[Bacteriological analysis of more than 600 febrile urinary infections managed in a community health network]

Guidelines for the management of male urinary tract infections in primary care: a lack of international consensus-a systematic review of the literature

BACKGROUND

The management of adult male urinary tract infections (mUTIs) in primary care lacks international consensus. The main objective of this study was to describe the different guidelines for the diagnosis and management of mUTIs in primary care, to assess their methodological quality, and to describe their evidence-based strength of recommendation (SoR).

METHODS

An international systematic literature review of the electronic databases Medline (PubMed) and EMBASE, and gray-literature guideline-focused databases was performed in 2021. The Appraisal of Guidelines for Research and Evaluation (AGREE II) assessment tool was used by 2 independent reviewers to appraise each guideline.

RESULTS

From 1,678 records identified, 1,558 were screened, 134 assessed for eligibility, and 29 updated guidelines met the inclusion criteria (13 from Medline, 0 from EMBASE, and 16 from gray literature). Quality assessment revealed 14 (48%) guidelines with high-quality methodology. A grading system methodology was used in 18 (62%) guidelines. Different classifications of mUTIs are described, underlining a lack of international consensus: an anatomic classification (cystitis, prostatitis, pyelonephritis) and a symptomatic classification (approach based on the intensity and tolerance of symptoms). The duration of antibiotic treatment for febrile mUTIs has been gradually reduced over the last 20 years from 28 days to 10-14 days of fluoroquinolones (FQ), which has become the international gold standard. Guidelines from Scandinavian countries propose short courses (3-5 days) of FQ-sparing treatments: pivmecillinam, nitrofurantoin, or trimethoprim. Guidelines from French-speaking countries use a watchful waiting approach and suggest treating mUTIs with FQ, regardless of fever.

CONCLUSIONS

This lack of scientific evidence leads to consensus and disagreement: 14 days of FQ for febrile mUTIs is accepted despite a high risk of antimicrobial resistance, but FQ-sparing treatment and/or short treatment for afebrile mUTIs is not. The definition of afebrile UTIs/cystitis is debated and influences the type and duration of antibiotic treatment recommended.

Predictors of ultrasound abnormalities among women treated for community-onset acute pyelonephritis: a prospective study

OBJECTIVES

Acute pyelonephritis (AP) is a common but potentially severe infection. It may be complicated by pyelocaliceal dilatation which requires emergency urine drainage. In outpatient care, ultrasound (US) appears to be the easier way to diagnose pyelocaliceal dilatation, though most APs will not be complicated and do not require immediate ultrasound. We aimed to identify predictors of ultrasound abnormalities in an outpatient AP cohort.

METHODS

A prospective study was conducted from April 2006 to September 2019 in an outpatient care network. Patients aged 15 and over treated for AP were included. Men, pregnant women, patients with solitary kidney, and patients without data on their management were excluded. A common algorithm ensured the same approach from diagnosis to treatment. Data were collected prospectively in an anonymized database. We described the characteristics of the patients. Univariate and then multivariate analyses were performed to identify predictors of ultrasound abnormalities.

RESULTS

2054 women were treated for AP. Among them, 32.5% (n = 667) had a history of urinary tract infections and 5.8% (n = 120) of uropathy. The most frequent uropathogen was E. coli (n = 1,432; 69.7%); Extended-Spectrum Beta-Lactamases (ESBLs) were found in 39 (1.9%) urine cultures. Ultrasound was abnormal in 7.3% (n = 149). Age over 55 years (OR = 2.23; 95% CI 1.58‒3.15; p < 0.0001) and uropathy (OR = 3.69; 95% CI 2.26‒6.01; p < 0.0001) were independently identified as predictors of ultrasound abnormalities. The risk increased by 1.8% (95% CI 1.0‒2.6) with each additional year of age.

CONCLUSIONS

This study identified age and uropathy as independent predictors of abnormal ultrasound in women treated with community-onset AP.

Factors Associated with Acute Community-Acquired Pyelonephritis Caused by Extended-Spectrum β-Lactamase-Producing Escherichia coli

This study aimed to identify the factors associated with the presence of extended-spectrum ß-lactamase-(ESBL) in patients with acute community-acquired pyelonephritis (APN) caused by Escherechia coli (E. coli), with a view of optimising empirical antibiotic therapy in this context. We performed a retrospective analysis of patients with community-acquired APN and confirmed E. coli infection, collecting data related to demographic characteristics, comorbidities, and treatment. The associations of these factors with the presence of ESBL were quantified by fitting multivariate logistic models. Goodness-of-fit and predictive performance were measured using the ROC curve. We included 367 patients of which 51 presented with ESBL, of whom 90.1% had uncomplicated APN, 56.1% were women aged ≤55 years, 33.5% had at least one mild comorbidity, and 12% had recently taken antibiotics. The prevalence of ESBL-producing E. coli was 13%. In the multivariate analysis, the factors independently associated with ESBL were male sex (OR 2.296; 95% CI 1.043-5.055), smoking (OR 4.846, 95% CI 2.376-9.882), hypertension (OR 3.342, 95% CI 1.423-7.852), urinary incontinence (OR 2.291, 95% CI 0.689-7.618) and recurrent urinary tract infections (OR 4.673, 95% CI 2.271-9.614). The area under the ROC curve was 0.802 (IC 95% 0.7307-0.8736), meaning our model can correctly classify an individual with ESBL-producing E. coli infection in 80.2% of cases.

[Infectious emergencies in urology]

OBJECTIVE

To report the nature, diagnosis and therapeutic strategy of infectious emergencies in urology.

MATERIAL AND METHODS

Bibliographic research from Pubmed, Embase, and Google scholar in July 2021. A synthesis of the guidelines of national infectious diseases societies.

RESULTS

Urosepsis and complicated urinary tract infection have a standardized definition. Diagnosis and therapeutic strategy are presented for upper tract urinary infection, male urinary infection, healthcare associated urinary infection, symptomatic canduria and urinary infections of the elderly. Appropriate antibiotherapy should be tailored to the degree of severity, bacterial ecosystem, patient characteristics et localization of the infection.

CONCLUSION

Urinary infections can be critical and require immediate care. Knowledge of the guidelines and of appropriate diagnosis and therapeutics strategy improve care which should be rapidly applied, and collegial.

[Is it necessary to perform urine culture systematically prior to double J ureteral stent removal?]

OBJECTIVE

To assess the value of systematic urine culture before ureteric double j removal.

MATERIAL AND METHODS

This prospective audit was performed to assess the validity of our current clinical practice. A cohort of informed patients without clinical signs of urinary tract infection and without predefined risk factors were programmed for ureteral double j stent removal in an outpatient setting. Urine was sampled for culture immediately before the procedure. Patients had to complete a self-questionnaire 15 days following stent removal, inquiring about tolerance and complications which were to be analyzed according to the culture results. The primary endpoint was the occurrence of febrile urinary tract infection.

RESULTS

Among the 56 participants, immediate preoperative urine culture revealed colonization in 9 patients (16.1%) and contamination in 6 patients (10.7%). A significant association was found between bacteriuria and double j placement following surgery with urinary tract injury (P<0.02) and diabetes (P<0.009). Two patients had fever including a man with sterile urine and a woman with Staphylococcus Aureus infection. No hospitalization was necessary. Twelve patients reported functional signs with lumbar pain being the most common. There was no significant association between functional signs and patients' clinical characteristics.

CONCLUSION

This evaluation was not in favor of modifying our protocol of care i.e. the lack of performing neither antibiotic prophylaxis nor systematic urine culture before JJ ureteral stent removal in a selected population.

LEVEL OF EVIDENCE

4.

A Cohort Study of Risk Factors That Influence Empirical Treatment of Patients with Acute Pyelonephritis

The aim of the current study was to compare community-acquired acute pyelonephritis (CA-APN) with health care-associated acute pyelonephritis (HCA-APN), describe the outcomes, and identify variables that could predict antimicrobial susceptibility. We conducted an observational study that included all consecutive episodes of acute pyelonephritis (APN) in adults during 2014 at a Spanish university hospital. From each episode, demographic data, comorbidities, clinical presentation, microbiological data, antimicrobial therapy, and outcome were recorded. A multivariable logistic regression model was performed to define the variables associated with antimicrobial resistance. A total of 607 patients, 503 (82.9%) with CA-APN and 104 (17.1%) with HCA-APN, were included in the study. Patients with HCA-APN were older than patients with CA-APN (70.4 versus 50.6 years; P < 0.001) and had higher rates of previous urinary tract infections (UTIs) (56.5% versus 24.5%; P < 0.001) and previous antibiotic use (56.8% versus 22.8%; P < 0.001). Escherichia coli was more frequently isolated from patients with CA-APN than from patients with HCA-APN (79.9% versus 50.5%; P < 0.001). The rates of resistance of Escherichia coli strains from CA-APN patients versus HCA-APN patients were as follows: amoxicillin-clavulanic acid, 22.4% versus 53.2% (P = 0.001); cefuroxime, 7.7% versus 43.5% (P = 0.001); cefotaxime, 4.3% versus 32.6% (P < 0.001); ciprofloxacin, 22.8% versus 74.5% (P < 0.001); and co-trimoxazole, 34.5% versus 58.7% (P = 0.003). The site of acquisition, recurrent UTIs, and previous antibiotic use were independent risk factors for antimicrobial resistance. Relapse rates were significantly higher when definitive antimicrobial treatment was not adequate (37.1% versus 9.3% when definitive antimicrobial treatment was adequate; P < 0.001). Our study reflects the rise of resistance to commonly used antibiotics in acute pyelonephritis. In order to choose the adequate empirical antibiotic therapy, risk factors for resistance should be considered.

[Ecology and fluoroquinolon resistance profiles in febrile urinary tract infections (FUTI) after prostate needle biopsy: A retrospective study in 466 biopsies]

OBJECTIVE

The biopsies of prostate are the reference examination to assert the diagnosis of prostate cancer. Even if the urinary infectious complications are rare thanks to the systematic oral antibiotic prophylaxis, they may still be serious. The SPILF (Society of Infectious Pathology and French language) published in 2014, an important increase of the resistances in fluoroquinolones for Escherichia coli (3 to 25%), whereas this is the most bacterium frequently found in the urinary infections (70-80%). The objectives of this study were to estimate the indicence of the febrile urinary tract infections after prostate needle biopsy and to define the ecology and the profile of E. coli's resistance.

METHODS

A total of 466 transrectal ultrasound-guided needle prostate biopsy were included in the study from 2012 to 2015. All the patients were taken care according to the recommendations of the AFU (Ouzzane et al., 2011). We estimated, for all the inclusive patients, if they had presented a clinic sign of urinary infection like fever or burning which suggestive of an urinary infection, and having a urines and blood culture, in the next 30 days the realization of the medical exam.

RESULTS

Among 466 realized biopsies, seven patients developed a febril urinary tract infection (1.5%) [prostatitis (n=6), orchitis (n=1)]. Five infections to E. coli were identified; two were resistant for fluoroquinolones (40%). No germ was able to be identified for two patients.

CONCLUSION

The infectious complications post-biopsy of prostate are rare (1.5%). E. coli is the germ most frequently identified with 40% of resistance with fluoroquinolones.

LEVEL OF EVIDENCE

4.

Temporal trends and risks factors for antimicrobial resistant Enterobacteriaceae urinary isolates from outpatients in Guadeloupe

BACKGROUND

Urinary tract infections are bacterial infections most commonly encountered in the community. The resistance rate of uropathogens to commonly prescribed antibiotics has increased worldwide but there are no published data concerning the resistance of strains isolated from community-acquired UTI in Guadeloupe. To assess the susceptibility patterns of Enterobacteriaceae strains isolated from outpatients in Guadeloupe we conducted a prospective study from December 2012 to May 2014 among outpatients consulting at private and public laboratories for urine analysis. Risk factors for E. coli resistance to amoxicillin, third-generation cephalosporin, and ciprofloxacin were also determined. To study the trends of E. coli resistance rates over the past 10 years, data on the susceptibility patterns of E. coli from 2003 to 2014 were also collected from three major laboratories for a retrospective study.

RESULTS

During the prospective study, we isolated 1293 bacterial strains from the urine of outpatients presenting for urine analysis. The most commonly isolated bacteria were E. coli (57 %) and Klebsiella pneumoniae (15.5 %). Thirty seven per cent of the E. coli strains were resistant to amoxicillin. Resistance rates to third generation cephalosporin were low for E. coli and other Enterobacteriaceae (3.1 and 12.2 % respectively) and mostly due to the presence of an Extended Spectrum Beta-lactamase. Resistance to cotrimoxazole and ciprofloxacin was moderate (17.8 and 15.6 % respectively). However, the resistance rate of E. coli to ciprofloxacin has significantly increased during the last 10 years. Risk factors were consistent with previously reported data, especially for the increasing ciprofloxacin resistance with age.

CONCLUSION

General practitioners in Guadeloupe need to be better informed to favor the prescription of fosfomycin-trometamol to reduce the risk of resistance to fluoroquinolones.