Antibiotics For Treatment Of Urinary Tract Infections Research Articles

Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection

Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. ClinicalTrials.gov Identifier: NCT03697096.

Which Antibiotic for Urinary Tract Infections in Pregnancy? A Literature Review of International Guidelines.

Urinary tract infection (UTI) is considered to be a major problem in pregnant women. It is also one of the most prevalent infections during pregnancy, being diagnosed in as many as 50-60% of all gestations. Therefore, UTI treatment during pregnancy is extremely important and management guidelines have been published worldwide to assist physicians in selecting the right antibiotic for each patient, taking into account the maternal and fetal safety profile. A review of the literature was carried out and all international guidelines giving recommendations about antibiotic treatments for pregnancy-related UTI were selected. The search came back with 13 guidelines from 4 different continents (8 from Europe, 3 from South America, 1 from North America and 1 from Oceania). Our review demonstrated concordance between guidelines with regard to several aspects in the antibiotic treatment of UTI during pregnancy and in the follow-up after treatment. Nonetheless, there are some areas of discordance, as in the case of antenatal screening for bacteriuria and the use of fluoroquinolones in lower or upper UTI. Given the current evidence that we have from international guidelines, they all agree on several key points about antibiotic use.

Prevalence, etiology and antibiotic resistance patterns of community-acquired urinary tract infections in Dhaka, Bangladesh.

Urinary tract infection (UTI) accounts for a significant morbidity and mortality across the world and is a leading cause for antibiotic prescriptions in the community especially in developing countries. Empirical choice of antibiotics for treatment of UTI is often discordant with the drug susceptibility of the etiologic agent. This study aimed to estimate the prevalence of community-acquired UTI caused by antibiotic resistant organisms. This was a cross-sectional study where urine samples were prospectively collected from 4,500 patients at the icddr,b diagnostic clinic in Dhaka, Bangladesh during 2016–2018. Urine samples were analyzed by standard culture method and the isolated bacteria were tested for antibiotic susceptibility by using disc diffusion method and VITEK-2. Descriptive statistics were used to estimate the prevalence of community acquired UTI (CA-UTI) by different age groups, sex, and etiology of infection. Relationship between the etiology of CA-UTI and age and sex of patients was analyzed using binary logistic regression analysis. Seasonal trends in the prevalence of CA-UTI, multi-drug resistant (MDR) pathogens and MDR Escherichia coli were also analyzed. Around 81% of patients were adults (≥18y). Of 3,200 (71%) urine samples with bacterial growth, 920 (29%) had a bacterial count of ≥1.0x105 CFU/ml indicating UTI. Women were more likely to have UTI compared to males (OR: 1.48, CI: 1.24–1.76). E. coli (51.6%) was the predominant causative pathogen followed by Streptococcus spp. (15.7%), Klebsiella spp. (12.1%), Enterococcus spp. (6.4%), Pseudomonas spp. (4.4%), coagulase-negative Staphylococcus spp. (2.0%), and other pathogens (7.8%). Both E. coli and Klebsiella spp. were predominantly resistant to penicillin (85%, 95%, respectively) followed by macrolide (70%, 76%), third-generation cephalosporins (69%, 58%), fluoroquinolones (69%, 53%) and carbapenem (5%, 9%). Around 65% of patients tested positive for multi-drug resistant (MDR) uropathogens. A higher number of male patients tested positive for MDR pathogens compared to the female patients (p = 0.015). Overall, 71% of Gram-negative and 46% of Gram-positive bacteria were MDR. The burden of community-acquired UTI caused by MDR organisms was high among the study population. The findings of the study will guide clinicians to be more selective about their antibiotic choice for empirical treatment of UTI and alleviate misuse/overuse of antibiotics in the community.

Impact of a Machine Learning-Based Decision Support System for Urinary Tract Infections: Prospective Observational Study in 36 Primary Care Practices.

BackgroundThere is increasing attention on machine learning (ML)-based clinical decision support systems (CDSS), but their added value and pitfalls are very rarely evaluated in clinical practice. We implemented a CDSS to aid general practitioners (GPs) in treating patients with urinary tract infections (UTIs), which are a significant health burden worldwide.ObjectiveThis study aims to prospectively assess the impact of this CDSS on treatment success and change in antibiotic prescription behavior of the physician. In doing so, we hope to identify drivers and obstacles that positively impact the quality of health care practice with ML.MethodsThe CDSS was developed by Pacmed, Nivel, and Leiden University Medical Center (LUMC). The CDSS presents the expected outcomes of treatments, using interpretable decision trees as ML classifiers. Treatment success was defined as a subsequent period of 28 days during which no new antibiotic treatment for UTI was needed. In this prospective observational study, 36 primary care practices used the software for 4 months. Furthermore, 29 control practices were identified using propensity score-matching. All analyses were performed using electronic health records from the Nivel Primary Care Database. Patients for whom the software was used were identified in the Nivel database by sequential matching using CDSS use data. We compared the proportion of successful treatments before and during the study within the treatment arm. The same analysis was performed for the control practices and the patient subgroup the software was definitely used for. All analyses, including that of physicians’ prescription behavior, were statistically tested using 2-sided z tests with an α level of .05.ResultsIn the treatment practices, 4998 observations were included before and 3422 observations (of 2423 unique patients) were included during the implementation period. In the control practices, 5044 observations were included before and 3360 observations were included during the implementation period. The proportion of successful treatments increased significantly from 75% to 80% in treatment practices (z=5.47, P<.001). No significant difference was detected in control practices (76% before and 76% during the pilot, z=0.02; P=.98). Of the 2423 patients, we identified 734 (30.29%) in the CDSS use database in the Nivel database. For these patients, the proportion of successful treatments during the study was 83%—a statistically significant difference, with 75% of successful treatments before the study in the treatment practices (z=4.95; P<.001).ConclusionsThe introduction of the CDSS as an intervention in the 36 treatment practices was associated with a statistically significant improvement in treatment success. We excluded temporal effects and validated the results with the subgroup analysis in patients for whom we were certain that the software was used. This study shows important strengths and points of attention for the development and implementation of an ML-based CDSS in clinical practice.Trial RegistrationClinicalTrials.gov NCT04408976; https://clinicaltrials.gov/ct2/show/NCT04408976

Spectrum and Antibiotic Resistance Pattern of Bacteria Causing Urinary Tract Infections (UTI) in a Tertiary Care Hospital

Background: Urinary tract infection (UTI) is one of the most common bacterial infections encountered by clinicians particularly in developing countries. Current knowledge on antimicrobial resistance pattern is essential for appropriate therapy. The aim of the present study was to identify the causative organisms for UTI and to determine the antibiotic susceptibility pattern of organisms causing UTI.&#x0D; Method: This cross sectional study was carried out in the department of Microbiology, Sir Salimullah Medical College, Dhaka, from a period of January 2014 to December 2014.&#x0D; Results: Out of 2136 clinical sample of urine, 430 (20.1%) showed significant bacterial growth. Escherichia coli was the commonest urinary pathogen (76.3%), followed by Pseudomonas spp. (7.9%), Proteus spp. (7.2%), Klebsiella spp., Citrobacter spp. (1.9% each) and Staphylococcus aureus (1.6%). Isolated uropathogens showed highest resistance for Amoxycillin (86%-97%) and Cefradin (71%-100%), resistance rate for other commonly used antimicrobial agents was high; Cefixime (52%-85%), Ceftriaxone (50%-71%), Ciprofloxacin (50%-88%), Cotrimoxazole (50%-75%), Gentamicin (57%-75%) and Nitrofurantoin (43%-100%), while uropathogens were least resistant to Imipenem (0%-15%) and Amikacin (0%-29%).&#x0D; Conclusion: Due to high degree of resistance to commonly used antimicrobials to treat UTI, routine monitoring and evaluation studies should be conducted to update physicians’ knowledge about most effective antibiotics for treatment of UTI.&#x0D; Journal of Surgical Sciences (2019) Vol. 23 (1) : 13-18

Prevalence and Antibiotic Resistance Patterns of Gram-Negative Uropathogens among Paediatric Patients in Nigeria

Objective: This study aimed to detect and compare the frequency and antibiotics resistant pattern of Gram-negative uropathogens implicated in urinary tract infections (UTIs) in paediatric patients attending some hospitals in Nigeria and to proffer recommendations for its management. Methods: Based on standard procedures, midstream urine samples were collected. Urinalysis was done as a preliminary diagnosis of UTI using Combi-9 test strip. Isolation of uropathogen was done and antibiotic sensitivity test was carried out using Kirby-Bauer technique. Results: Out of 489 samples collected, 130 (26.4%) was positive for UTI. The prevalence rate of UTI in the investigated areas such as Nsukka, Otukpo, Gboko and Kastina Ala was 31.8%, 17.5%, 34.3% and 17.1%, respectively. The prevalence of UTI was higher in males 81 (30.9%) than in females 49 (21.6%), but there was no statistically significant association between gender and UTI (p = 0.636). The prevalence of UTI was greater among the age of 2 - 5 years (28.2%) and decreased with the increase in age, although there was no significant association between UTI and the age groups (p = 0.870). Generally, Klebsiella pneumonae (88.8%) was the most dominant bacterium (it was even more in males), followed by E. coli (40.6%), which was more in females, then Pseudomonas spp. (45.0%) and Proteus mirabilis (13.8%). The in-vitro antibiotic susceptibility testing shows that the isolate was highly resistant to Augmentin, Cotrimoxazoel, Amoxicilin and Tetracycline, while some of the isolate shows intermediate resistant to Nitrofurantoin and Nalixidic acid. Ofloxacine and Gentamicin were the most effective antibiotics against the isolates from all the study areas. The isolates had a varied range of MICs and MBCs. Conclusion: K. pneumonia predominated all isolates. The resistant patterns of the isolates to some of the antibiotics show that the first line of antibiotics for treatment of UTI in children in these areas is Ofloxacine and Gentamicin.

A 4-year Study of Community Acquired Urinary Tract Infections from a Tertiary Diagnostic Centre in Mumbai with Special Reference to MIC Values

Urinary Tract Infections (UTIs) are among the most frequent infectious diseases affecting humans, and represent an important public health problem with a substantial economic burden. Due to the high empiric use of antibiotics for treatment of UTI, antibacterial resistance of Enterobacteriaceae, specifically the main uropathogens Escherichia coli and Klebsiella pneumoniae, has significantly increased worldwide. A retrospective analysis of cases of community acquired UTI reported over last 4 years at Suburban Diagnostics was done. A total of 27,501 cases of UTI were analysed retrospectively. Growth was found in 12,476 (45.36%). 15,025 (54.63%) cases were sterile on culture. Community acquired UTI is showing increasing resistance as seen in our study of 4 years with around 27,000 cases of UTI and around 12,000 isolates. High rates of ESBL-64% of E. coli and 54% Klebsiella isolates found in our study reinforce the fact that this form of resistance is common in community acquired UTI.

Delay in Antibiotic Treatment for UTIs and Renal Scarring

Research Article| October 01 2016 Delay in Antibiotic Treatment for UTIs and Renal Scarring AAP Grand Rounds (2016) 36 (4): 38. https://doi.org/10.1542/gr.36-4-38 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Delay in Antibiotic Treatment for UTIs and Renal Scarring. AAP Grand Rounds October 2016; 36 (4): 38. https://doi.org/10.1542/gr.36-4-38 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: renal scarring, urinary tract infections, fever Source: Shaikh N, Mattoo TK, Keren R, et al. Early antibiotic treatment for pediatric febrile urinary tract infection and renal scarring [published online ahead of print July 25, 2016]. JAMA Pediatr; doi: https://doi.org/10.1001/jamapediatrics.2016.1181 Investigators at multiple institutions conducted a retrospective cohort study of data from 2 previous longitudinal studies (the Randomized Intervention for Children With Vesicoureteral Reflux [RIVUR] trial and the Careful Urinary Tract Infection Evaluation [CUTIE] Study) to determine whether delay in the initiation of antimicrobial treatment for febrile urinary tract infection (UTI) is associated with the occurrence of renal scarring in children. Participants in the RIVUR and CUTIE studies were 2 to 72 months old, presented for their first or second UTI at primary or subspecialty care settings, and were prospectively followed up for 2 years. The RIVUR study enrolled children with vesicoureteral reflux (VUR), while the CUTIE study enrolled children without VUR. Parents of participants in each study were asked at enrollment about the duration of their child’s fever before antimicrobial therapy for the index UTI was started. Children in both studies also received a technetium Tc 99m DMSA renal scan at baseline and at either the 24-month follow-up appointment or several months after being withdrawn from the study due to recurrent UTIs. The primary exposure variable was delay in the initiation of antimicrobial therapy, defined as parent self-reported duration of time between the onset of fever and the start of antimicrobial therapy. The primary outcome was new renal scarring, defined as the presence of areas of photopenia plus contour changes on the follow-up DMSA scan that were not present on the baseline scan. Logistic regression was used to determine the association of delay in initiating antimicrobial therapy and new renal scarring after adjusting for potential confounding variables. Of the 802 participants in the RIVUR and CUTIE studies, 482 were included in analysis. Among included participants, 90% were female, 78% were white, 7% had new renal scarring, and the median number of hours to initiation of antimicrobial therapy was 56.3 hours. Participants with new renal scarring had a significantly longer median time to initiation of antimicrobial therapy than those without new renal scarring (72 vs 48 hours, respectively; P = .003). Older age, Hispanic ethnicity, recurrent UTIs, and bladder and bowel dysfunction were also associated with new renal scarring. The association between delay in the initiation of antibiotic therapy and renal scarring remained statistically significant after adjusting for these other variables. The researchers conclude that there is an association between a delay in the initiation of antibiotic treatment and renal scarring. Dr. Brady has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. This study demonstrated that a delay of >48 hours in initiating antibiotics for a UTI increases the odds of renal scarring. Strengths of this study are its longitudinal follow-up of children for 2 years and its comparison of baseline and late DMSA scans for... You do not currently have access to this content.

Bacterial Etiologies and Antibiotic Susceptibility Pattern of Urinary Tract Infections at the Pediatric Ward of Dastgheib Hospital, Shiraz, Iran: A Three-Year Study (2009 - 2011)

Background: Urinary tract infection (UTI) is one of the most common infections in children. Timely diagnosis and appropriate treatment of UTI requires knowledge of etiologic agents and antibiotic resistance pattern of common uropathogens. Objectives: The aim of this study was to determine bacterial agents and their antibiotic susceptibility patterns at pediatric ward of Dastgheib hospital, Fars province, Shiraz, Iran. Patients and Methods: In this three-year (2009 - 2011) cross-sectional descriptive study, 2854 urine specimens were collected by midstream, urine bag, catheter and suprapubic methods from patients in the age range of 1 month to 14 years. For isolation of uropathogens, samples were cultured on differential and selective media and identified with biochemical tests. Antimicrobial susceptibility testing was then performed using the Kirby Bauer method, following the clinical and laboratory standard institute (CLSI) guidelines. All data were analyzed with the SPSS software (version 15). Results: The most common pathogen was Escherichia coli (65.2%) followed by Staphylococcus saprophyticus (10.9%). Escherichia coli isolates showed the highest and lowest resistance rates to cephalexin (60.5%) and imipenem (11.6%), respectively. Staphylococcus saprophyticus isolates were mostly susceptible to vancomycin (81%), followed by nitrofurantoin (76.8%); however, only 36% of staphylococcus saprophyticus isolates were susceptible to co-trimoxazole. Conclusions: In this study, like previous researches, E. coli was the most common pathogen. Our results suggested a high rate of antibiotic resistance to common antibiotics for treatment of UTI. Because of the high resistance to cephalexin, cefotaxime and cotrimoxazole, their use is not recommended for treatment of UTIs. Imipenem and vancomycin were the most active drugs against E. coli and Staphylococcus saprophyticus, respectively.

Urinary cytokines as markers of latent inflammation in children with chronic pyelonephritis and anorectal malformations

Anorectal malformations (ARMs) comprise a range of defects in the development of the lowest portion of the intestinal tract that are often associated with anomalies of the urinary tract. We hypothesize that ARMs may specifically predispose the patients to prolonged urinary tract infection (UTI) and transition from a state of active (clinically apparent) inflammation to a state of latent inflammation following antibiotic treatment. Yet diagnosis of latent inflammation in the urinary tract is problematic. The aim was to investigate the urinary levels of proinflammatory (IL-1β, IL-6, IL-8, and MCP-1), anti-inflammatory (IL-10), and proangiogenic (VEGF) cytokines in the clinical course of chronic pyelonephritis (CP) as potential biomarkers of latent inflammation in the urinary tract in children with ARM. A total of 34 children (age range 4-120 months) with CP in the active phase of inflammation were divided into two groups: CP with ARM group included 20 patients and CP without ARM group included 14 patients. The control group included 20 healthy children similar by age and gender. Urine samples were collected at the time of enrollment, 5-7 days after institution of antibiotic treatment, and 1.5 months after enrollment. Cytokine concentrations were measured by ELISA. Upon enrollment, we detected increased urinary levels of IL-10 and MCP-1 and normal levels of IL-1β, IL-6, IL-8, and VEGF in CP with ARM patients as well as normal levels of all of these cytokines in CP without ARM patients. After 5-7 days of antibiotic treatment, despite significant clinical and laboratory improvement observed in both patient groups, we documented a prominent increase in the urinary concentrations of all measured cytokines indicating ongoing inflammation in the urinary tract. Following 1.5 months of enrollment, in CP without ARM patients, IL-8 and MCP-1 were increased, IL-1, IL-6, and VEGF were close to control, and IL-10 was below the control level, indicating partial resolution of the inflammatory process. In contrast, in CP with ARM patients, IL-1β, IL-6, IL-8, MCP-1, and VEGF were increased suggesting persistent inflammation in the urinary tract (Table). Based on the urinary cytokine profile, we conclude that presence of ARM may be associated with transition from active to latent inflammation in the urinary tract after antibiotic treatment for UTI. Follow-up monitoring of the urinary cytokines may provide a better assessment of inflammatory activity in the urinary tract in children with combined urological and anorectal pathologies.

Susceptibility of Urinary Tract Bacteria to Newer Antimicrobial Drugs.

Urinary tract infections (UTIs) are among the commonest types of bacterial infections. The antibiotic treatment for UTIs is associated with important medical and economic implications. Many different microorganisms can cause UTIs though the most common pathogens are E. coli and members of family Enterobacteriaceae. The knowledge of etiology and antibiotic resistance pattern of the organisms causing urinary tract infection is essential. The present study was undertaken to evaluate trends of antibiotic susceptibility of commonly isolated uropathogens using newer antimicrobial agents, prulifloxacin, fosfomycin (FOM) and doripenem. We conclude that maintaining a record of culture results and the antibiogram may help clinicians to determine the empirical and/or specific treatment based on the antibiogram of the isolate for better therapeutic outcome.

Community-acquired urinary tract infections: Causative agents and their resistance to antimicrobial drugs.

Urinary tract infections (UTIs) are among the most common infections in outpatients. The aim of this study was to define the causative agents of urinary tract infections and their resistance to antimicrobial drugs in the urban area of central Serbia, as well as to evaluate eventual differences associated with age and gender of the patients. This retrospective study analysed data taken from routine, consecutively collected urine cultures of outpatients with symptomatic UTIs, collected from the Department of Microbiology, Institute of Public Health in Kragujevac, Serbia, from January 2009 to December 2013. There were 71,905 urine cultures, and 24,713 (34.37%) of them were positive for bacterial pathogens. The most common pathogen was Escherichia coli (E. coli) (56.56%), followed by Klebsiella spp. (16.20%), Proteus spp. (14.68%), Enterococcus spp. (5.29%) and Pseudomonas aeruginosa (3.74%). E. coli and Enterococcus spp. isolation rates were lower in males ≥ 60 years old (23.71% and 4.87%, respectively), while Klebsiella spp. was more prevalent in this group (32.06%). The most common causative agents isolated from 15–29 years old male patients were Enterococcus spp. and Pseudomonas aeruginosa (13.28% each). Among women, the isolation rate of E.coli was high in all age groups (around 70%). Proteus spp. was frequently isolated from females ≤ 14 years old (13.27%), while Klebsiella spp. was the most frequent in the oldest age female group (10.99%). Choice of antibiotics for treatment of UTIs should be governed not only by the local resistance patterns, but also by gender and age of patients.

PS-368 12 Years Data On Resistance Pattern Of Uropathogens: Abstract PS-368 Table 1

Background Urinary tract infection (UTI) is a common bacterial infection in infants and children. Traditionally, Trimethoprim has been the first line antibiotic of choice for the treatment of Coliform UTI. Empirical antibiotic treatment in UTI in children should be based on local surveillance data on the epidemiology and resistance patterns of common uropathogens. This has been endorsed in the guideline on UTI in children by National Institute for Health and Care Excellence in the UK. Aim To evaluate the resistance pattern to commonly used antibiotics in children with culture proven UTI. Methods We retrospectively analysed all cases with proven UTI from 2002–2013. Cases were identified by the clinical coding system and data obtained from the Hospital Information Support System. Results 1151 cases were identified; 95% (1090/1151) had pure growth of E.coli. Microbiology results were analysed to evaluate the sensitivities to commonly used antibiotics. Increasing resistance to Trimethoprim (TMP) and Co-Amoxiclav was observed during 2002–2008. Change in antibiotic policy has resulted in some decline in TMP resistance (Table below) over the recent years. Conclusion This comprehensive data on children with culture proved UTI supports the use of cefalexin as empirical treatment of choice for all presumed UTIs (pending culture results) in our region. Alternatively, TMP can be used (provided that urine sensitivity is known before commencing antibiotic treatment) if it is sensitive to coliform. It is vital to continue to monitor the resistance pattern to ensure early identification of emergence of drug resistance.

The Diagnosis of Urinary Tract Infection

Urinary tract infections (UTI) are among the leading reasons for treatment in adult primary care medicine, accounting for a considerable percentage of antibiotic prescriptions. Because this problem is so common and so significant in routine clinical practice, a high level of diagnostic accuracy is essential. Antibiotics should not be prescribed excessively, particularly in view of the increasing prevalence of antibiotic resistance. Systematic review of relevant articles that were retrieved by a search of the Medline, Embase, and Cochrane Library databases. The recommendations of selected international guidelines were also taken into account, as were the German national quality standards for microbiological diagnosis. The diagnosis of UTI by clinical criteria alone has an error rate of approximately 33%. The use of refined diagnostic algorithms does not completely eliminate uncertainty. With the aid of a small number of additional diagnostic criteria, antibiotic treatment for UTI can be provided more specifically and thus more effectively. Differentiating UTI from asymptomatic bacteriuria, which usually requires no treatment, can lower the frequency of unnecessary antibiotic prescriptions.

URINARY TRACT INFECTIONS IN SPINAL CORD INJURY: PREVENTION AND TREATMENT GUIDELINES

Objectives and Methods: The literature on prevention and therapy of urinary tract infection (UTI) in patients with spinal cord injury (SCI) was reviewed using 3 levels of evidence. Results: Antibiotic therapy is only indicated in symptomatic bacteriuria or in symptomatic exacerbations of chronic UTI. During the acute phase of a SCI, UTI’s are more prevalent and bacteria are different and more resistant to antibiotics compared with the chronic phase of SCI. In SCI in general, routine screening urine cultures are not valuable as a high species turn over is seen. Intermittent catheterisation, tapping or Crédé manoeuvre coincide significantly with lower frequency of UTI compared to permanent catheter drainage. No measures are proven efficient in the long term in prevention of bacteriuria or UTI. Methenamine salts are perhaps useful in the prevention of UTI but not in patients with a permanent catheter (level III). Antibiotic prophylaxis was found useful in reducing asymptomatic bacteriuria but not in the prevention of symptomatic infections (level I). However, during prophylaxis a doubling of antibiotic resistance was found. In patients with augmented bladder antibiotic prophylaxis is useless (level II). In chronic SCI the first choice antibiotics are nitrofurantoin or trimethoprim, the second choice are fluoroquinolones (level III) whereas in acute SCI a higher resistance profile to antibiotics is frequent and therefore fluoroquinolones or cefuroxime are suggested (level III). There is no consensus in the literature but we suggest 5 days of antibiotic treatment in UTI during chronic SCI without fever, 7 days in acute SCI without fever and a minimum of 14 days in patients with UTI and fever (level III).