Empiric Therapy Of Urinary Tract Infections Research Articles

Urinary Tract Infections in Children: Clinical and Antibiotic Susceptibility Data from a Tertiary Care Hospital

Aim: Urinary tract infections (UTIs) are among the most common bacterial infections in children.
 Empirical antibiotic treatment is recommended until the antibiogram reports of urine culture are
 available. It is essential to initiate local UTI agents and their antimicrobial susceptibility patterns in
 specific geographical regions to choose the best empirical antibiotics. The current study aimed to
 determine causative microorganisms and antibiotic resistance patterns in children diagnosed with UTI.
 Material and Methods: The study was carried out retrospectively with 216 children diagnosed with
 UTIs for the first time. The patients were categorized into two groups according to age (≤1 year and >1
 year). Demographic data, presenting symptoms, imaging findings, and urine and culture analysis results
 were collected and compared between these two groups.
 Results: Cefazolin and nitrofurantoin use may be preferred in the empirical treatment of UTIs caused
 by Escherichia coli and Enterococcus spp. Additionally, amoxicillin/clavulanate was recommended in
 the empirical therapy of UTIs caused by Enterococcus spp., Klebsiella spp., and Proteus spp. The
 trimethoprim-sulfamethoxazole and nitrofurantoin resistance of E. coli was found to be statistically
 significantly higher in the ≤1 year group (p=0.03 and p=0.01, respectively), while the nitrofurantoin
 resistance of Klebsiella was statistically significantly higher in the >1 year group (p=0.01). The gentamicin
 resistance of Klebsiella spp. was statistically significantly higher in the ≤1 year group (p=0.03).
 Conclusion: It is important to detect regional antibiotic resistance patterns to manage UTIs and minimize
 related complications. Antibiotic susceptibility studies are necessary to reduce improper antibiotic use
 and resistance rates of antibiotics.

Resistant Uropathogens in Gulmi Hospital: High Time to Take Action

Introduction: Recent study in Nepal showed 29.5% culture positive cases of Urinary Tract Infections (UTIs). Extensive consumption of broad-spectrum antibiotics leading to increased AMR rates amongst uropathogens. This study has been carried out to determine the proportion and types of uropathogens causing infections and their antibiotics susceptibility pattern based on WHO classification of antibiotics- access, watch and reserve ('AWaRe') categories. Methods: Record review of the urine isolates with antibiotic susceptibility testing reported from Laboratory of Gulmi Hospital from April 2019 to April 2021. Ethics approval was obtained from Nepal Health Research Council (NHRC). Calculation of frequencies and proportions and cross-tabulation was done. Results: Bacterial yield was found in more than one-third of the total 315 samples. Majorities (84.48%) of them were gram negative bacteria. More than three-fourth of the urine isolates were of female. Urinary isolates showed variable resistance to the 'access' and 'watch' group of antibiotics. There was high resistance to the conveniently prescribed antibiotics like cefixime, ciprofloxacin, ofloxacin, for UTIs. Among tested urine isolates, 75.7% were sensitive to Nitrofurantoin. Conclusion: The yield of urine culture was 36.83% in our study with higher proportions in female. The resistance was high for conveniently prescribed antibiotics. Sensitive antibiotics like Nitrofurantoin were incorporated in the empirical therapy for UTI in this hospital after the study. It is an awakening call to implement measures to strengthen antimicrobial surveillance with inclusion of the peripheral hospitals to the reporting by capacitating them for quality reporting of the antibiograms.

Empiric Guideline Therapy for Simple Urinary Tract Infection at Outpatient Clinics: A Prospective Observational Study

Background: Community-acquired urinary tract infection is a widespread problem encountered in the outpatient clinics of most hospitals. UTI has various clinical presentations; some are simple UTIs that can be managed with outpatient antibiotics. The current treatment of UTI is empirical, based on the limited and predictable spectrum of etiological microorganisms. Objectives: To collect information on the susceptibility tests of microorganisms in simple urinary tract infections (UTIs) and outline the best empiric antimicrobial prescribed for them. Methods: A total of 117 patients from 14 to 70 years of age (mean age = 43.61years, standard deviation = + 24.5) received the care of our surgical and urological outpatient clinics in Alnuman Teaching Hospital, Baghdad, Iraq, between March 1, 2019, and September 1, 2020. The patients who were showing symptoms of simple uncomplicated UTI and were prescribed empiric antibacterial treatment and requested for a sample of midstream urine for culture and sensitivity tests were enrolled in this prospective study. The susceptibility test for (ciprofloxacin, trimethoprim, gentamycin, and ceftriaxone) was performed using the Kirby–Bauer disc diffusion method. The data were input into SPSS 22.0 for statistical analysis. Pearson’s chi-squared test was used to compare parameters. The data have been presented as the number of variables (n) and percentages (%). Statistical significance was set at P < 0.05. Results: The frequencies of isolated uropathogens were as follows: E. coli, n = 65 (77.4%); Klebsiella spp., n = 9 (10.7%), Proteus spp., n = 3 (3.57%), Enterobacter spp., n = 3 (3.57%)., Staphylococcus spp., n = 2 (2.38%)., Pseudomonas spp., n = 1 (1.19%), and Candida spp., n = 1 (1.19%). The resistance rates of the most prevalent microorganisms were E. coli isolates to trimethoprim, ciprofloxacin, gentamycin, and ceftriaxone. The lower resistance rates to ceftriaxone in E. coli isolates (29.7%) was not clinically significant, with p < 0.05. Gentamycin showed significant sensitivity and resistance rates of 58.3% and 33.3% respectively, among the antimicrobials used (p < 0.05). The clinical effectiveness of empirical antimicrobial use in the treatment of simple UTIs showed no statistically significant correlation with P < 0.05. Conclusions: Trimethoprim and ciprofloxacin should not be used in empirical therapy for UTIs because of their increased resistance rates. A review of the local guidelines should be considered.

Evaluation of Treatment Practices for Urinalyses and Urine Cultures at an Outpatient Multiple Sclerosis Clinic.

Patients with multiple sclerosis (MS) experience disease flares that can be precipitated by the presence of infection. Discerning asymptomatic bacteriuria from urinary tract infection (UTI) in patients with MS is complicated by lower urinary tract dysfunction, leading to potentially inappropriate antimicrobial use. In this study the antimicrobial treatment practices for positive urine cultures in patients with MS were evaluated. In this single-center, retrospective study, positive cultures in patients with MS were included. The primary outcome was the proportion of patients appropriately treated with or without antimicrobial therapy. Secondary end points included antimicrobial selection and urinalysis positivity. Two hundred thirty-six cultures from 139 patients were evaluated. Treatment was inappropriate in 81 of 201 treated cultures (40%). Frequency, nocturia, dysuria, and foul-smelling urine were reported by patients in 54 (23%), 10 (4%), 25 (11%), and 14 (6%) cultures, respectively. The antimicrobial selected was too broad in spectrum for 35 of 201 (17%). Of those, fluoroquinolones were the agents used in 33 of 35 cases (94%). A urinalysis was sent in 203 cases (86%), with 197 (84%) positive for at least one predefined positivity criteria. Urinalyses and urine cultures are performed frequently in patients with MS, often independent of symptoms. Patients with MS could be treated for asymptomatic bacteriuria at higher rates than the general population, and traditional urinary symptoms may not be appropriate indicators of infection. Empirical therapy for UTI is frequently used in this population, often resulting in inappropriate and/or too broad of antimicrobial therapy.

1679. Evaluation of the Treatment of Urinalyses and Urine Cultures in Multiple Sclerosis Patients

BackgroundPatients with Multiple Sclerosis (MS) experience lower urinary tract dysfunction (LUTD) that in some cases, may necessitate catheterization. Discerning asymptomatic bacteriuria (ASB) from urinary tract infection (UTI) in MS patients is complicated by LUTD, leading to potentially inappropriate antimicrobial use. The purpose of this study was to evaluate the antimicrobial treatment practices of positive urine cultures in patients with MS.Methods: A single-center, retrospective study. Positive cultures in patients with diagnosed MS (ICD10: G35) were included. The primary outcome was the proportion of patients that were appropriately treated with or without antimicrobial therapy. Secondary endpoints included antimicrobial selection and urinalysis obtainment and positivity.Results236 cultures from 139 patients were evaluated. Frequency, nocturia, dysuria, and foul-smelling urine were reported by patients in 54 (23%), 10 (4%), 25 (11%), and 14 (6%) of cases, respectively. Treatment was inappropriate in 81/201 (40%) of treated cultures. The agent selected was considered too broad in 35/201 (17%) instances. Of those, fluoroquinolones were the agents utilized in 33/35 (94%) cases. A urinalysis was sent in 200 (85%) cases, with 197/200 (99%) positive for at least one of four pre-defined positivity criteria.ConclusionUrinalyses and urine cultures are obtained frequently in patients with MS, often independent of patient symptomatology. Multiple sclerosis patients may be treated for ASB at higher rates than the general population, and traditional urinary symptoms may not be appropriate indicators of infection. Empiric therapy for UTI is frequently utilized in this population, often resulting in too broad of antimicrobial therapy.Disclosures All Authors: No reported disclosures

Coexistence of fluoroquinolone resistance and ESBL production in urinary isolates

Background: Enterobacteriaceae group of organisms are commonly implicated for causing urinary tract infection (UTI). Fluoroquinolones (FQ) are widely used as empirical therapy for UTI. Enterobacteriaceae exhibits high resistance rates to FQs. The plasmid mediated extended spectrum beta lactamase (ESBL) production confers resistance for FQs as well. The aim of the study is to determine the prevalence of fluoroquinolones resistance in urinary isolates and to study the coexistence of FQ resistance and ESBL production in urinary isolates.Methods: Retrospective data of the urine samples received in our microbiology laboratory between December 2018 to May 2019 were reviewed. The organisms were isolated and identified as per standard procedures and the antibiotic susceptibility testing was done following CLSI 2019 guidelines. Ceftazidime (30 µg) and ceftazidime-clavulinic acid (30 µg/10 µg) were used for detection of ESBL production. Levofloxacin (5 µg) and ciprofloxacin (5 µg) were used for detecting FQ resistance.Results: Out of a total of 1403 urine samples received in our laboratory, 240 (17.1%) sample showed growth of Enterobacteriaceae. The different species were E. coli (80.4%), Klebsiella spp (12.2%), Citrobacter spp (4.2%), Enterobacter spp (1.6%) and Proteus mirabilis (1.6%). Amongst these organisms 121(50.4%) were ESBL producers. Co-existence of FQ resistance among the ESBL producers was observed in 106(87.6%) isolates which is higher as compared to that among the ESBL non producers 71(59.7%).Conclusions: Around 50% of the UTI Enterobacteriaceae bacteria are ESBL producers. Fluroquinolone resistance amongst ESBL producing Enterobacteriaceae is very high (87.6%).

Epidemiology and antimicrobial susceptibility profiles of pathogens causing urinary tract infections in the Asia-Pacific region: Results from the Study for Monitoring Antimicrobial Resistance Trends (SMART), 2010–2013

A total of 9599 isolates of Gram-negative bacteria (GNB) causing urinary tract infections (UTIs) were collected from 60 centres in 13 countries in the Asia-Pacific region from 2010–2013. These isolates comprised Enterobacteriaceae species (mainly Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Klebsiella oxytoca, Enterobacter cloacae and Morganella morganii) and non-fermentative GNB species (predominantly Pseudomonas aeruginosa and Acinetobacter baumannii). In vitro susceptibilities were determined by the agar dilution method and susceptibility profiles were determined using the minimum inhibitory concentration (MIC) interpretive breakpoints recommended by the Clinical and Laboratory Standards Institute in 2015. Production of extended-spectrum β-lactamases (ESBLs) amongst E. coli, K. pneumoniae, P. mirabilis and K. oxytoca isolates was determined by the double-disk synergy test. China, Vietnam, India, Thailand and the Philippines had the highest rates of GNB species producing ESBLs and the highest rates of cephalosporin resistance. ESBL production and hospital-acquired infection (isolates obtained ≥48h after admission) significantly compromised the susceptibility of isolates of E. coli and K. pneumoniae to ciprofloxacin, levofloxacin and most β-lactams, with the exception of imipenem and ertapenem. However, >87% of ESBL-producing E. coli strains were susceptible to amikacin and piperacillin/tazobactam, indicating that these antibiotics might be appropriate alternatives for treating UTIs due to ESBL-producing E. coli. Fluoroquinolones were shown to be inappropriate as empirical therapy for UTIs. Antibiotic resistance is a serious problem in the Asia-Pacific region. Therefore, continuous monitoring of evolutionary trends in the susceptibility profiles of GNB causing UTIs in Asia is crucial.

Ciprofloxacin resistance in community- and hospital-acquired Escherichia coli urinary tract infections: a systematic review and meta-analysis of observational studies.

BackgroundDuring the last decade the resistance rate of urinary Escherichia coli (E. coli) to fluoroquinolones such as ciprofloxacin has increased. Systematic reviews of studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli urinary tract infections (UTI) are absent. This study systematically reviewed the literature and where appropriate, meta-analysed studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli UTIs.MethodsObservational studies published between 2004 and 2014 were identified through Medline, PubMed, Embase, Cochrane, Scopus and Cinahl searches. Overall and sub-group pooled estimates of ciprofloxacin resistance were evaluated using DerSimonian-Laird random-effects models. The I2 statistic was calculated to demonstrate the degree of heterogeneity. Risk of bias among included studies was also investigated.ResultsOf the identified 1134 papers, 53 were eligible for inclusion, providing 54 studies for analysis with one paper presenting both community and hospital studies. Compared to the community setting, resistance to ciprofloxacin was significantly higher in the hospital setting (pooled resistance 0.38, 95 % CI 0.36-0.41 versus 0.27, 95 % CI 0.24-0.31 in community-acquired UTIs, P < 0.001). Resistance significantly varied by region and country with the highest resistance observed in developing countries. Similarly, a significant rise in resistance over time was seen in studies reporting on community-acquired E. coli UTI.ConclusionsCiprofloxacin resistance in E. coli UTI is increasing and the use of this antimicrobial agent as empirical therapy for UTI should be reconsidered. Policy restrictions on ciprofloxacin use should be enhanced especially in developing countries without current regulations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1282-4) contains supplementary material, which is available to authorized users.

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department.

Urinary tract infections (UTIs) and sexually transmitted infections (STIs) are commonly diagnosed in emergency departments (EDs). Distinguishing between these syndromes can be challenging because of overlapping symptomatology and because both are associated with abnormalities on urinalysis (UA). We conducted a 2-month observational cohort study to determine the accuracy of clinical diagnoses of UTI and STI in adult women presenting with genitourinary (GU) symptoms or diagnosed with GU infections at an urban academic ED. For all urine specimens, UA, culture, and nucleic acid amplification testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis were performed. Of 264 women studied, providers diagnosed 175 (66%) with UTIs, 100 (57%) of whom were treated without performing a urine culture during routine care. Combining routine care and study-performed urine cultures, only 84 (48%) of these women had a positive urine culture. Sixty (23%) of the 264 women studied had one or more positive STI tests, 22 (37%) of whom did not receive treatment for an STI within 7 days of the ED visit. Fourteen (64%) of these 22 women were diagnosed with a UTI instead of an STI. Ninety-two percent of the women studied had an abnormal UA finding (greater-than-trace leukocyte esterase level, positive nitrite test result, or pyuria). The positive and negative predictive values of an abnormal UA finding were 41 and 76%, respectively. In this population, empirical therapy for UTI without urine culture testing and overdiagnosis of UTI were common and associated with unnecessary antibiotic exposure and missed STI diagnoses. Abnormal UA findings were common and not predictive of positive urine cultures.

A one-year prospective study on the antibiotic resistance of E. coli strains isolated in urinary specimens of children hospitalized at the University Pediatric Medical Center in Novi Sad, Serbia

Urinary tract infections (UTIs), the most common serious bacterial infections in children, are frequently caused by Escherichia coli. The purpose of this study was to investigate E. coli resistance/multidrug resistance to antibiotics most frequently used for UTIs. Children 0-18years of age, hospitalized at the University Pediatric Hospital in Novi Sad, Serbia, were included in a 1-year observational prospective study. The microbiological analysis was performed using the standard Kirby-Bauer disk diffusion method. The results were analyzed using WHONET 5.4 software. E. coli was isolated from 61.7% of positive urine specimens. In general, higher average E. coli antibiotic resistance was found in infants and toddlers compared to children and adolescents (33.4 vs. 25.0%) (p<0.0001). Furthermore, it was observed that the average resistance to all the tested antibiotics was higher in boys than in girls (37.0 vs. 25.1%) (p<0.0001). E. coli was highly susceptible to piperacillin/tazobactam (>93.1%), amikacin (86.3%), quinolones (>75.0%), and penems (>96.6%). The prevalence of multiresistant E. coli strains was significantly higher in infants and toddlers (72.3 vs. 36.8%) (p<0.0001). E. coli, a common cause of UTIs in children admitted to pediatric hospitals, is highly resistant/multidrug-resistant to commonly used antibiotics. Higher average resistance is found in infants and toddlers than in children and adolescents, as well as in boys compared to girls. These findings are important for the regional empiric therapy of UTIs and call for actions to decrease E. coli antibiotic resistance.

Prulifloxacin versus Ciprofloxacin in the Treatment of Adults with Complicated Urinary Tract Infections

Introduction: The present study was performed to evaluate the efficacy and safety of a 10-day regimen of prulifloxacin 600 mg once daily as compared to ciprofloxacin 500 mg twice daily in the treatment of patients with complicated urinary tract infections (UTIs). Materials and Methods: 257 patients (mean age ± SD 62.3 ± 16.5) were enrolled and orally treated with prulifloxacin (127 patients) or ciprofloxacin (130 patients). The study was designed as a randomized, double-blind, double-dummy, controlled clinical trial. The primary efficacy parameter was the eradication of infecting strains (<10³ cfu/ml). The clinical outcome and tolerability were also assessed. Results: At baseline, the most common infecting strains were Escherichia coli (62.8%), Proteus mirabilis (7.1%) and Klebsiella pneumoniae (4.1%). At the early follow-up, the rate of patients showing successful treatment was 90.8% in the prulifloxacin group, and 77.8% in the ciprofloxacin group (p = 0.008). A positive clinical outcome was observed in 94.8 and 93.3% of prulifloxacin- and ciprofloxacin-treated patients. Both drugs were well tolerated. Two patients dropped out for treatment-related adverse events. Conclusions: The high urinary concentrations of prulifloxacin, combined with a broad-spectrum antimicrobial activity, allow its use in the empiric therapy of UTIs.

Impact of Changing Patterns of Antimicrobial Resistance in Uropathogens: Emerging Treatment and Strategies.

Urinary tract infection (UTI) is common, especially in women, and the microbiology of UTI is predictable. Over the past decade, numerous reports have documented increasing resistance among uropathogens to first-line agents for the treatment of UTI, especially trimethoprim/sulfamethoxazole (TMP/SMX). It is recommended that TMP/SMX should not be administered as empiric therapy for UTI in communities where resistance rates exceed 20%. However, reliable data regarding the true prevalence of resistance in a community are often lacking. Preliminary work has suggested that recent antimicrobial use is an important risk factor for infection with a TMP/SMX-resistant isolate. A better understanding of the epidemiology of resistance is needed to aid therapeutic decisions and devise interventions to reduce or slow emerging resistance.