplete presentations were frequent: fever was absent in 6.7%, pain in 17.8%, lower urinary tract symptoms in 52.9%. At CT or MR scan the lesions were bilateral in 12.6%, multiple in 79.8%; abscesses were present in 39.5%. Renal scars were found in 15.1%. Positive cultures were correlated with multiple foci (multivariate OR 4.2; CI 1.139-15.515). No other sign/symptom discriminated between small lesions, abscesses or multifocal involvement.

CONCLUSIONS

APN is a protean disease. In the absence of strict correlation with clinical or biochemical markers, imaging studies are required to assess the severity of kidney involvement.

[Antimicrobial and clinical efficacy of nitrofurantoin in the treatment of acute lower urinary tract infections in adults]

BACKGROUND AND PURPOSE

In the light of increasing resistance to antibiotics used for the treatment of acute urinary tract infections, nitrofurantoin currently experiences a renaissance. Nitrofurantoin shows good efficacy against most bacteria expected in urinary tract infection, and the development of resistance is low. A study on the antimicrobial and clinical efficacy of nitrofurantoin in the treatment of acute lower urinary tract infections was conducted in Mexico City, an area where resistance rates of uropathogens to trimethoprim/sulfamethoxazole (cotrimoxazole) are high.

PATIENTS AND METHODS

In this open-label, single-arm study 20 adult patients (18 females, 2 males) with positive urine culture were treated orally with nitrofurantoin sustained release 100 mg twice daily for 7 days. Urinary nitrofurantoin concentrations were determined at baseline and day 4 of the study. Primary endpoint was the antimicrobial efficacy of nitrofurantoin at 12 to 16 days after baseline, assessed by changes in urine culture results.

RESULTS

In the patient population treated per protocol, primary endpoint analysis revealed a microbial eradication rate of 92.3%. At 35 to 42 days, the eradication rate was 83.3%. At these times, all patients in the per protocol population were free of symptoms. In patients with complicating factors, e.g. diabetic polyneuropathy, both antimicrobial and clinical efficacy appeared to be reduced. Urinary nitrofurantoin concentrations were mostly above minimum inhibitory concentrations of the isolated uropathogens. The study drug was generally well tolerated. Most frequent drug-related adverse event was mild headache, occurring in 10.8% of patients. Two patients discontinued the study due to rash.

CONCLUSION

The results of the present study indicate good antimicrobial and clinical efficacy of nitrofurantoin in the treatment of acute uncomplicated urinary tract infections as well as acceptable tolerability in adults.

Control of antibiotic use by a unit-dose drug distribution system

The aim of the study was to test a new model of drug distribution known as unit-dose drug distribution including the effects of implementing this system on total drug consumption, especially in curbing antimicrobial use.

The study was carried out in the Department of Surgery at the University Clinical Center in Nis, Serbia. During the first six months of the study (comparative period), drugs were delivered directly from the pharmacy to the urology and orthopedic wards in the traditional way (ward stock system). During the next six months (study period), drugs were delivered directly from the pharmacy to the patients (unit-dose drug distribution system). Drug consumption was measured using the statistical unit defined daily dose (DDD) per 100 bed days according to the anatomical-therapeutic-chemical classification of drugs. Following implementation of the unit-dose drug distribution system, total drug consumption was reduced by 24.34% in the urology ward and by 21.43% in the orthopedic ward. During the comparative period, in the urology and orthopedic wards, systemic antiinfectives (group J) comprised 263.54 and 227.61 DDD/100 bed days or 43.05% and 25.52% of total drug consumption respectively, whereas, during the pilot study period this group of drugs comprised 191.63 and 173.52 DDD/100 bed days or 41.37% and 24.96% of total drug consumption respectively.

The unit-dose distribution system of drugs in hospitals leads to a control of drug consumption and substantial savings. Also, the pharmacist-physician interaction began to emerge as an important factor as a direct result of the changes in the drug distribution system.

Evaluation of subgingival bacterial plaque changes and effects on periodontal tissues in patients with renal transplants under immunosuppressive therapy

OBJECTIVE

The purpose of this study was to identify the presence of periodontal microrganisms in 35 renal transplant patients before the transplant procedure.

STUDY DESIGN

At each time point, clinical parameters were recorded and subgingival plaque samples were collected from 4 different sites at days 30 and 90 after surgery. Samples were plated onto selective and nonselective media to determine total colony counts and the presence of putative periodontal pathogens. After transplant surgery, patients received immunosuppressive therapy.

RESULTS

Statistical analysis of the microbiologic data showed significant changes between time points. An increase in total counts of microrganisms was observed on day 90 after surgery. As a side effect of cyclosporine, 14 patients developed gingival overgrowth. Beta-hemolytic Streptococcus was more frequently detected in patients who did not present gingival overgrowth 90 days after surgery.

CONCLUSION

Quantitative and qualitative changes of the subgingival microflora can occur 90 days after transplant surgery, while patients are still under immunosupressive drugs.

Rational antibiotic treatment of outpatient genitourinary infections in a changing environment

In the outpatient setting, genitourinary infections (GUIs) remain costly to treat and are a significant cause of morbidity. Recent evidence supports more substantial roles for pathogens other than Escherichia coli, particularly gram-positive pathogens, in the pathogenesis of GUIs. Broad-spectrum agents should be considered in order to address this etiologic change appropriately. Criteria for antimicrobial selection set forth by the Council for Appropriate and Rational Antibiotic Therapy (CARAT) recommend using antibiotics that are supported by strong clinical evidence, have good susceptibility profiles, are safe, are cost-effective, and are used for the optimal duration. Evidence-based guidelines recommend considering local E coli resistance rates to trimethoprim-sulfamethoxazole and using fluoroquinolones as second-line therapy when resistance is high. Fluoroquinolones are recommended for the treatment of pyelonephritis and prostatitis. Among the fluoroquinolones, levofloxacin and gatifloxacin offer coverage for the gram-negative and gram-positive pathogens, which may make them preferable in treating urinary tract infections empirically in such patient groups. For the treatment of bacterial prostatitis, only trimethoprim and the fluoroquinolones possess both the appropriate bactericidal activity and the ability to diffuse into the prostate. Levofloxacin shows particularly good penetration into prostatic tissue. Safety issues to consider include imbalances in intestinal microflora caused by antimicrobial agents that may lead to overgrowth of vancomycin-resistant enterococci and Clostridium difficile-associated diarrhea. Once the optimal agent is identified, the optimal duration of treatment should be determined to maximize treatment success while minimizing the potential for resistance. Finally, cost considerations include the costs of treatment failure due to inappropriate therapy or nonadherence to the therapeutic regimen.

Fosfomycin tromethamine in uncomplicated urinary tract infections: a clinical study

The aim of our study was to verify if the empiric therapy with a single dose of 3 g fosfomycin tromethamine in patients with uncomplicated urinary tract infections (UTIs) was able to clinically resolveand to microbiologically eradicate the infection. A total of 387 out of the 400 patients (274 cases with acute and 113 cases with recurrent uncomplicated UTIs) were enrolled in the clinical study. Clinical and microbiological assessments were performed before and at 8-10 days after the administration. At follow-up high clinical recovery (88.9%) and bacteriological (94.9%) eradication rates were achieved. Gastrointestinal side effects were found in only 4.3% of patients. In conclusion, a single-dose administration regimen of fosfomycin tromethamine should be encouraged as a first choice of drug therapy for uncomplicated UTIs.