Joint report of SBI (Brazilian Society of Infectious Diseases), FEBRASGO (Brazilian Federation of Gynecology and Obstetrics Associations), SBU (Brazilian Society of Urology) and SBPC/ML (Brazilian Society of Clinical Pathology/Laboratory Medicine): recommendations for the clinical management of lower urinary tract infections in pregnant and non-pregnant women

Prevalence and antimicrobial resistance profile of pathogens isolated from patients with urine tract infections admitted to a university hospital in a medium-sized Brazilian city

This study aimed to determine the antibiotic profile of microorganisms isolated from urine samples of patients with community urine tract infections (UTI) admitted to the University Hospital of the Federal University of Sao Carlos to support an appropriate local empirical treatment. A retrospective cross-sectional study was conducted from October 2018 to October 2020. Data from 1,528 positive urine cultures for bacterial pathogens and antibiograms were tabulated. Bacterial species prevalence and their resistance profile were analyzed and compared by sex and age. For Gram-negative fermenting bacteria, resistance rates were compared between patients with previous hospitalization and the total of infections caused by this group. For comparisons, the Chi-square test was performed, using Fisher's exact test when necessary (BioEstat program, adopting p ≤ 0.05). A multivariate analysis was applied to assess the effect of the studied variables in predicting multidrug resistance. Infections were more prevalent in women and older adults. Gram-negative bacteria represented 90.44% of total cultures. In both sexes, E. coli prevalence was significantly higher in adults compared with older adults (p < 0.0001). For several antibiotics, resistance rates were higher in the older adults compared with other ages and in patients with Gram-negative fermenting infections and previous hospitalization compared with the total of infections by this group of bacteria. The closer to the hospitalization, the higher the number of antibiotics with superior resistance rates. Resistance rates for aminoglycosides, carbapenems, ceftazidime, nitrofurantoin, piperacillin+tazobactam, and fosfomycin were less than 20%, considered adequate for empirical treatment. Only hospitalization in the previous 90 days was statistically significant in predicting infections by multidrug-resistant bacteria.

Urinary Tract Infections in Pregnant Individuals

SUMMARY

Urinary tract infection (UTI) is one of the more common perinatal complications, affecting approximately 8% of pregnancies (1, 2). These infections represent a spectrum, from asymptomatic bacteriuria, to symptomatic acute cystitis, to the most serious, pyelonephritis. The presence of UTIs has been associated with adverse pregnancy outcomes, including increased rates of preterm delivery and low birth weight. Screening for and treating asymptomatic bacteriuria have been shown in multiple studies to reduce the incidence of pyelonephritis in pregnancy (3-5). Given the frequency at which UTIs are encountered in pregnancy, the ability to recognize, diagnose, and treat them is essential for those providing care to pregnant individuals. This Clinical Consensus document was developed using an established protocol in conjunction with the authors listed.

Evaluation of pharmacist's practices regarding the antimicrobials dispensing: a simulated patient study

BACKGROUND

The indiscriminate use of antimicrobials is considered a major contributing factor to the increase in antimicrobial resistance. Community pharmacies are the main source of access to antimicrobials, and pharmacists are in a strategic position to promote rational use of these medicines. Therefore, it is important to know dispensing service quality.

OBJECTIVE

To evaluate the behavior of pharmacists in dispensing antimicrobials in community pharmacies in northeast Brazil.

METHODS

This cross-sectional pilot study was conducted from August to October 2021 in a private community pharmacy chain in Sergipe. Dispensing was evaluated using the simulated patient (SP) technique. Two SP asked the pharmacists for the antimicrobials (case clinic 1: upper respiratory infection; case clinic 2: urinary tract infection) and recorded the service through audio. Dispensing practices were independently analyzed by two researchers based on the tools available in the literature. Data were presented using descriptive statistics.

RESULTS

A total of 54 simulated patient visits were conducted. Based on the 12 steps recommended by the research team for good dispensing, pharmacists asked an average of 1 (±1.17) question for upper respiratory infections and 0.3 (±0.54) for urinary tract infections, as well as provided counseling (mean number of recommendations, 2.6 (±1.44) and 4.5 (±2.35), respectively). As for communication skills, pharmacists had a regular score (3.07 ± 0.34). Furthermore, there was no significant difference in the number of steps and counseling recommendations by pharmacists in dispensing clinical cases 1 and 2 (p = 0.0674).

CONCLUSION

The quality of antimicrobial dispensing was evaluated as suboptimal, requiring improvements in practice and multifaceted strategies to promote continuing education of these professionals. In addition, awareness actions for the population must be implemented to promote the rational use of antimicrobials and reduce microbial resistance.

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.

Antibiotic resistance pattern in urine cultures from community-dwelling women in southern Brazil - a cross-sectional study short communication

OBJECTIVE

The increase in antibiotic resistance (AR) is a global phenomenon with regional variation. This survey aims to describe the AR in urine cultures of women from the community in a southern Brazil city.

METHODS

A retrospective cross-sectional single-center study in urine cultures of community dwelling individuals. The main outcome was the AR profile of bacterial isolates from women in outpatient care.

RESULTS

From 4,011 urine cultures, 524 were positive (91% from women). The most frequently isolated bacteria were Escherichia coli (E. coli) (67.0%) and Klebsiella spp. (19.4%). E. coli presented low resistance to nitrofurantoin (3.7%), moderate to levofloxacin (15.6%), amoxacillin-clavulonate (16.4%) and ciprofloxacin (17.4%), and high to trimethoprim-sulfamethoxazole (26.9%).

CONCLUSIONS

Nitrofurantoin seems to be the best choice for the empirical treatment of low urinary tract infections in women, whereas sulfonamides are no longer an option, since E. coli resistance to this drug is above 20%.

Characterization of Uropathogenic Escherichia coli Reveals Hybrid Isolates of Uropathogenic and Diarrheagenic (UPEC/DEC) E. coli

(1) Background: Pathogenic Escherichia coli are divided into two groups: diarrheagenic (DEC) and extraintestinal pathogenic (ExPEC) E. coli. ExPEC causing urinary tract infections (UTIs) are termed uropathogenic E. coli (UPEC) and are the most common cause of UTIs worldwide. (2) Methods: Here, we characterized 112 UPEC in terms of phylogroup, serotype, the presence of virulence factor-encoding genes, and antimicrobial resistance. (3) Results: The majority of the isolates were assigned into the phylogroup B2 (41.07%), and the serogroups O6 (12.5%) and O25 (8.9%) were the most frequent. Five hybrid UPEC (4.5%), with markers from two DEC pathotypes, i.e., atypical enteropathogenic (aEPEC) and enteroaggregative (EAEC) E. coli, were identified, and designated UPEC/aEPEC (one isolate) and UPEC/EAEC (four isolates), respectively. Three UPEC/EAEC harbored genes from the pap operon, and the UPEC/aEPEC carried ibeA. The highest resistance rates were observed for ampicillin (46.4%) and trimethoprim/sulfamethoxazole (34.8%), while 99.1% of the isolates were susceptible to nitrofurantoin and/or fosfomycin. Moreover, 9.8% of the isolates were identified as Extended Spectrum β-Lactamase producers, including one hybrid UPEC/EAEC. (4) Conclusion: Our data reinforce that hybrid UPEC/DEC are circulating in the city of Botucatu, Brazil, as uropathogens. However, how and whether these combinations of genes influence their pathogenicity is a question that remains to be elucidated.

Herbal Medicines-Are They Effective and Safe during Pregnancy?

Since the teratogenicity of Thalidomide has been proven, herbal products are more commonly used in pregnancy to not only relieve morning sickness but also to fight infections. These products are frequently considered as natural and therefore harmless. However, herbs contain a number of active substances that, when used during pregnancy, can affect the development of the fetus. Often, pregnant women do not consult the usage of herbal medicines with a physician. The access to these products is easy and treatment of certain ailments with the use of herbs is common in many countries. The aim of the present literature review was to discuss available data regarding the efficacy and safety of cranberry, chamomile, Echinacea purpurea, garlic, ginger, Ginkgo biloba, and peppermint, which are used to counteract the most common ailments during pregnancy, i.e., infections and pregnancy-related ailments (e.g., nausea and vomiting, dizziness, and headache). Analysis of available data showed that ginger is one of the most extensively analyzed herbal remedies. The dose of ginger below 1000 mg per day may help to relief hypereremesis gravidarum, and such an amount of ginger did not increase frequency of adverse effects for either woman or developing fetus. Data regarding other herbs are most often heterogeneous and give conflicting results with no clear conclusions. However, all herbal products should be used with a special caution in pregnancy. Further high-quality human studies should be determined to confirm the safe doses of herbal products which could be used by pregnant or breast-feeding women.

Padrão de resistência antimicrobiana em culturas ambulatoriais de urina em mulheres no sul do Brasil - comunicação breve de um estudo transversal

RESUMO Objetivo O aumento da resistência aos antibióticos (AR) é um fenômeno global com variações regionais. Esta pesquisa tem como objetivo descrever a AR em culturas de urina de mulheres oriundas da comunidade em uma cidade sul-brasileira. Métodos Um estudo de centro único, transversal e retrospectivo em culturas de urina oriundas da comunidade. O principal desfecho foi o perfil de AR de bactérias isoladas de uroculturas ambulatoriais. Resultados De 4.011 culturas de urina, 524 foram positivas (91% de mulheres). As bactérias mais frequentemente isoladas em mulheres foram Escherichia coli (67,0%) e Klebsiella spp. (19,4%). E. coli apresentou baixa resistência à nitrofurantoína (3,7%), moderada a levofloxacina (15,6%), amoxacilina-clavulonato (16,4%) e ciprofloxacina (17,4%) e alta ao trimetoprim-sulfametoxazol (26,9%) entre mulheres. Conclusões A nitrofurantoína parece ser a melhor escolha para o tratamento empírico das infecções do trato urinário inferior em mulheres, enquanto as sulfonamidas não são mais uma opção, uma vez que a resistência de E. coli a essa droga é superior a 20%.

A global perspective on improving patient care in uncomplicated urinary tract infection: Expert consensus and practical guidance

BACKGROUND

Uncomplicated urinary tract infections (uUTIs) are a common problem in women. Management is mainly based on empirical prescribing, but there are concerns about overtreatment and antimicrobial resistance (AMR), especially in patients with recurrent uUTIs.

METHODS

A multidisciplinary panel of experts met to discuss diagnosis, treatment, prevention, guidelines, AMR, clinical trial design, and the impact of COVID-19 on clinical practice.

RESULTS

Symptoms remain the cornerstone of uUTI diagnosis, and urine culture is necessary only when empirical treatment fails, or rapid recurrence of symptoms or AMR is suspected. Specific antimicrobials are first-line therapy (typically nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, and pivmecillinam; dependent on availability and local resistance data). Fluoroquinolones are not first-line options for uUTIs due primarily to safety concerns, but also rising resistance rates. High-quality data to support most non-antimicrobial approaches are lacking. Local AMR data specific to community-acquired uUTIs are needed, but representative information is difficult to obtain; instead, identification of risk factors for AMR can provide a basis to guide empirical antimicrobial prescribing. The COVID-19 pandemic has impacted management of uUTIs in some countries and may have long-lasting implications for future models of care.

CONCLUSIONS

The management of uUTIs in women can be improved without increasing complexity, including simplified diagnosis, and empirical antimicrobial prescribing based on patient characteristics, including review of recent antimicrobial use and past pathogen resistance profiles, drug availability, and guidelines. Current data for non-antimicrobial approaches are limited. The influence of COVID-19 on telehealth could provide an opportunity to enhance patient care in the long term.