Uncomplicated Urinary Tract Infection in Adults Including Uncomplicated Pyelonephritis

Likelihood of Antimicrobial Resistance in Urinary E coli Isolates among US Female Patients with Recurrent vs Non-Recurrent Uncomplicated Urinary Tract Infection

OBJECTIVE

To assess the relative likelihood of antimicrobial resistance (AMR) and multi-drug resistance (MDR) among E coli isolates from outpatients with recurrent versus non-recurrent uncomplicated urinary tract infection (uUTI).

METHODS

In this retrospective observational US cohort study, female outpatients (≥12 years) with uUTI, positive E coli culture, and treated with ≥1 oral antibiotic within ±5 days of diagnosis were grouped into recurrent and non-recurrent uUTI cohorts per their UTI history (past 12 months). AMR to specific drug classes was evaluated at index. Univariable and multivariable logistic regression models estimated the likelihood of not-susceptible E coli isolates (AMR/MDR) among patients with recurrent uUTI versus non-recurrent uUTI.

RESULTS

Recurrent (N = 12,234) and non-recurrent (N = 68,033) uUTI cohorts had similar distributions (race, ethnicity, region). Patients with recurrent uUTI had a higher prevalence of E coli resistance to trimethoprim-sulfamethoxazole (21.8% vs 18.7%) and fluoroquinolones (14.2% vs 8.6%), and more isolates were extended-spectrum β-lactamase-producing (5.9% vs 4.1%) compared to non-recurrent uUTI patients. Patients with recurrent uUTI had a higher likelihood (odds ratio [95% confidence interval]) of any AMR (1.28 [1.22-1.34]), single drug-class resistance (1.18 [1.12-1.24]), and resistance to 2 (1.53 [1.41-1.67]) or ≥3 drug classes (1.70 [1.48-1.96]) (all P <.001).

CONCLUSION

This study delineated the likelihood of AMR and MDR among E coli isolates from patients with recurrent versus non-recurrent uUTI. While some treatment guidelines support empiric therapy in recurrent uUTI, the increased likelihood of resistance among these patients suggests that culture and susceptibility testing should be undertaken to inform recurrent uUTI treatment.

Urinary Tract Infections in Patients Undergoing Invasive Urodynamic Study: A Prospective Observational Study at a Tertiary Care Centre in Eastern India

OBJECTIVE

The aim of the study was to find the estimate of the prevalence of urinary tract infections following invasive urodynamic studies (UDS) in a hospital setup and to identify the risk factors related to it.

METHOD

A total of 100 patients were enrolled in this prospective observational study after standard preoperative work, which included both urine analysis and culture procedure. The study was carried out from April 2022 to April 2023 at the Department of Urology, Indira Gandhi Institute of Medical Sciences, India. Three days following the UDS test, all the patients underwent repeat urine analysis and culture, besides screening for any lower urinary tract symptoms, abdominal pain, and fever.

RESULT

Among all, 14 patients (i.e., 6.1% of 85 individuals) had significant bacteriuria, and six patients (4.7%) developed symptoms of UTI. However, a strong association was observed between the maximal detrusor pressure during voiding (Pdet at Q max) and post-void residue (PVR), which were >20 mL before UDS, along with positive urine cultures after UDS, which was significant at <0.05.

CONCLUSION

The study demonstrated that the risk of UTIs with this diagnostic technique is minimal and that prophylactic antibiotic medication is not necessary prior to UDS in all patients.

One Health Determinants of Escherichia coli Antimicrobial Resistance in Humans in the Community: An Umbrella Review

To date, the scientific literature on health variables for Escherichia coli antimicrobial resistance (AMR) has been investigated throughout several systematic reviews, often with a focus on only one aspect of the One Health variables: human, animal, or environment. The aim of this umbrella review is to conduct a systematic synthesis of existing evidence on Escherichia coli AMR in humans in the community from a One Health perspective. PubMed, EMBASE, and CINAHL were searched on "antibiotic resistance" and "systematic review" from inception until 25 March 2022 (PROSPERO: CRD42022316431). The methodological quality was assessed, and the importance of identified variables was tabulated across all included reviews. Twenty-three reviews were included in this study, covering 860 primary studies. All reviews were of (critically) low quality. Most reviews focused on humans (20), 3 on animals, and 1 on both human and environmental variables. Antibiotic use, urinary tract infections, diabetes, and international travel were identified as the most important human variables. Poultry farms and swimming in freshwater were identified as potential sources for AMR transmission from the animal and environmental perspectives. This umbrella review highlights a gap in high-quality literature investigating the time between variable exposure, AMR testing, and animal and environmental AMR variables.

Antibiotic prescription patterns in patients with suspected urinary tract infections in Ecuador

BACKGROUND

Urinary tract infections (UTI) are among the most common cause to prescribe antibiotics in primary care. Diagnosis is based on the presence of clinical symptoms in combination with the results of laboratory tests. Antibiotic therapy is the primary approach to the treatment of UTIs; however, some studies indicate that therapeutics in UTIs may be suboptimal, potentially leading to therapeutic failure and increased bacterial resistance.

METHODS

This study aimed to analyze the antibiotic prescription patterns in adult patients with suspected UTIs and to evaluate the appropriateness of the antibiotic prescription. This is a cross-sectional study of patients treated in outpatient centers and in a second-level hospital of the Ministry of Public Health (MOPH) in a city in Ecuador during 2019. The International Classification of Disease Tenth Revision (ICD-10) was used for the selection of the acute UTI cases. The patients included in this study were those treated by family, emergency, and internal medicine physicians.

RESULTS

We included a total of 507 patients in the analysis and 502 were prescribed antibiotics at first contact, constituting an immediate antibiotic prescription rate of 99.01%. Appropriate criteria for antibiotic prescription were met in 284 patients, representing an appropriate prescription rate of 56.02%. Less than 10% of patients with UTI had a urine culture. The most frequently prescribed antibiotics were alternative antibiotics (also known as second-line antibiotics), such as ciprofloxacin (50.39%) and cephalexin (23.55%). Factors associated with inappropriate antibiotic prescribing for UTIs were physician age over forty years, OR: 2.87 (95% CI, 1.65-5.12) p<0.0001, medical care by a general practitioner, OR: 1.89 (95% CI, 1.20-2.99) p = 0.006, not using point-of-care testing, OR: 1.96 (95% CI, 1.23-3.15) p = 0.005, and care at the first level of health, OR: 15.72 (95% CI, 8.57-30.88) p<0.0001.

CONCLUSIONS

The results of our study indicate an appropriate prescription rate of 56.02%. Recommended antibiotics such as nitrofurantoin and fosfomycin for UTIs are underutilized. The odds for inappropriate antibiotic prescription were 15.72 times higher at the first level of care compared to the second. Effective strategies are needed to improve the diagnosis and treatment of UTIs.

Extreme pubic hair removal as a potential risk factor for recurrent urinary tract infections in women

Urinary tract infections (UTIs) are the most common infections experienced by women. Previously, scalp and facial hair in men have been shown to inhibit the growth of pathogenic bacteria. Here we hypothesize that having hairy genitalia might protect women from UTI. This study investigated grooming habits and occurrence of UTIs in the past 12 months in 2409 women (aged 18-45). Women who reported removing all their pubic hair at least weekly were defined as extreme groomers (66.8%). We collected additional information on covariates including age, having a first UTI at or before age 15, spermicide use, having a new sex partner, and frequency of sexual intercourse during the past year. Extreme grooming was not associated with the risk of being diagnosed with UTI (OR = 1.17, 95% CI = 0.90-1.52), but was associated with a higher risk of recurrent UTIs, defined as three or more UTIs within 12 months (OR = 3.09, 95% CI = 1.35-7.06), after controlling for age, history of UTIs, and sexual practices. Other studies have found that hygienic purposes are the most common motivations for pubic hair removal. These results suggest that along with their pubes, women may be getting rid of important microbial niche and protection against recurrent UTIs.

Antimicrobial resistance of clinical Enterobacterales isolates from urine samples, Germany, 2016 to 2021

IntroductionEmpirical therapy for the treatment of urinary tract infections should be tailored to the current distribution and susceptibility of potential pathogens to ensure optimal treatment.AimWe aimed to provide an up-to-date overview of the epidemiology and susceptibility of Enterobacterales isolated from urine in Germany.MethodsWe retrospectively analysed antimicrobial susceptibility data from 201,152 urine specimens collected between January 2016 and June 2021 from in- and outpatients. Multiple logistic regression analysis was used to evaluate the association between year of investigation and antibiotic resistance, adjusted for age, sex and species subgroup. Subgroup analyses were performed for midstream urine samples obtained from (i) female outpatients aged 15 to 50 years, (ii) female outpatients older than 50 years and (iii) male outpatients.ResultsResistance rates of less than 20% were observed for nitroxoline (3.9%), fosfomycin (4.6%), nitrofurantoin (11.7%), cefuroxime (13.5%) and ciprofloxacin (14.2%). Resistance to trimethoprim/sulfamethoxazole (SXT) (20.1%), amoxicillin-clavulanic acid (20.5%), trimethoprim (24.2%), pivmecillinam (29.9%) and ampicillin (53.7%) was considerably higher. In the subgroup of outpatient women aged 15-50 years, resistance rates were generally lower. Resistance rates of all antibiotics decreased from 2016 to 2021. Multiple logistic regression revealed the lowest adjusted odds ratio (ORadj) of 0.838 (95% confidence interval (CI): 0.819-0.858; p < 0.001) for pivmecillinam and the highest ORadj of 0.989 (95% CI: 0.972-1.007; p = 0.226) for nitrofurantoin.ConclusionsResistance has generally decreased over the past years, independent of sex, age and causative pathogen. Our data provide an important basis for empirical antibiotic recommendations in various settings and patient collectives.

Older patient age and prior antimicrobial use strongly predict antimicrobial resistance in Escherichia coli isolates recovered from urinary tract infections among female outpatients

BACKGROUND

Increasing prevalence of antimicrobial resistance (AMR), including multidrug resistance (MDR), among Escherichia coli (E. coli) makes treatment of uncomplicated urinary tract infection (uUTI) difficult. We assessed risk factors for fluoroquinolone (FQ)-not-susceptible (NS) and MDR E. coli among US female outpatients.

METHODS

This retrospective cohort study utilized data from female outpatients aged ≥ 12 years with E. coli positive urine culture and oral antimicrobial prescription ± 1 day from index. We assessed patient-level factors within 90 and 91-360 days prior to index as predictors of FQ NS (intermediate/resistant) and MDR (NS to ≥ 1 drug across ≥ 3 classes) E. coli: age, prior oral antimicrobial dispensing, prior AMR phenotypes, prior urine culture, and prior hospitalization.

RESULTS

Among 1,858 outpatients with urine-isolated E. coli, 369 (19.9%) had FQ NS and 59 (3.2%) had MDR isolates. After multivariable adjustment, independent risk factors (p < 0.03) for FQ NS E. coli were older age, prior FQ NS isolates, prior dispensing of FQ, and dispensing of any oral antibiotic. Independent risk factors (p < 0.02) for MDR were prior extended-spectrum β-lactamase-producing isolates (ESBL+), prior FQ dispensing, and prior oral antibiotic dispensing.

CONCLUSIONS

In women with uUTI due to E. coli, prior dispensing of FQ or any oral antibiotic within 90 days predicted FQ NS and MDR urine E. coli. Prior urine culture with FQ NS isolates and older age were predictive of FQ NS E. coli. Prior ESBL+ was predictive of MDR E. coli. These data could help identify patients at risk for AMR E. coli and inform empiric prescribing.

Multi-year antimicrobial-resistance trends in urine Escherichia coli isolates from both community-based and hospital-based laboratories of an Australian local health district

OBJECTIVES

Efforts to monitor and combat antimicrobial resistance (AMR) are typically focused on the hospital-based laboratory setting. The aim of this study was to longitudinally examine and compare trends in AMR among urine Escherichia coli isolates from a private community-based laboratory and a public hospital-based laboratory in an Australian local health district.

METHODS

A total of 108 262 urine E. coli isolates from a public hospital-based laboratory (N = 34 103) and a private community-based laboratory (N = 74 159) in a single health district between 2007-2019 were analysed. Linear regression was used to identify significance of change in AMR rates in both laboratories independently and detect any significant interaction of each setting in proportional change over the study period.

RESULTS

Similar AMR trends were detected among urinary E. coli isolates in private community-based laboratory and public hospital-based laboratory settings over 12 y. AMR rates were consistently higher in the public hospital-based setting. Ampicillin was the only antibiotic for which the E. coli resistance trend did not significantly change over the time period in either laboratory setting. All other antibiotics showed a significant increase in AMR rates over time in both settings.

CONCLUSIONS

AMR rates in both the private community-based laboratory and public hospital-based laboratory settings increased over time and were consistently higher in the public hospital-based laboratory setting. Since private laboratories handle the vast majority of pathology volumes in community outpatient settings in Australia, interventions incorporating the community-based laboratory setting are critical to addressing AMR in the community.

The Risk of Pyelonephritis Following Uncomplicated Cystitis: A Nationwide Primary Healthcare Study

BACKGROUND

The risk of pyelonephritis following uncomplicated lower urinary tract infection (cystitis) in women has not been studied in well-powered samples. This is likely due to the previous lack of nationwide primary healthcare data. We aimed to examine the risks of pyelonephritis following cystitis in women and explore if antibiotic treatment, cervical cancer, parity, and sociodemographic factors are related to these risks.

METHODS

This was a nationwide cohort study (2006-2018) of 752,289 women diagnosed with uncomplicated cystitis in primary healthcare settings. Of these, 404 696 did not redeem an antibiotic prescription within five days from cystitis. Logistic regression models were used to calculate odds ratios for pyelonephritis within 30 days and 90 days following the cystitis event.

RESULTS

Around one percent (7454) of all women with cystitis were diagnosed with pyelonephritis within 30 days, of which 78.2% had not redeemed an antibiotic for their cystitis. Antibiotic treatment was inversely associated with both outpatient registration and hospitalization due to pyelonephritis, with odds ratios of 0.85 (95% CI 0.80 to 0.91) and 0.65 (95% CI 0.55 to 0.77), respectively. Sociodemographic factors, parity, and cervical cancer were, with few exceptions (e.g., age and region of residency), not associated with pyelonephritis.

CONCLUSIONS

Antibiotic treatment was inversely associated with pyelonephritis, but the absolute risk reduction was low. Non-antibiotic treatment for cystitis might be a safe option for most women. Future studies identifying the women at the highest risks will help clinicians in their decision making when treating cystitis, while keeping the ecological costs of antibiotics in mind.

The Diagnostic Accuracy Of Procalcitonin for Urinary Tract Infection in Hospitalized Older Adults: a Prospective Study

BACKGROUND

The diagnosis of urinary tract infection (UTI) is challenging among hospitalized older adults, particularly among those with altered mental status.

OBJECTIVE

To determine the diagnostic accuracy of procalcitonin (PCT) for UTI in hospitalized older adults.

DESIGN

We performed a prospective cohort study of older adults (≥65 years old) admitted to a single hospital with evidence of pyuria on urinalysis. PCT was tested on initial blood samples. The reference standard was a clinical definition that included the presence of a positive urine culture and any symptom or sign of infection referable to the genitourinary tract. We also surveyed the treating physicians for their clinical judgment and performed expert adjudication of cases for the determination of UTI.

PARTICIPANTS

Two hundred twenty-nine study participants at a major academic medical center.

MAIN MEASURES

We calculated the area under the receiver operating characteristic curve (AUC) of PCT for the diagnosis of UTI.

KEY RESULTS

In this study cohort, 61 (27%) participants met clinical criteria for UTI. The median age of the overall cohort was 82.6 (IQR 74.9-89.7) years. The AUC of PCT for the diagnosis of UTI was 0.56 (95% CI, 0.46-0.65). A series of sensitivity analyses on UTI definition, which included using a decreased threshold for bacteriuria, the treating physicians' clinical judgment, and independent infectious disease specialist adjudication, confirmed the negative result.

CONCLUSIONS

Our findings demonstrate that PCT has limited value in the diagnosis of UTI among hospitalized older adults. Clinicians should be cautious using PCT for the diagnosis of UTI in hospitalized older adults.

The relation of body mass index, body height, and parity to pyelonephritis: A nationwide population-based cohort study of over one million parous women (1997-2018)

OBJECTIVES

We aimed to explore the association between various physiological factors and pyelonephritis in parous women.

METHODS

Swedish nationwide registers were used to identify 1,073,467 parous women aged 15-50 years. The study period began in 1997 and ended in 2018, or at the first incidence of pyelonephritis, death, or emigration. Cox proportional hazards methods were used to determine hazard ratios (HRs) and 95% confidence intervals (CIs) of pyelonephritis in relation to body mass index (BMI) and body height adjusted for age, parity, and individual-level sociodemographic variables.

RESULTS

A total of 21,625 women (2.0%) were diagnosed with pyelonephritis during follow-up. In the fully adjusted model, low BMI (<18.5) was associated with pyelonephritis (HR 1.13, 95% CI 1.06-1.21). Parity and certain sociodemographic characteristics were also independently associated with pyelonephritis. Body height <161 cm was associated with pyelonephritis (HR 1.12, 95% CI 1.09-1.16) in all but the fully adjusted model.

CONCLUSION

Low BMI and body height seem to be associated with uncomplicated pyelonephritis. More research is needed to verify these findings and identify possible mechanisms.

What are the risk factors for recurrent UTI with repeated ESBL-producing Enterobacteriaceae? A retrospective cohort study

INTRODUCTION

A previous study has shown that two-thirds of patients with urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae experience recurrence with the same bacteria on subsequent UTI episodes. However, little is known about which patients suffer from UTI due to ESBL-producing Enterobacteriaceae repeatedly. This study aimed to investigate the risk factors for recurrent UTI due to repeated ESBL-producing organism infections.

METHODS

This retrospective, single-center, observational cohort study screened all patients with UTI caused by ESBL-producing strains between January 2012 and April 2019. Among the patients who were followed up, patients who experienced UTI recurrence were enrolled and divided into two groups: ESBL recurrence group and non-ESBL recurrence group. Multivariable Cox proportional hazards regression analyses were performed to evaluate the association between patient characteristics and the development of recurrent UTI caused by ESBL-producing Enterobacteriaceae.

RESULTS

A total of 330 patients were followed up after the diagnosis of UTI caused by ESBL-producing organisms. Among the patients, 115 (34.8%) experienced UTI recurrence, and 71 (61.7%) of them experienced subsequent recurrent UTI due to ESBL-producing organisms. Patient's age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.04; P = 0.046) and recurrent UTI history (HR, 1.69; 95% CI, 1.05-2.72; P = 0.031) were significantly associated with an increased risk of recurrence with ESBL-producing Enterobacteriaceae.

CONCLUSION

These findings showed that a history of previous frequent UTI recurrence is the risk factor for recurrence of UTI due to repeated ESBL producing Enterobacteriaceae infections.

Reported Cases of Urinary Tract Infections and the Susceptibility of Uropathogens from Hospitals in Northern Ghana

As global studies report varying trends in antibiotic susceptibility of uropathogens, it is necessary to have current and constant information on the prevalence of urinary tract infections, the causative pathogens, and their susceptibility profiles, for effective management in specific geographical settings. This prospective cross-sectional study focused on the prevalence of urinary tract infections, etiological agents, and their antibiogram in a secondary and tertiary care hospital in Northern Ghana. Urine samples collected from 219 patients of all age groups were cultured on cysteine lactose electrolyte deficient agar. Pathogens were identified following standard microbiological methods, and their susceptibility to antibiotics was determined by the Kirby-Bauer disk diffusion method. Approximately 34% of the patients had significant bacteria, but the prevalence was slightly higher (P = .763) in the Tertiary care hospital (37.3%) than in the Secondary hospital (30.3%). Patients who were 60 years and above (27.0%) were commonly found with UTIs followed by the year group 20 to 29 years (20.3%). Although all the diagnoses had a positive relationship with urinary tract infection except Pyelonephritis, none of the underlying conditions was a significant (P > .05) predictor of urinary tract infection, with the odds ratio indicating that patients with hyperparathyroidism and dysuria had 2.606 times more likely increased risk or predictor of urinary tract infection. Ten different pathogens were identified, but Escherichia coli and Staphylococcus saprophyticus were frequently encountered. Gram-negative isolates generally showed more resistance. High resistance against ampicillin (100%), trimethoprim-sulfamethoxazole (88.5%), chloramphenicol (84.6%), augmentin (69.2%), ceftriaxone (69.2%), and ciprofloxacin (61.5%) were recorded. Amikacin was relatively effective against isolated pathogens. The high records of resistance among uropathogens and the occurrence of multidrug resistance (92%) reiterate the urgent call for rigorous surveillance of antimicrobial resistance among infectious pathogens in Ghana.

Decreasing susceptibility of bacteria to ampicillin/ sulbactam and third generation cephalosporins in urinary tract infections

Background

Urinary tract infections (UTIs) are among the most common bacterial infections worldwide and have become more difficult to treat over the years. Inappropriate antibiotic use has led to increased antibiotic resistance.

Materials and methods

We examined 1921 urine culture samples from a single hospital and analyzed them for bacterial spectrum and antibiotic susceptibility. We further analyzed changes in the rates of detected bacteria and of the sensitivity of these uropathogens to antibiotics over the years.

Results

In our hospital-based analysis, cystitis was the most frequently diagnosed UTI in women (76%) and men (79%). Escherichia coli (48%) was the most commonly identified uropathogen. Samples demonstrated an increase in the proportion of E. coli (p < 0.001) and a decrease in Enterococcus faecalis (p < 0.001) over the study time period. Antimicrobial susceptibility analysis showed an increase over time in the number of isolates with resistance to ampicillin/sulbactam (p < 0.001) and to third-generation cephalosporins cefotaxime (p = 0.043) and ceftazidime (p < 0.001).

Conclusions

Ampicillin/sulbactam and third-generation cephalosporins are antibiotics frequently used in the treatment of UTIs. When selecting an optimal antimicrobial treatment regimen for patients with UTIs, it is imperative to understand regional and timedependent differences in the prevalence of various uropathogens and antimicrobial resistance patterns. Therefore, continuous surveillance of local pathogen and antimicrobial susceptibility patterns for frequently used antibiotics should be prioritized.

Urine Flow Cytometry Parameter Cannot Safely Predict Contamination of Urine—A Cohort Study of a Swiss Emergency Department Using Machine Learning Techniques

Background: Urine flow cytometry (UFC) analyses urine samples and determines parameter counts. We aimed to predict different types of urine culture growth, including mixed growth indicating urine culture contamination. Methods: A retrospective cohort study (07/2017–09/2020) was performed on pairs of urine samples and urine cultures obtained from adult emergency department patients. The dataset was split into a training (75%) and validation set (25%). Statistical analysis was performed using a machine learning approach with extreme gradient boosting to predict urine culture growth types (i.e., negative, positive, and mixed) using UFC parameters obtained by UF-4000, sex, and age. Results: In total, 3835 urine samples were included. Detection of squamous epithelial cells, bacteria, and leukocytes by UFC were associated with the different types of culture growth. We achieved a prediction accuracy of 80% in the three-class approach. Of the n = 126 mixed cultures in the validation set, 11.1% were correctly predicted; positive and negative cultures were correctly predicted in 74.0% and 96.3%. Conclusions: Significant bacterial growth can be safely ruled out using UFC parameters. However, positive urine culture growth (rule in) or even mixed culture growth (suggesting contamination) cannot be adequately predicted using UFC parameters alone. Squamous epithelial cells are associated with mixed culture growth.

Cyclic swelling enabled, electrically conductive 3D porous structures for microfluidic urinalysis devices

Urinalysis is a simple and non-invasive approach for the diagnosis and monitoring of organ health and also is often used as a facile technique in assessment of substance abuse. However, quantitative urinalysis is predominantly limited to clinical laboratories. Here, we present an electrical sensing based, reusable, cellular microfluidic device that offers a fast urinalysis through quantitative reading of the electrical signals. The spatial soft porous scaffolds decorated with electrically conductive multiwalled carbon nanotubes that are capable of physically interacting with biomarkers in urine are developed through a cyclic swelling/absorption process of soft materials and are utilized to manufacture the cellular microfluidic device. The sensing capability, sensitivity and reusability (via sunlight exposure) of the device to monitor red blood cells, Escherichia coli, and albumin are systemically demonstrated by programming mechanical deformation of porous scaffolds. Ex vivo experiments in disease mouse models confirm the diagnosis robustness of the device in comparable results with existing biochemical tests. The full integration of electrically conductive nanomaterials into soft scaffolds provides a foundation for devising bioelectronic devices with mechanically programmable microfluidic features in a low-cost manner, with broad applications for rapid disease diagnoses through body fluid.

Elucidating the effect of body mass index, height, and parity on uncomplicated cystitis: a nationwide population-based cohort study

In this nationwide cohort of one million fertile women, BMI, height, and parity only had minor but statistically significant effects on the risk of uncomplicated cystitis. The results indicate that underweight women and certain sociodemographic groups might have higher risks, which could have underlying explanations that need further studying.

A quantitative sensing system based on a 3D-printed ion-selective electrode for rapid and sensitive detection of bacteria in biological fluid

Bacterial infections, such as urinary tract infections, are crucial health problems. Here, we report a new potentiometric sensor to detect bacteria sensitively, accurately, and quickly. First, a customizable, 3D printed Ag⁺ selective electrode was fabricated as the probe. Our 3D printed electrode showed sensitive, linear, and selective responses to Ag⁺. Compared to commercial Ag⁺ selective electrodes, ours required less sample volume, shorter responding time, and lower costs. Next, a novel potentiometer was developed with Arduino to couple the electrode for data transducing and transferring, which was programmed to transfer results to cell phones wirelessly. Moreover, a filter was designed to quickly remove interfering species in a biofluid sample (e.g., Cl^-). By detecting the lost Ag⁺ taken by bacteria, the bacterial number could be elucidated. With this sensor system, bacteria numbers could be detected as low as 80 CFU/mL (LOD) within 15 min, which is sufficient for many diagnoses (e.g., urinary tract infection >1000 CFU/mL). An amplification method was presented for single-digit bacteria detection. Overall, we are presenting a bacteria detector with three innovative components: the electrode (signal transduction and detection), the potentiometer (transducer and data processing), and the 3D printed filter (sample preparation), which showed robust and improved (than previously reported ones) analytical merits. The low-cost and customizable (the electrode and the open-source coding) nature enhances the transnationality of the system, especially in underdeveloped areas.

Fluoroquinolones and Other Antibiotics Redeemed for Cystitis—A Swedish Nationwide Cohort Follow-Up Study (2006–2018)

Background: Antibiotics are commonly prescribed for outpatient management of cystitis. Previous evidence suggests that certain factors likely beyond the infection seem to influence the choice of antimicrobial treatment. However, studies on the specific antibiotic treatments for cystitis are lacking. This study aimed to explore the antibiotic treatments for cystitis using nationwide primary healthcare data and investigate if factors beyond the infection could be associated with fluoroquinolone treatment. Methods: This nationwide follow-up cohort study consisted of 352,507 women with cystitis. The primary aim was to investigate what specific classes of antibiotics were redeemed by patients within five days from the cystitis diagnosis. Each patient could only be included once. Logistic regression models were also used to examine the relationship between fluoroquinolone (FQ) treatment, parity, and sociodemographic factors. Results: In total, 192,065 antibiotic prescriptions were redeemed. Pivmecillinam (58.4%) followed by nitrofurantoin (22.2%), trimethoprim (12.0%), fluoroquinolone (5.6%), and cephalosporins (1.5%) were the most redeemed antibiotics. Sociodemographic factors were weakly associated with fluoroquinolone treatment; young age was inversely associated with fluoroquinolone treatment. Parity and cervical cancer history were not associated with fluoroquinolone treatment. The proportion of fluoroquinolone and trimethoprim treatments decreased over time, while pivmecillinam and nitrofurantoin increased. Conclusions: The treatment trends of antibiotics redeemed within five days from a cystitis diagnosis were similar to the national surveillance program of these antibiotics (not diagnosis linked). Fluoroquinolones were weakly associated with sociodemographic factors, which likely is only of historical relevance.

Vesicourachal Diverticulum: A Rare Cause of Recurrent Urinary Tract Infections

Urinary tract infection is a common medical condition encountered in outpatient clinics and emergency departments. Recurrence of urinary tract infections is common. The recurrence can arise from behavioral, mechanical, and physiological factors. Urachal anomalies are very rare congenital clinical entities. We present the case of a 41-year-old woman who presented to the emergency department with dysuria, frequency, urgency, and incontinence. There was no history of fever or flank pain. Physical examination revealed no abnormalities. Initial laboratory markers were within the normal range. However, urinalysis findings showed numerous white blood cells and positive leukocyte esterase and nitrite. While these findings are suggestive of acute simple cystitis, the patient had a concerning history of recurrent urinary tract infections. The urology team advised performing an abdominal computed tomography scan to rule out any structural abnormalities. The patient underwent a computed tomography scan, which demonstrated the presence of a fluid-filled structure arising from the dome of the bladder and extending superiorly toward the umbilicus, representing a vesicourachal diverticulum. The patient underwent surgical resection after antibiotic therapy. The vesicourachal diverticulum is a very rare type of urinary tract anomalies. The case highlights the importance of considering congenital urachal anomalies in patients with recurrent urinary tract infections. A computed tomography scan can make the diagnosis of such anomalies with high accuracy.

The Effect of Sociodemographic Factors, Parity and Cervical Cancer on Antibiotic Treatment for Uncomplicated Cystitis in Women: A Nationwide Cohort Study

BACKGROUND

Uncomplicated cystitis is one of the most common reasons for antibiotic treatment in otherwise healthy women. Nationwide studies on antibiotic treatment for this infection and in relation to factors beyond the infection itself have hitherto not been available.

METHODS

This was a nationwide open cohort study consisting of 352,507 women aged 15-50 years with uncomplicated cystitis (2006-2018). The outcome was a redeemed antibiotic prescription within five days from the cystitis diagnosis. Logistic regression models were used to examine the relationship between the outcome and the predictor variables.

RESULTS

This study identified 192,065 redeemed treatments (54.5%). Several sociodemographic variables were associated with antibiotic treatment. For example, women with the lowest income had an odds ratio (OR) of 1.26 (95% CI 1.23-1.28) compared to those with the highest income. History of cervical cancer and high parity were also associated with lower treatment rates.

CONCLUSION

This study presents novel factors beyond the infection which seem to affect the antibiotic treatment for uncomplicated cystitis in women. Future studies to investigate possible mechanisms are warranted in order to properly use our findings. This may help healthcare workers and planners to provide a more equal treatment plan for this common infection, which may reduce misuse of antibiotics, decrease costs and improve efforts against antibiotic resistance.

Sink/Float Magnetic Immunoassays for In-Field Bioassays

Analytical tests/devices that are used outside laboratory settings are required to have a very simple analytical protocol to get clearance by regulatory authorities. This study describes sink/float magnetic immunoassays, a new type of rapid, mix-and-observe, instrument-free tests for the detection of biomarkers in untreated biological samples that are very simple and might meet the simple-to-use criterion of authorities to be used in the field. These tests can tell whether an analyte is above or below a predetermined level within 25-45 minutes based on the sinking or floating of a mm-sized sphere on the surface of which an immunoassay that uses reporter antibodies conjugated to superparamagnetic nanoparticles is performed. This manuscript describes the theory and proof-of-concept applications of sink/float magnetic immunoassays for the detection of C-Reactive Protein, anti-Treponema pallidum antibodies and E. coli bacteria.

Sociodemographic factors and uncomplicated pyelonephritis in women aged 15-50 years: a nationwide Swedish cohort register study (1997-2018)

OBJECTIVE

To study the relationship between sociodemographic factors and pyelonephritis.

METHODS

A nationwide open cohort study consisting of 2 052 873 women (76.2% Swedish-born) aged 15-50 years was conducted (1997-2018). The outcome was first event of acute uncomplicated pyelonephritis diagnosed in primary health care settings in relation to the sociodemographic factors. Cox regression models were used in the analyses.

RESULTS

The study identified 40 724 cases. In the fully adjusted model, women from non-western countries had higher risks of pyelonephritis compared to Swedish-born women. Women from Latin America/Caribbean had highest risk (Hazard ratio = 1.60; 95% CI 1.49-1.72), followed by Eastern Europe (HR = 1.26; 95% CI 1.21-1.32) and Middle East/North Africa (HR = 1.25; 95% CI 1.19-1.30). Low education, low income, urban living, and young age were also associated with higher risks of pyelonephritis.

CONCLUSION

This study presents novel risk factors associated with pyelonephritis. Women from non-western countries and with low socioeconomic status might suffer disproportionately from this serious infection. This might be due to biological predispositions and the fact that immigrant women do not acquire the same level of health or might receive less health care compared to native women, even in the presence of universal health care.

Antimicrobial activity of extracts and fractions of Euphorbia lateriflora (Schum. and Thonn) on microbial isolates of the urinary tract

Euphorbia lateriflora is used in ethnomedicine for treating several conditions, including genital and urinary tract infections (UTI). Although ethnobotanical claims support its use in therapy, there is limited evidence on its effect on UTI, even though UTI remains a public health problem in Nigeria especially due to increasing antimicrobial resistance. We investigated the activity of E. lateriflora extracts and fractions on bacterial and fungal isolates from symptomatic urinary tract infections and vaginosis respectively. Qualitative phytochemical screening was conducted on dried pulverised leaves. Successive gradient extraction was carried out with the aid of a soxhlet extractor with n-Hexane, ethyl acetate and methanol respectively. Bioactivity guided fractionation was conducted on the ethyl acetate extract using Vacuum Liquid Chromatography. Antimicrobial susceptibility testing by disc diffusion was conducted on test isolates. Antimicrobial susceptibility of isolates to extracts and fractions was done using the agar well diffusion technique. Minimum Inhibitory Concentrations (MIC) and Minimum Biocidal Concentrations (MBC) were determined by agar and broth dilutions respectively. Time-kill assay of the ethyl acetate extract was conducted using the viable count technique. Phytochemicals present include saponins, tannins and flavonoids. The majority of isolates used in this study were multidrug resistant. Extracts and fractions of E. lateriflora produced appreciable zones of inhibition on both antibiotic susceptible and resistant bacteria with MICs of 6.25 mg/mL and MBC ranging from 6.25–50 mg/mL. Bactericidal activity of the ethyl acetate extract was concentration and time dependent with 100% kill at 25 mg/mL after 6 h for E. coli and 2 h for C. albicans. Euphorbia lateriflora contains phytochemicals which possess antimicrobial activity on antibiotic resistant bacteria and has potential in the development of chemotherapeutics for bacterial and fungal infections.

Sociodemographic factors and uncomplicated cystitis in women aged 15-50 years: a nationwide Swedish cohort registry study (1997-2018)

Background

Symptoms suggestive of uncomplicated cystitis constitutes one of the most common reasons to seek health care in otherwise healthy women. Previous studies regarding the relationship between sociodemographic factors and uncomplicated cystitis are limited, mainly because of the lack of nationwide population-based data from primary healthcare settings, where most uncomplicated cystitis are diagnosed.

Methods

A Swedish nation-wide open cohort study consisting of 2 044 065 females who were 15–50 years of age during the study period (1997–2018) was conducted. The outcome was first event uncomplicated cystitis diagnosed in primary health care rather than an assessment of the "true" incidence, which is not feasible in nationwide datasets. Cox regression models were used in the statistical analyses.

Findings

The study identified 546 076 first events of uncomplicated cystitis (26•7% of the study population), corresponding to an incidence rate per 100 person-years of 2•91 (95% CI 2•90–2•91). In fully adjusted models, rural living was associated with lower risks of uncomplicated cystitis (Hazard ratio, HR, 0•67; 95% CI, 0•66–0•68) compared to urban living, while both Middle Eastern/North African (HR, 1•15; 95% CI, 1•14–1•16) and Latin American/Caribbean (HR, 1•24; 95% CI, 1•22–1•27) women had higher risks compared to Swedish women. Low education and low income were also associated with higher risks compared to high education and high income.

Interpretation

This study presents novel risk factors associated with uncomplicated cystitis in women. The findings may help health care workers in the treatment of women with symptoms of uncomplicated cystitis.

Funding

The Primary Healthcare Management and ALF funding (Region Skåne, Sweden) and the Swedish Research Council.

Development of a Fast Raman-Assisted Antibiotic Susceptibility Test (FRAST) for the Antibiotic Resistance Analysis of Clinical Urine and Blood Samples

Human health is at great risk due to the spreading of antimicrobial resistance (AMR). The lengthy procedure of conventional antimicrobial susceptibility testing (AST) usually requires a few days. We developed a fast Raman-assisted antibiotic susceptibility test (FRAST), which detects single bacterial metabolic activity in the presence of antibiotics, using Raman single-cell spectroscopy. It was found that single-cell Raman spectra (SCRS) would show a clear and distinguishable Raman band at the "silent zone" (2000-2300 cm^-1), due to the active incorporation of deuterium from heavy water (D₂O) by antibiotic-resistant bacteria. This pilot study has compared the FRAST and the conventional AST for six clinical standard quality controls (four Gram-negative and two Gram-positive bacteria strains) in response to 38 antibiotics. In total, 3200 treatments have been carried out and approximately 64 000 SCRS have been acquired for FRAST analysis. The result showed an overall agreement of 88.0% between the FRAST and the conventional AST assay. The gram-staining classification based on the linear discriminant analysis (LDA) model of SCRS was developed, seamlessly coupling with the FRAST to further reduce the turnaround time. We applied the FRAST to real clinical analysis for nine urinary infectious samples and three sepsis samples. The results were consistent with MALDI-TOF identification and the conventional AST. Under the optimal conditions, the "sample to report" of the FRAST could be reduced to 3 h for urine samples and 21 h for sepsis samples. The FRAST provides fast and reliable susceptibility tests, which could speed up microbiological analysis for clinical practice and facilitate antibiotic stewardship.

Rising prevalence of multidrug-resistant uropathogenic bacteria from urinary tract infections in pregnant women

Objectives

This study aimed to determine the prevalence of urinary tract infections (UTI) in pregnant women and characterise the uropathogenic bacterial strains associated with symptomatic and asymptomatic bacteriuria in Lahore, Pakistan.

Methods

Between December 2018 and June 2019, we analysed the uropathogenic bacterial strains from midstream urine samples in 80 pregnant women. The age of the pregnant women ranged from 19 to 45 years, and they resided in urban and rural areas. We also recorded socioeconomic factors in this cohort. The isolated strains were phenotypically identified and evaluated for multiple drug resistance (MDR) patterns against recommended antimicrobial drugs.

Results

Of the 80 pregnant women, 65 had UTI, reflecting an 81% prevalence of UTI in women during pregnancy. The majority of participants aged 24–35 years, were multipara, and were in their third trimester. Results showed that 67 uropathogenic bacterial strains belonged to Escherichia (31%), Klebsiella (23%), Pseudomonas (16%), Streptococcus (4%), Enterococcus (4%), Staphylococcus (4%), and Proteus (3%) genera, as identified using biochemical characterisation. The highest overall resistance of Escherichia was seen against amoxicillin, pipemidic acid, and ampicillin; for Klebsiella against pipemidic acid, ampicillin, and cefotaxime; and for Pseudomonas against ciprofloxacin and cefotaxime. The three strains with the highest MDR were identified using 16S rRNA as Pseudomonas aeruginosa strain UA17, Escherichia coli strain UA32, and Klebsiella pneumoniae strain UA47.

Conclusion

In this study, the MDR uropathogenic strains showed the highest resistance pattern. The alarming signs of MDR uropathogenic infections are infrequently addressed and thus, urgent attention to this matter is essential.

Efficacy of Acacia nilotica aqueous extract in treating biofilm-forming and multidrug resistant uropathogens isolated from patients with UTI syndrome

Escherichia coli is the dominant bacterial cause of UTI among the uropathogens in both developed and developing countries. This study is to investigate the effect of Acacia nilotica aqueous extract on the survival and biofilm of isolated pathogens to reduce UTIs diseases. A total of 170 urine samples were collected from Luxor general hospital and private medical analysis laboratories in Luxor providence, Egypt. Samples were screened for the incidence of uropathogens by biochemical tests, antibiotics susceptibility, detection of virulence, and antibiotic-resistant genes by multiplex PCR, biofilm formation, and time-killing assay. Escherichia coli is by far the most prevalent causative agent with the percentage of 73.7% followed by Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeuroginosa, and Acinetobacter baumanii. Isolates were multidrug-resistant containing blaTEM, blaSHV, blaCTX, qnrs, and aac(3)-Ia resistant genes. All isolates were sensitive to 15-16.7 mg ml-1 of Acacia nilotica aqueous extract. Time killing assay confirmed the bactericidal effect of the extract over time (20-24 h). A high percentage of 3-Cyclohexane-1-Carboxaldehyde, 2,6,6-trimethyl (23.5%); á-Selinene (15.12%); Oleic Acid (14.52%); Globulol (11.35%) were detected among 19 bioactive phytochemical compounds in the aqueous extract of A. nilotica over the GC-mass spectra analysis. The plant extract reduced significantly the biofilm activity of E. coli, K. pneumoniae, P. mirabilis, and P. aeuroginosa by 62.6, 59. 03, 48.9 and 39.2%, respectively. The challenge to improve the production of A. nilotica phytochemicals is considered a very low price for the return.

Is Non-Steroidal Anti-Inflammatory Therapy Non-Inferior to Antibiotic Therapy in Uncomplicated Urinary Tract Infections: a Systematic Review

BACKGROUND

Amid growing antimicrobial resistance, there is an increasing focus on antibiotic stewardship efforts to reduce inappropriate antibiotic prescribing. In this context, novel approaches for treating infections without antibiotics are being explored. One such strategy is the use of non-steroidal anti-inflammatory drugs (NSAIDs) for uncomplicated urinary tract infections (UTIs). Therefore, we conducted a systematic review of randomized controlled trials to evaluate the rates of symptom resolution and infectious complications in adult women with uncomplicated UTIs treated with antibiotics versus NSAIDs.

METHODS

We systematically searched PubMed, CINHAL, Scopus, Web of Science Core Collection, EMBASE, and ClinicalTrials.gov from inception until January 13, 2020, for randomized controlled trials comparing NSAIDs with antibiotics for treatment of uncomplicated UTIs in adult women. Studies comparing symptom resolution between groups were eligible. Two authors screened all studies independently and in duplicate; data were abstracted using a standardized template. Risk of bias was assessed using the Cochrane Collaboration tool.

RESULTS

Five randomized trials that included 1309 women with uncomplicated UTI met inclusion criteria. Three studies (1130 patients) favored antibiotic therapy in terms of symptom resolution. Two studies (179 patients) found no difference between NSAIDs and antibiotics in terms of symptom resolution. Three studies reported rates of pyelonephritis, two of which found higher rates in patients treated with NSAIDs versus antibiotics. Between two studies that reported this outcome (747 patients), patients randomized to NSAIDs received fewer antibiotic prescriptions compared with those in the antibiotics group. Three studies were at low risk of bias, one had an unclear risk of bias, and one was at high risk of bias.

DISCUSSION

For the outcomes of symptom resolution and complications in adult women with UTI, evidence favors antibiotics over NSAIDs.

PROSPERO

CRD42018114133.

Management of acute pyelonephritis in the emergency department observation unit

INTRODUCTION

This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre.

METHODS

We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes.

RESULTS

Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful.

CONCLUSION

EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.

Antimicrobial Agents and Urinary Tract Infections

Urinary Tract Infections (UTIs); second-ranking infectious diseases are regarded as a significant global health care problem. The UTIs annually cost tens of millions of dollars for governments worldwide. The main reason behind these costs is incorrect or indefinite treatment. There are a wide range of gram-negative and grampositive bacteria which may cause UTIs in males and females, children and adults. Among gram-negative bacteria, some members of Enterobacteriaceae such as Escherichia coli (E.coli) strains have significant contribution in UTIs. Uropathogenic E.coli (UPEC) strains are recognized as typical bacterial agents for UTIs. Thus, sharp and accurate diagnostic tools are needed for detection and identification of the microbial causative agents of UTIs. In parallel with the utilization of suitable diagnostic methods-to reduce the number of UTIs, effective and definite treatment procedures are needed. Therefore, the prescription of accurate, specific and effective antibiotics and drugs may lead to a definite treatment. However, there are many cases related to UTIs which can be relapsed. Due to a diversity of opportunistic and pathogenic causative microbial agents of UTIs, the treatment procedures should be achieved by the related antimicrobial agents. In this review, common and effective antimicrobial agents which are often prescribed for UTIs caused by UPEC will be discussed. Moreover, we will have a sharp look at their (antimicrobials) molecular treatment mechanisms.

Three versus five days of pivmecillinam for community-acquired uncomplicated lower urinary tract infection: A randomised, double-blind, placebo-controlled superiority trial

BACKGROUND

To investigate if a 5-day course pivmecillinam (amdinocillin pivoxil) 400 mg three times daily is superior to a 3-day course in women with uncomplicated urinary tract infection (UTI).

METHODS

A randomised, double-blind, placebo-controlled trial conducted at nine primary care centres in Denmark. 368 women (18-70 years) with symptoms compatible with UTI were randomised to blinded therapy of 5 days [5d] or 3 days followed by 2 days of placebo [3d] from May 2015 to November 2017. Clinical data were assessed using a validated questionnaire at inclusion (day-0), daily the following 7 days and once again within the 2nd to 6th week after intervention. Bacteriological data were collected prior to intervention and twice between day 7 and 42. Main clinical endpoints were days to symptom resolution within 7 days after inclusion and proportions with clinical success at the end of intervention. Main bacteriological endpoint was proportion of participants with significant reduction of bacteriuria (≥ 10² CFU/mL) in 1st control urine sample. ClinicalTrialsRegister.eu: 2014-001321-32.

FINDINGS

180 (5d) and 188 (3d) participants were included in the study (mean age: 35.4 [5d] and 34.9 [3d]). Of these, 125 (70% [5d]) and 122 (66% [3d]) had a positive baseline urine culture. Forty-four participants were lost to follow-up, leaving 161 [5d] and 163 [3d] participants for analysis, respectively. Mean time to symptom resolution was 2.91 (SD 1.46; [5d]) days and 2.94 (SD 1.42; [3d]) days (P = .894). Clinical success at the end of treatment occurred for 117 of 153 (76%) receiving the 5d-course and for 115 of 157 (73%) receiving the 3d course (difference 3.2% [95% CI -7.1% - 13.5%]; P = .601). Bacteriological success was seen in 92 of 104 (88%) participants given the 5d course and in 86 of 99 (87%) given the 3d course (difference 1.6% [95% CI -8.4%-11.6%]; P = .895).

INTERPRETATIONS

A 5-day course of pivmecillinam was not superior to a 3-day course in clinical or bacteriological outcomes for UTI.

PRIMARY FUNDING SOURCE

The Danish Regions [no. 14/217].

Treatment duration of pivmecillinam in men, non-pregnant and pregnant women for community-acquired urinary tract infections caused by Escherichia coli: a retrospective Danish cohort study

Objectives

To evaluate the importance of treatment duration for therapeutic efficacy of pivmecillinam for community-acquired urinary tract infections (UTIs) caused by Escherichia coli.

Methods

A retrospective cohort study was conducted between 1 January 2010 and 30 September 2016 in adults with community-acquired E. coli bacteriuria, treated empirically with pivmecillinam. Regimens of 3, 5 and 7 days were compared using clinical treatment failure (i.e. redemption of a new antibiotic or hospitalization due to UTI) within 14 and 30 days as outcome. HR and risk difference with 95% CI were estimated for treatment failure. Results were stratified by age (18–50, 51–70, >70 years) and sex.

Results

Of the 21864 cases of E. coli UTI that were analysed, 2524 (11.5%) were in men. In 954 cases (4.4%) E. coli produced ESBL and 125 (13.1%) of the cases were in men. The 3 day regimen increased the risk of treatment failure for all groups. The risk differences between the 3 and 5 day regimens were <10% for women, but >10% for men. Comparing the 7 day and 5 day regimens, only women aged >50 years demonstrated an increased risk of treatment failure within 14 days with the 5 day regimen, but not within 30 days.

Conclusions

With the current data, where data on clinical classification of the E. coli UTI were missing, a 5 day treatment with pivmecillinam at 400 mg three times daily seems to be the rational recommendation for lower UTI in men, pregnant women and women >50 years old. A 3 day regimen seems sufficient for non-pregnant women <50 years old.

Prevalence of Bacterial Urinary Tract Infections and Associated Factors among Patients Attending Hospitals in Bushenyi District, Uganda

Urinary tract infections (UTIs) are one of the major causes of morbidity and comorbidities in patients with underlying conditions, and it accounts for the majority of the reasons for hospital visit globally. Sound knowledge of factors associated with UTI may allow timely intervention that can easily bring the disease under control. This study was designed to determine the prevalence of UTI by isolating and characterizing the different bacterial etiological agents and to evaluate the factors associated with UTI. In this cross-sectional study, a total of 267, clean catch midstream urine (MSU) samples were collected aseptically and analyzed using standard microbiology methods. Data for the factors associated with UTI were obtained by use of questionnaires and standard laboratory tests for selected underlying conditions. The study revealed 86/267 (32.2%) UTI prevalence among patients attending hospitals in Bushenyi District, Uganda. Escherichia coli was the most prevalent bacterial uropathogen with 36/86 (41.9%) followed by Staphylococcus aureus 27/86 (31.4%), Klebsiella pneumoniae 10/86 (11.6%), Klebsiella oxytoca 6/86 (7.0%), Proteus mirabilis 3/86 (3.5%), Enterococcus faecalis 3/86 (3.5%), and Proteus vulgaris 1/86 (1.2%). This study has demonstrated that age ≤19 years, female gender, married individuals, genitourinary tract abnormalities, diabetes, hospitalization, indwelling catheter <6 days, and indwelling catheter >6 days had statistically significant relationships (p < 0.05) with UTI. Screening for UTI in hospitalized patients, female gender, married individuals, genitourinary tract abnormalities, indwelling catheter, and diabetics should be adopted.

Infection of urinary tract in menopausal women

Urinary infections are, by frequency, in the second place, immediately behind respiratory infections. The prevalence of urinary tract infections is generally increasing. UTI (urinary tract infections) is more common in women and very young people. The rates of occurrence generally reflect predisposing factors such as congenital anomalies in childhood, the onset of sexual activity, especially in women, and, of course, postmenopausal changes in older women. It is assumed that 50-60% of women can expect an episode of urinary infection during their lifetime. In postmenopausal women, there is a deficit in estrogen. It is one of the important factors that indirectly protects the vaginal mucous membranes as well as the uroepitel from infection. Bacteria from the digestive tract colonize the skin of the perineum, then the vulva, the vagina and the outer opening of the urethra. Normal vaginal flora (lactobacilli) protects the vagina from colonization by fecal bacteria because it lowers pH and creates unfavorable conditions for survival of bacteria.

Silver nanoparticles for the visual detection of lomefloxacin in the presence of cystine

A novel optical sensors for lomefloxacin based on the plasma resonance properties of silver nanoparticles (AgNPs) for the first time. The hydrogen bonds and electrostatic force between the lomefloxacin and AgNPs could induce the change in color and absorption spectra of AgNPs suspension, which provided a theoretical basis for the optical detection of lomefloxacin. In addition, we made the AgNPs-lomefloxacin detection system reach the critical point of discoloration by adding cystine to improve the sensitivity. Furthermore, the influence of some factors such as temperature, reaction time and pH on the AgNPs-lomefloxacin detection system was investigated. The results of UV-vis spectra showed that the absorption ratio (A₅₂₀/A₃₉₅) was linear with the concentration of lomefloxacin in the range from 0.2 to 5 μmol/L with linear coefficients of 0.991. The proposed method can be applied to detecting lomefloxacin with an ultralow detection limit of 0.6 μmol/L without any complicated instruments and complex pretreatment. The selectivity of AgNPs-lomefloxacin detection system is proved excellent by comparing with other ions and analytes in urine. The method in our study is appropriate to be used to monitor quantitatively entecavir in human urine owing to its rapid response rate, visible color changes, wide linear range and excellent selectivity.

Incidence of single-drug resistant, multidrug-resistant and extensively drug-resistant Escherichia coli urinary tract infections: An Australian laboratory-based retrospective study

OBJECTIVES

The aim of this study was to evaluate the incidence of single-drug resistant, multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) Escherichia coli urinary tract infections (UTIs) in a sample of Australian Capital Territory (ACT) residents.

METHODS

Laboratory-based retrospective data from all ACT residents whose urine samples were processed from January 2009 to December 2013 at ACT Pathology were utilised. Multivariate logistic regression models were constructed to determine the associations of age, sex, urine sample source and socioeconomic status with risk of resistant infections.

RESULTS

A total of 146 915 urine samples from 57 837 ACT residents were identified over 5 years. The mean±standard deviation age of residents at first sample submitted was 48±26years, and 64.4% were female. The 5-year incidence of single-drug resistant E. coli UTI was high for ampicillin, trimethoprim and cefazolin (6.8%, 3.5% and 1.9%, respectively). No PDR E. coli UTI was detected. Five-year incidences of MDR and XDR E. coli UTIs were 1.9% and 0.2%, respectively, which is low in comparison with international rates. Female sex and age ≥38 years were significantly associated with single-drug and multidrug resistance. The risk of single-drug resistance was significantly higher in samples from after-hours general practice (GP) clinics compared with hospitals, office-hours GP clinics, and community and specialist health services (adjusted odds ratio=2.6, 95% confidence interval 2.2-3.1).

CONCLUSIONS

These findings have significant implications for antimicrobial prescribing given the identified risk factors for the detection of resistance, especially in patients attending after-hours GP clinics.

Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial

IMPORTANCE

Increased hydration is often recommended as a preventive measure for women with recurrent cystitis, but supportive data are sparse.

OBJECTIVE

To assess the efficacy of increased daily water intake on the frequency of recurrent cystitis in premenopausal women.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, open-label, controlled, 12-month trial at a clinical research center (years 2013-2016). Among 163 healthy women with recurrent cystitis (≥3 episodes in past year) drinking less than 1.5 L of fluid daily assessed for eligibility, 23 were excluded and 140 assigned to water or control group. Assessments of daily fluid intake, urinary hydration, and cystitis symptoms were performed at baseline, 6- and 12-month visits, and monthly telephone calls.

INTERVENTIONS

Participants were randomly assigned to drink, in addition to their usual fluid intake, 1.5 L of water daily (water group) or no additional fluids (control group) for 12 months.

MAIN OUTCOMES AND MEASURES

Primary outcome measure was frequency of recurrent cystitis over 12 months. Secondary outcomes were number of antimicrobial regimens used, mean time interval between cystitis episodes, and 24-hour urinary hydration measurements.

RESULTS

The mean (SD) age of the 140 participants was 35.7 (8.4) years, and the mean (SD) number of cystitis episodes in the previous year was 3.3 (0.6). During the 12-month study period, the mean (SD) number of cystitis episodes was 1.7 (95% CI, 1.5-1.8) in the water group compared with 3.2 (95% CI, 3.0-3.4) in the control group, with a difference in means of 1.5 (95% CI, 1.2-1.8; P < .001). Overall, there were 327 cystitis episodes, 111 in the water group and 216 in the control group. The mean number of antimicrobial regimens used to treat cystitis episodes was 1.9 (95% CI, 1.7-2.2) and 3.6 (95% CI, 3.3-4.0), respectively, with a difference in means of 1.7 (95% CI, 1.3-2.1; P < .001). The mean time interval between cystitis episodes was 142.8 (95% CI, 127.4-160.1) and 84.4 (95% CI, 75.4-94.5) days, respectively, with a difference in means of 58.4 (95% CI, 39.4-77.4; P < .001). Between baseline and 12 months, participants in the water group, compared with those in the control group, had increased mean (SD) urine volume (1.4 [0.04] vs 0.1 [0.04] L; P < .001) and voids (2.4 [0.2] vs -0.1 [0.2]; P < .001) and decreased urine osmolality (-402.8 [19.6] vs -24.0 [19.5] mOsm/kg; P < .001).

CONCLUSIONS AND RELEVANCE

Increased water intake is an effective antimicrobial-sparing strategy to prevent recurrent cystitis in premenopausal women at high risk for recurrence who drink low volumes of fluid daily.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02444975.

Outcomes of Urinary Tract Infection Management by Pharmacists (RxOUTMAP): A study of pharmacist prescribing and care in patients with uncomplicated urinary tract infections in the community

Background

Pharmacists have the authorization to prescribe medications for the treatment of uncomplicated urinary tract infections (UTI) in some provinces. However, there are limited data on the outcomes of this care by pharmacists. Our objective was to evaluate the effectiveness, safety and patient satisfaction with pharmacist prescribing and care in patients with uncomplicated UTI.

Methods

We conducted a prospective registry trial in 39 community pharmacies in the Canadian province of New Brunswick. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (Pharmacist-Initial Arm) or if they presented with a prescription for an antibacterial to treat UTI from another health care provider (Physician-Initial Arm). Pharmacists assessed patients and if they had complicating factors or red flags for systemic illness or pyelonephritis, they were excluded from the study. Pharmacists either prescribed antibacterial therapy, modified antibacterial therapy, provided education only or referred to physician, as appropriate. The primary outcome was clinical cure at 2 weeks and the secondary outcomes included adverse events and patient satisfaction.

Results

A total of 750 patients were enrolled (87.4% in the Pharmacist-Initial Arm), average age was 40.9 (SD 16.0) years. Clinical cure was achieved in 88.9% of patients. Of those that did not have sustained symptom resolution, most (5.5% overall) had symptom recurrence after completion of therapy. Adverse events were reported by 7.2% of patients and 88.9% of those continued their medication. Most adverse events were gastrointestinal-related and transient. The patient satisfaction survey reflected very high levels of satisfaction for the care they received, as well as for trust and accessibility of the pharmacist.

Conclusion

Pharmacist management of uncomplicated UTI is effective, safe, and patient satisfaction appears very high.

Mecillinam for the treatment of acute pyelonephritis and bacteremia caused by Enterobacteriaceae: a literature review

Purpose

The pharmacokinetic properties of mecillinam (MEC) for urinary tract infections are excellent, and the resistance rate in Enterobacteriaceae is low compared to other recommended antibiotics. The oral prodrug pivmecillinam (P-MEC) has been used successfully as first choice for cystitis in the Nordic countries for many years. Norwegian and Danish guidelines also recommend P-MEC for acute uncomplicated pyelonephritis (AUP) and intravenous (IV) MEC for suspected urosepsis (only in Denmark). Here, we wish to present an updated investigation on the clinical data behind these recommendations together with sparse but more current clinical data.

Methods

Prospective clinical trials evaluating MEC as monotherapy or in polytherapy with one other beta-lactam (mostly ampicillin [AMP]) for pyelonephritis or bacteremia were reviewed. Outcomes of primary interest were clinical and bacteriological success and relapse, respectively. Search databases used were PubMed, Cochrane Library, and Embase.

Results

Twelve clinical studies (1979-2015) were included in this integrated literature review. Clinical success was seen in 38/51 (75%) patients treated with MEC as monotherapy and in 152/164 (93%) patients treated with MEC and one other beta-lactam. Bacteriological success was seen in 35/47 (74%) and 117/167 (70%) patients treated with MEC alone and with one other beta-lactam, respectively. In complicated infections, bacteriological success was much lower. Clinical relapse rate was not well described. Several uropathogenic bacteremia cases were treated successfully with MEC alone (ie, 10/15 [67%] and 13/15 [87%] for clinical and bacteriological success, respectively) or with one other beta-lactam (ie, 57/65 [88%] and 53/63 [84%] for clinical and bacteriological success, respectively). However, data on bacteremia are very sparse. Adverse reactions were few and mild (73/406 [18%]) and primarily seen when AMP was co-administered (69/73 [95%]). No serious adverse reactions were reported.

Conclusion

IV MEC or oral P-MEC for 14 days may be suitable for the treatment of AUP and pediatric pyelonephritis. Randomized controlled trials using a single standardized dose of P-MEC compared to other current recommendations are warranted. Similarly, more evidence is required before MEC should be recommended for bacteremia or sepsis due to Enterobacteriaceae.

Risk factors for urinary tract infection in patients with urolithiasis-primary report of a single center cohort

Background

Urinary tract infection (UTI) is very common in patients with urolithiasis, which makes the treatment of urolithiasis complicated, even dangerous. The objective of this study was to determine the risk factors for UTI in patients with urolithiasis.

Methods

Eight hundred six patients with urolithiasis were retrospectively evaluated in the fourth affiliated hospital of China Medical University. All patients admitted to the study were divided into either a UTI infection group or a non-infection group. Sex, age, smoking, stone shape, alcohol consumption, position of stones, and presence of obstruction were used as exposure factors for the cross-sectional study.

Results

One hundred seventy-eight patients (22.0%) had UTI. Through a urine culture test, gram-negative bacilli were the most common pathogen, followed by gram-positive bacilli and fungi.

Conclusions

Sex, age, obstruction, stone shape, and multiple sites of stones could be considered the independent factors for UTI in patients with urolithiasis; smoking and drinking had no statistically significant correlation with the condition. Gram-negative bacilli are the most common pathogen in UTI in patients with urolithiasis.

Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial

IMPORTANCE

The use of nitrofurantoin and fosfomycin has increased since guidelines began recommending them as first-line therapy for lower urinary tract infection (UTI).

OBJECTIVE

To compare the clinical and microbiologic efficacy of nitrofurantoin and fosfomycin in women with uncomplicated cystitis.

DESIGN, SETTING, AND PARTICIPANTS

Multinational, open-label, analyst-blinded, randomized clinical trial including 513 nonpregnant women aged 18 years and older with symptoms of lower UTI (dysuria, urgency, frequency, or suprapubic tenderness), a positive urine dipstick result (with detection of nitrites or leukocyte esterase), and no known colonization or previous infection with uropathogens resistant to the study antibiotics. Recruitment took place from October 2013 through April 2017 at hospital units and outpatient clinics in Geneva, Switzerland; Lodz, Poland; and Petah-Tiqva, Israel.

INTERVENTIONS

Participants were randomized in a 1:1 ratio to oral nitrofurantoin, 100 mg 3 times a day for 5 days (n = 255), or a single 3-g dose of oral fosfomycin (n = 258). They returned 14 and 28 days after therapy completion for clinical evaluation and urine culture collection.

MAIN OUTCOMES AND MEASURES

The primary outcome was clinical response in the 28 days following therapy completion, defined as clinical resolution (complete resolution of symptoms and signs of UTI without prior failure), failure (need for additional or change in antibiotic treatment due to UTI or discontinuation due to lack of efficacy), or indeterminate (persistence of symptoms without objective evidence of infection). Secondary outcomes included bacteriologic response and incidence of adverse events.

RESULTS

Among 513 patients who were randomized (median age, 44 years [interquartile range, 31-64]), 475 (93%) completed the trial and 377 (73%) had a confirmed positive baseline culture. Clinical resolution through day 28 was achieved in 171 of 244 patients (70%) receiving nitrofurantoin vs 139 of 241 patients (58%) receiving fosfomycin (difference, 12% [95% CI, 4%-21%]; P = .004). Microbiologic resolution occurred in 129 of 175 (74%) vs 103 of 163 (63%), respectively (difference, 11% [95% CI, 1%-20%]; P = .04). Adverse events were few and primarily gastrointestinal; the most common were nausea and diarrhea (7/248 [3%] and 3/248 [1%] in the nitrofurantoin group vs 5/247 [2%] and 5/247 [1%] in the fosfomycin group, respectively).

CONCLUSIONS AND RELEVANCE

Among women with uncomplicated UTI, 5-day nitrofurantoin, compared with single-dose fosfomycin, resulted in a significantly greater likelihood of clinical and microbiologic resolution at 28 days after therapy completion.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01966653.

The Soluble Form of Toll-Like Receptor 2 Is Elevated in Serum of Multiple Sclerosis Patients: A Novel Potential Disease Biomarker

Multiple sclerosis (MS) is an immune-mediated inflammatory demyelinating disease of the central nervous system. It was previously shown that toll-like receptor (TLR)-2 signaling plays a key role in the murine experimental autoimmune encephalomyelitis (EAE) model of MS, and that TLR2-stimulation of regulatory T cells (Tregs) promotes their conversion to T helper 17 (Th17) cells. Here, we sought potential sources of TLR2 stimulation and evidence of TLR2 activity in MS patient clinical samples. Soluble TLR2 (sTLR2) was found to be significantly elevated in sera of MS patients (n = 21), in both relapse and remission, compared to healthy controls (HC) (n = 24). This was not associated with the acute phase reaction (APR) as measured by serum C-reactive protein (CRP) level, which was similarly increased in MS patients compared to controls. An independent validation cohort from a different ethnic background showed a similar upward trend in mean sTLR2 values in relapsing-remitting MS (RRMS) patients, and significant differences in sTLR2 values between patients and HC were preserved when the data from the two cohorts were pooled together (n = 41 RRMS and 44 HC, P = 0.0006). TLR2-stimulants, measured using a human embryonic kidney (HEK)-293 cells transfectant reporter assay, were significantly higher in urine of MS patients than HC. A screen of several common urinary tract infections (UTI)-related organisms showed strong induction of TLR2-signaling in the same assay. Taken together, these results indicate that two different markers of TLR2-activity—urinary TLR2-stimulants and serum sTLR2 levels—are significantly elevated in MS patients compared to HC.