Clinical Guideline for the Diagnosis and Treatment of Urinary Tract Infections: Asymptomatic Bacteriuria, Uncomplicated & Complicated Urinary Tract Infections, Bacterial Prostatitis

Impact of Urinary Tract and Vaginal Infections on the Physical and Emotional Well-being of Women

Urinary Tract Infection (UTI) is a common bacterial infection that can affect various parts of the urinary system, with symptoms including frequent urination, painful urination, and lower back pain. UTIs are more common in women due to their shorter urethra, and they can lead to serious complications if left untreated. Vaginitis is an inflammation or infection of the vagina caused by factors like bacteria, fungi (Candida), or protozoa (Trichomonas). Symptoms include vaginal itching, abnormal discharge, and discomfort during urination or sexual activity. Treatment depends on the underlying cause and may involve antifungal or antimicrobial medications. Vaginal infections, such as bacterial vaginosis, yeast infections, trichomoniasis, cervicitis, and atrophic vaginitis, can have various physical, emotional, sexual, and social impacts on the lives of women. These impacts may include discomfort, embarrassment, reduced sexual satisfaction, social isolation, and emotional distress. Support and resources for managing these infections include healthcare providers who can diagnose and prescribe treatment, pharmacies that provide medications and guidance, telemedicine for remote consultations and prescriptions, support groups for emotional and informational support, and online resources for reliable information. They offer a sense of community, information sharing, and emotional support, making it easier for individuals to manage their vaginitis and related concerns. Utilizing these resources can contribute to a more informed and empowered approach to vaginal infection prevention and treatment.

Trend of antibiotics usage for acute pyelonephritis in Korea based on national health insurance data 2010-2014

BACKGROUND

The objective of this study is to describe the changes in prescribing practices of antibiotics to treat acute pyelonephritis (APN) in Korea.

METHODS

The claim data base of the Health Insurance Review and Assessment Service in Korea was used to select patients with ICD-10 codes N10 (acute tubulo-interstitial nephritis) or N12 (tubulo-interstitial nephritis, not specified as acute nor chronic) as the primary discharge diagnosis during 2010-2014. Consumption of each class of antibiotics was converted to Defined Daily Dose (DDD)/event.

RESULTS

Throughout the five-year period, the average antibiotic consumption were 11.3 DDD per inpatient event and 6.0 DDD per outpatient event. The annual average antibiotic consumption increased for inpatients (P = 0.002), but remained stable for outpatients (P = 0.066). The use of parenteral antibiotics increased for inpatients (P < 0.001), but decreased for outpatients (P = 0.017). As for the the antibiotic classes, 3rd generation cephalosporins (3rd CEPs) was the most commonly prescribed (41.4%) for inpatients, followed by fluoroquinolones (FQs) (28.5%); for outpatient, FQs (54.8%) was the most commonly prescribed, followed by 3rd CEPs (13.1%). The use of 3rd CEPs (P < 0.001), beta-lactam/beta-lactamase inhibitors (P = 0.007), and carbapenems (P < 0.001) increased substantially for the treatment of hospitalized APN patients. In particular, carbapenems use increased 3.1-fold over the 5 years.

CONCLUSIONS

Prescription of broad-spectrum antibiotics increased much for the treatment of APN in Korea during 2010-2014.

Clinical Usefulness of Unenhanced Computed Tomography in Patients with Acute Pyelonephritis

BACKGROUND

Unenhanced computed tomography (UCT) may be useful for evaluating acute pyelonephritis; however, no study has compared UCT with enhanced computed tomography (ECT) as a diagnostic tool. We evaluated a clinical usefulness of UCT versus ECT in acute pyelonephritis (APN).

METHODS

We reviewed the clinical and radiological data from 183 APN-suspected patients who underwent UCT and ECT simultaneously at emergency room (ER) over a two-year period. Demographic, clinical parameters and computed tomography (CT) parameters of 149 patients were compared.

RESULTS

The average patient age was 61.2 (± 10) years: 31 patients were men. Ninety-nine (66.4%) patients showed stones (18.7%), perinephric infiltration (56%), swelling (21%), and hydronephrosis (6.7%) on UCT. Seventeen patients (11.4%) had an atypical clinical course, requiring additional tests for accurate diagnosis. In 7 patients UCT and ECT results did not differ; in 10 patients, the diagnosis changed on ECT. On ECT, 112/149 (75.2%) patients had stones (16.7%), perinephric infiltrations (57%), swelling (21%), and hydronephrosis (6.7%); 62.5% showed parenchymal involvement: 34 (22.8%) patients had no abnormal ECT findings. APN CT findings are similar on stone, perinephric infiltration, swelling and hydronephrosis on both CTs. Twelve patients (8.0%) had an abnormal ECT finding, i.e., low-grade (1 and 2) parenchymal involvement. Six (4%) patients developed contrast-induced acute kidney injury within 2 days after ECT.

CONCLUSION

We demonstrate that UCT is not inferior to ECT as an initial tool for evaluating APN for screening nephrolithiasis and hydronephrosis without the risk of contrast-induced acute kidney injury (CIAKI). However, patients with an atypical clinical course may still need ECT.

Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections

Urinary tract infections (UTIs) are infectious diseases that commonly occur in communities. Although several international guidelines for the management of UTIs have been available, clinical characteristics, etiology and antimicrobial susceptibility patterns may differ from country to country. This work represents an update of the 2011 Korean guideline for UTIs. The current guideline was developed by the update and adaptation method. This clinical practice guideline provides recommendations for the diagnosis and management of UTIs, including asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. This guideline targets community-acquired UTIs occurring among adult patients. Healthcare-associated UTIs, catheter-associated UTIs, and infections in immunocompromised patients were not included in this guideline.

Antimicrobial Susceptibilities of Enterobacteriaceae in Community-Acquired Urinary Tract Infections during a 5-year Period: A Single Hospital Study in Korea

Background

Through investigating antimicrobial susceptibility patterns of Enterobacteriaceae in community-acquired urinary tract infection (CA-UTI), we provide basic evidence for the use of empirical antibiotics in CA-UTI.

Materials and Methods

We retrospectively reviewed the medical records of patients over the age of 19 years who visited a hospital in Seoul between January 2012 and December 2016 for a CA-UTI. Urine cultures were used to identify causative organisms. We investigated extended-spectrum β-lactamase (ESBL) production and the antimicrobial susceptibility of Enterobactereiaceae. We evaluated recommended empirical antibiotics numerically by calculating the syndrome-specific likelihood of inadequate therapy (LIT) for the last 2 years (interpretation of the LIT A value: 1 out of A people is likely to receive inadequate empirical antibiotics).

Results

Urine cultures were performed in 1,605 out of 2,208 patients who were diagnosed with CA-UTI, and causative pathogens were identified in 1,134 (70.7%) cases. There were 998 (88.0%) cases of Enterobacteriaceae and Escherichia coli was the most common pathogen, accounting for 80.3% of cases (911 cases). The overall resistance rates to trimethoprim-sulfamethoxazole, fluoroquinolones, and cefotaxime were 31.7%, 23.2%, and 13.5%, respectively. There were 128 (10.8%) cases of ESBL-producing Entererobacteriaceae with an increasing but non-significant trend (P = 0.255). The LIT for CA-UTI in the past two years was highest for ertapenem and imipenem. Fluoroquinolones ranked 11th, with a LIT of 8.2, and cefotaxime ranked higher, at 10.5. In ESBL-producing Enterobacteriaceae, except for carbapenems, amikacin and piperacillin-tazobactam showed the highest susceptibility rates at 99.2% and 94.3%, respectively.

Conclusion

Empiric treatment with fluoroquinolones in CA-UTI should be carefully considered, given the high resistance rate. The proportion of ESBL-producing Entererobacteriaceae in CA-UTI has increased to a high level in Korea. Amikacin and piperacillin-tazobactam could be considered for empiric treatment in patients at risk for ESBL-producing Entererobacteriaceae when considering alternatives to carbapenems.

Virulence factors and clinical patterns of hypermucoviscous Klebsiella pneumoniae isolated from urine

BACKGROUND

Klebsiella pneumoniae with hypermucoviscosity (HM) phenotype is generally more virulent than HM-negative strains. The aim of this study was to investigate the prevalence of HM phenotype among urinary isolates and to compare the virulence factors, antimicrobial susceptibility patterns and clinical characteristics of HM-positive and -negative K. pneumoniae isolated from urine of hospitalized patients.

METHODS

From June to October 2013, a total of 81 non-repetitive K. pneumoniae strains were isolated from urine. HM phenotype was determined by a string test. The K1 and K2 genotypes, the allS, kfu, rmpA, rmpA2 and wabG, aerobactin gene were detected by polymerase chain reaction.

RESULTS

Of the 81 K. pneumoniae isolates, 12.3% produced a positive string test. The aerobactin (80.0%[8/10] vs. 15.5%[11/71], p = .0001), allS (40.0%[4/10] vs. 9.9%[7/71], p = .009), rmpA (70.0%[7/10] vs. 14.1%[10/71], p = .0001) and rmpA2 (60.0%[6/10] vs. 16.9%[12/71], p = .002) genes were more prevalent in HM positive than in HM negative strains. The K1 (20.0%[2/10) vs. 8.5%[6/71]] and K2 (30.0%[3/10] vs. 4.2%[3/71]) capsular serotypes were more common in HM strains than in non-HM strains (p = .0001). HM-positive K. pneumoniae isolates were more susceptible to amoxicillin/clavulanic acid (p = .02), cefazolin (p = .03), cefotaxime (p = .02) and ciprofloxacin (p = .03) than HM-negative isolates. Multivariate analysis showed that HM phenotype (OR, 23.87; 95% CI, 3.91-145.4, p < .01) and age >60 years (OR, 8.33; 95% CI, 1.25-55.31, p = .03) were significant risk factors for concurrent bacteraemia.

CONCLUSION

Klebsiella pneumoniae with expression of HM phenotype isolated from urine were more likely to be associated with concurrent bacteraemia than isolates without the HM phenotype, and were more susceptible to antibiotics. Physicians have to be aware of the possibility of bacteraemia in patients with K. pneumoniae bacteriuria, especially if strains are HM positive and the patient is >60 years old.

Development of Epidural and Paraspinal Abscesses after Insufficient Evaluation and Treatment of Acute Pyelonephritis Caused by Staphylococcus aureus

Diagnoses of pyelonephritis caused by Staphylococcus aureus should be accompanied by investigations of concomitant bladder obstruction and metastatic infections, especially to the spine or heart. Complicated pyelonephritis due to S. aureus requires more than 2 weeks of antibiotics, which is the typically recommended treatment duration for pyelonephritis. We describe a patient who was diagnosed with complicated epidural and paraspinal abscesses after insufficient evaluation and treatment of acute pyelonephritis due to S. aureus. A 62-year-old man with type 2 diabetes was admitted with fever, increased urinary frequency, and left flank pain. He was diagnosed with acute pyelonephritis caused by S. aureus. His fever and flank pain subsided after 3 days of intravenous antibiotics. Evaluation of bladder obstruction and metastatic infection were not performed, as he declined further evaluation. The patient was discharged with oral antibiotics and was requested to attend weekly appointments but was lost to follow-up. One month later, the patient presented at the outpatient clinic with similar symptoms. Computed tomography showed recurrent pyelonephritis and a distended bladder. His flank pain persisted despite administration of an opioid agent. Therefore, magnetic resonance imaging was performed, revealing epidural and paraspinal abscesses. Ultrasound-guided aspiration of the paraspinal muscle layer was performed, and blood and percutaneous aspirated fluid cultures revealed S. aureus growth. The pattern of antimicrobial sensitivity was identical to that at his first admission. Following more than 4 weeks of antibiotics, magnetic resonance imaging showed the abscesses had decreased in size. The patient was discharged without neurologic sequelae and was provided with oral antibiotics.

Prevalence of antibiotic susceptibility and resistance of Escherichia coli in acute uncomplicated cystitis in Korea: Systematic review and meta-analysis

BACKGROUND

The aim of this study is to determine the prevalence of antibiotic susceptibility and resistance of Escherichia coli Escherichia coli (E coli) in female uncomplicated cystitis in Korea using meta-analysis.

METHODS

A cross-search of the literature was performed with MEDLINE for all relevant data published before October 2015 and EMBASE from 1980 to 2015, the Cochrane Library, KoreaMed, RISS, KISS, and DBPia were also searched. Observational or prospective studies that reported the prevalence of antimicrobial susceptibility and resistance of E coli were selected for inclusion. No language or time restrictions were applied. We performed a meta-analysis using a random effects model to quantify the prevalence of antimicrobial susceptibility and resistance of E coli.

RESULTS

Ten studies were eligible for the meta-analysis, which together included a total of 2305 women with uncomplicated cystitis. The overall resistance rate to antibiotics was 0.28 (95% confidence interval [CI]: 0.25, 0.32). The pooled resistance rates were 0.08 (95% CI: 0.06, 0.11) for cephalosporin, 0.22 (95% CI: 0.18, 0.25) for fluoroquinolone (FQ), and 0.43 (95% CI: 0.35, 0.51) for trimethoprim/sulfamethoxazole (TMP/SMX). Regression analysis showed that resistance to FQ is increasing (P = 0.014) and resistance to TMP/SMX is decreasing (P = 0.043) by year. The generation of cephalosporin was not a significant moderator of differences in resistance rate.

CONCLUSION

The resistance rate of FQ in Korea is over 20% and is gradually increasing. Although the resistance rate of TMP/SMX is over 40%, its tendency is in decreasing state. Antibiotic strategies used for the treatment of uncomplicated cystitis in Korea have to be modified.

Role of age and sex in determining antibiotic resistance in febrile urinary tract infections

OBJECTIVES

To identify the age- and sex-specific antimicrobial susceptibility patterns of Gram-negative bacteria (GNB) in outpatient febrile urinary tract infections (UTIs) in Korea.

METHODS

A total 2262 consecutive samples collected from patients aged 1-101 years with febrile UTIs, during the period January 2012 to December 2014, were analyzed in this multicentre, retrospective cohort study.

RESULTS

The sensitivities to cefotaxime and cefoxitin were over 85% for females but under 75% for males. Sex played an important role in the susceptibility of GNB to cefotaxime (p<0.001) and cefoxitin (p<0.001). The sensitivity to ciprofloxacin (age >20 years) was under 75% in both sexes, and was not influenced by sex (p=0.204). Age distributions of the incidences of resistance to cefotaxime, cefoxitin, and ciprofloxacin (age >20 years) were similar to the age distribution of the incidence of GNB, which indicates that the resistance patterns to these drugs were not affected by age (Kolmogorov-Smirnov test, female/male: p=0.927/p=0.509, p=0.193/p=0.911, and p=0.077/p=0.999, respectively).

CONCLUSIONS

Age is not a considerable factor in determining the antibiotic resistance in febrile UTIs. Ciprofloxacin should be withheld from both sexes until culture results indicate its use. Second- or third-generation cephalosporins such as cefoxitin and cefotaxime can be used empirically only in females.

Microbiological Characteristics of Unresolved Acute Uncomplicated Cystitis

This study sought to compare the antimicrobial susceptibility rates between acute uncomplicated cystitis patients with failed initial antimicrobial treatment, who were considered unresolved cases, and newly presenting acute uncomplicated cystitis patients without recent antimicrobial use within 3 months and to determine whether different treatment strategies should be applied according to recent antimicrobial exposure (RAE). Female acute uncomplicated cystitis patients with Escherichia coli growth, who visited our hospital's urology department from 2010 to 2014, were divided according to RAE. The antimicrobial susceptibility of E. coli was compared between the group with RAE and the group with no antimicrobial exposure (NAE) within 3 months. The total number of acute uncomplicated cystitis patients with E. coli growth was 259: 40 patients comprised the RAE group and 219 patients formed the NAE group. The mean age was significantly older and previous recurrent cystitis history was higher in the RAE group (p < 0.05). Furthermore, the antimicrobial susceptibility of E. coli to amoxicillin-clavulanic acid, cefotaxime, cefoxitin, ciprofloxacin, and trimethoprim-sulfamethoxazole was significantly lower in the RAE group, with susceptibility results of 64.7%/88.0% (RAE/NAE), 77.5%/89.0%, 79.4%/95.3%, 31.3%/64.2%, and 42.5%/70.6%, respectively. RAE was an independent factor for antimicrobial resistance. This study showed that antimicrobial susceptibilities were significantly lower in acute uncomplicated cystitis patients with failed initial antimicrobial treatment, who are defined as unresolved cases. Our results suggest that first-line antimicrobials might show poor efficacy in cases of unresolved, acute uncomplicated cystitis and alternative or secondary antimicrobials should be considered in these cases.

A comparison of the clinical characteristics of elderly and non-elderly women with community-onset, non-obstructive acute pyelonephritis

BACKGROUND/AIMS

Acute pyelonephritis (APN) is the most common cause of community-onset bacteremia in hospitalized elderly patients. The objectives of this study were to investigate the differences in the clinical and microbiological data of hospitalized elderly and non-elderly women with community-onset APN.

METHODS

Women with community-onset APN as a discharge diagnosis were identified from January 2004 to December 2013 using an electronic medical records system. We compared the clinical and microbiologic data in elderly and non-elderly women with community-onset APN due to Enterobacteriaceae.

RESULTS

Of the 1,134 women with community-onset APN caused by Enterobacteriaceae, 443 were elderly and 691 were non-elderly women. The elderly group had a lower frequency of upper and lower urinary tract symptoms/signs than the non-elderly. The incidence of bacteremia, extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, patients with a C-reactive protein (CRP) level ≥ 15 mg/dL, and patients with a leukocyte count ≥ 15,000/mm(3) in the blood, were significantly higher in the elderly group than in the non-elderly group. The proportion of patients requiring hospitalization for 10 days or more was significantly higher in the elderly group compared to the non-elderly group (51.5% vs. 26.2%, p < 0.001). The clinical cure rates at 4 to 14 days after the end of therapy were 98.3% (338/344) and 97.4% (519/533) in the elderly and non-elderly groups, respectively (p = 0.393).

CONCLUSIONS

Elderly women with APN exhibit higher serum CRP levels, a higher frequency of bacteremia, a higher proportion of ESBL-producing uropathogens, and require a longer hospitalization than non-elderly women, although these patients may not complain of typical urinary symptoms.

Propensity-matched analysis to compare the therapeutic efficacies of cefuroxime versus cefotaxime as initial antimicrobial therapy for community-onset complicated nonobstructive acute pyelonephritis due to Enterobacteriaceae infection in women

This study was performed to compare the therapeutic efficacy of cefuroxime with that of cefotaxime as initial antimicrobial therapies in women with complicated nonobstructive acute pyelonephritis (APN) caused by Enterobacteriaceae infections. The clinical characteristics and outcomes of a cefuroxime-treated group (n = 156) were compared with those of a cefotaxime-treated group (n = 166). Of these 322 women, 90 from each group were matched by propensity scores. The defervescence rates were not significantly different in the cefuroxime and cefotaxime groups at 72 h after the start of antimicrobial therapy (81.1% versus 78.9%, P = 0.709). The clinical and microbiological cure rates during the follow-up visits that were 4 to 14 days after the end of the antimicrobial therapies were not significantly different in the cefuroxime versus cefotaxime groups, which were 97.8% (87/89) versus 97.8% (87/89) (P > 0.999) and 89.5% (68/76) versus 90.7% (68/75) (P = 0.807), respectively. The median hospital stay duration and the median times to defervescence in the cefuroxime versus cefotaxime groups were 8 days (interquartile range [IQR], 7 to 10 days) versus 9 days (IQR, 7 to 11 days), respectively, and 55 h (IQR, 37 to 70 h) versus 55 h (IQR, 35 to 69 h), respectively. Bacteremia, extended-spectrum-β-lactamase-producing Enterobacteriaceae, C-reactive protein levels of ≥ 15 mg/dl, and white blood cell counts of ≥ 15,000/mm(3) of blood had independent effects on the rates of early clinical failure. Our data suggest that the effects of cefuroxime are not different from those of cefotaxime when they are used as an initial antimicrobial treatments for community-onset complicated nonobstructive APN in women.

A prospective Korean multicenter study for infectious complications in patients undergoing prostate surgery: risk factors and efficacy of antibiotic prophylaxis

This multicenter study was undertaken to determine the efficacy of antibiotic prophylaxis and identify the risk factors for infectious complications after prostate surgery in Korean patients. A total of 424 patients who underwent surgery of the prostate were reviewed. All patients underwent urinalysis and urine culture preoperatively and postoperatively. Efficacy of antibiotic prophylaxis and risk factors for infectious complications were investigated. Infectious complications were observed in 34.9% of all patients. Factors independently associated with infectious complications were diabetes mellitus (adjusted OR, 1.99; 95% CI, 1.09-3.65, P=0.025) and operation time (adjusted OR, 1.08; 95% CI, 1.03-1.13, P=0.004). Clinicians should be aware of the high risk of infectious complications in patients with diabetes and those who undergo a prolonged operation time. Neither the type nor duration of prophylactic antibiotics resulted in differences in infectious complications.

The efficacy of non-carbapenem antibiotics for the treatment of community-onset acute pyelonephritis due to extended-spectrum β-lactamase-producing Escherichia coli

OBJECTIVE

Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli has become an important cause of community-onset urinary tract infections. We aimed to evaluate the efficacy of non-carbapenem antibiotics for acute pyelonephritis (APN) due to ESBL-producing E. coli.

METHODS

We conducted a retrospective cohort study of patients with community-onset APN due to ESBL-producing E. coli at a single centre in Korea from 2007 to 2013. Outcomes included both microbiological and clinical failure. To adjust for non-random assignment of antibiotics, the propensity score method of inverse probability of treatment weighting and a multivariable analysis using Cox proportional hazards modelling were employed to estimate the efficacy of non-carbapenem antibiotics as compared with carbapenems.

RESULTS

Of 152 eligible patients, 85 (55.9%) received carbapenems and 67 (44.1%) received non-carbapenems. Non-carbapenem antibiotics used in this cohort included aminoglycosides (n = 30), β-lactam/β-lactamase inhibitors (n = 13), fluoroquinolones (n = 12) and trimethoprim/sulfamethoxazole (n = 5). Microbiological failure was observed in 16 patients receiving carbapenems (16/83, 19.3%) versus 4 patients receiving non-carbapenem (4/67, 6.0%). After weighting, the risk of microbiological failure was similar between the two groups [weighted hazard ratio (HR) 0.99; 95% CI 0.31-3.19]. In a multivariable regression analysis combined with weights, the estimate did not change (weighted adjusted HR 0.96; 95% CI 0.41-2.27). The clinical failure rate was also similar in the two groups (weighted HR 1.05; 95% CI 0.24-4.62).

CONCLUSIONS

These results suggest that non-carbapenem antibiotics were as effective as carbapenems as definitive therapy for treating community-onset APN caused by ESBL-producing E. coli if they are active in vitro.

Clinical Efficacy of Ertapenem for Recurrent Cystitis Caused by Multidrug-Resistant Extended-Spectrum β-Lactamase-Producing Escherichia coli in Female Outpatients

Purpose

To evaluate the clinical outcomes of ertapenem administered as an outpatient parenteral antibiotic therapy for intractable cystitis caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli.

Materials and Methods

We retrospectively reviewed a case series of 3 years of therapeutic experience with ertapenem for intractable recurrent cystitis caused by ESBL-producing E. coli. Ertapenem 1 g/d was parenterally administered to the patients on an outpatient basis until the acquisition of symptomatic improvement and negative conversion of urine culture. Demographic and clinical characteristics of patients, antimicrobial resistance, and clinical response data were analyzed from the patients' medical records.

Results

During the course of this study, a total of 383 patients were diagnosed with cystitis, and 24 of them showed ESBL-producing E. coli (6.26%). The mean treatment duration of all patients was 8.5 days. The early clinical and microbiological cure rates 0 to 7 days after the end of treatment were 91.7% (22/24) and 90.9% (20/22), respectively. The late clinical and microbiological cure rates 4 to 6 weeks after the end of treatment were 72.2% (13/18) at both time points.

Conclusions

Parenteral ertapenem treatment can be an effective and well-tolerated treatment option for intractable recurrent cystitis by multidrug-resistant ESBL-producing E. coli.

Factors associated with ciprofloxacin- and cefotaxime-resistant Escherichia coli in women with acute pyelonephritis in the emergency department

BACKGROUND

High rates of antimicrobial resistance in Escherichia coli isolated from patients with urinary tract infections have been reported worldwide. The aim of this study was to identify risk factors for resistance to ciprofloxacin (CIP) and cefotaxime (CTX) in E. coli isolated from patients with acute pyelonephritis (APN).

METHODS

We prospectively identified women over 18 y of age who visited the emergency department of one of 10 hospitals with APN and whose urine culture grew E. coli. The study was conducted from April 16 to June 10, 2012.

RESULTS

Of the 229 patients identified, 173 (75.5%) had community-associated (CA) infections and 56 (24.5%) had healthcare-associated (HCA) infections. Sixty-seven isolates (29.3%) were resistant to CIP, 45 (19.7%) to CTX, and 29 (12.7%) to both CIP and CTX. Multivariate analyses revealed that hematologic disease, chronic kidney disease, a bed-ridden state, indwelling urinary catheter, antibiotic treatment in the preceding 3 months, and isolation of CIP-resistant E. coli in the urine within the preceding 3 months, were significantly associated with resistance to both CIP and CTX.

CONCLUSIONS

Chronic conditions and healthcare-associated factors were related to resistance to both fluoroquinolones and third-generation cephalosporins in women with APN. Continued and vigilant surveillance is necessary to monitor the dissemination of antimicrobial resistance in uropathogens.

Impact of extended-spectrum beta-lactamase on acute pyelonephritis treated with empirical ceftriaxone

BACKGROUND

Ceftriaxone is frequently administered empirically for hospitalized patients with acute pyelonephritis (APN) due to prevalent quinolone resistance in our hospital; however, its use is inappropriate for extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli, an increasing problem.

METHODS

A retrospective, 1:2 matched cohort study was performed to evaluate the impact of ESBL on APN treated with empirical ceftriaxone. Each patient in ESBL group was matched with two patients in the non-ESBL group, using a 16-point scoring system, which included age, sex, bacteremia, simplified acute physiology score 2, Charlson comorbidity index and APN severity score.

RESULTS

From 2009 to 2011, among 1,322 community-onset cases of the E. coli bacteriuria with 212 (16%) ESBL producers, 261 patients with APN were treated empirically with ceftriaxone in a secondary care hospital. Among these 261 cases, twenty-six patients in the ESBL group and 52 matched patients in the non-ESBL group (1:2) were included. Mean time to defervescence was 4.6±2.2 days in the ESBL group and 2.6±1.3 days in the non-ESBL group (p<0.01). Rate of microbiological resolution within 5 days after antibiotic treatment was 77% (17/22) in the ESBL group and 100% (45/45) in the non-ESBL group (p=0.01). The duration of hospitalization was 13.3±8.2 days in the ESBL group and 7.3±3.5 days in the non-ESBL group (p<0.01). No patient died in either group.

CONCLUSION

Empirical ceftriaxone therapy for APN caused by ESBL-producing E. coli is inappropriate, and consequently can delay recovery and result in longer hospitalization.

Comparison of ertapenem and ceftriaxone therapy for acute pyelonephritis and other complicated urinary tract infections in Korean adults: a randomized, double-blind, multicenter trial

The efficacy and safety of ertapenem, 1 g once daily, were compared with that of ceftriaxone, 2 g once daily, for the treatment of adults with acute pyelonephritis (APN) and complicated urinary tract infections (cUTIs) in a prospective, multicenter, double-blinded, randomized study. After ≥ 3 days of parenteral study therapy, patients could be switched to an oral agent. Of 271 patients who were initially stratified by APN (n = 210) or other cUTIs (n = 61), 66 (48.9%) in the ertapenem group and 71 (52.2%) in the ceftriaxone group were microbiologically evaluable. The mean duration of parenteral and total therapy, respectively, was 5.6 and 13.8 days for ertapenem and 5.8 and 13.8 days for ceftriaxone. The most common pathogen was Escherichia coli. At the primary efficacy endpoint 5-9 days after treatment, 58 (87.9%) patients in the ertapenem group and 63 (88.7%) in the ceftriaxone had a favorable microbiological response. When compared by stratum and severity, the outcomes in the two groups were equivalent. The frequency and severity of drug-related adverse events were generally similar in both treatment groups. The results indicate that ertapenem is highly effective and safe for the treatment of APN and cUTIs.