Recurrent urinary tract infections in men. Characteristics and response to therapy.

All men with recurrent urinary tract infections entered into a study had a positive antibody-coated bacteria test, and 52% had evidence for prostate infection. Escherichia coli infection was present in 74% and urinary tract symptoms in 57% of those randomized. Thirty-eight patients were randomized in a double-blind clinical trial to receive either 10d of treatment with trimethoprim/sulfamethoxazole or a 12-week course of the drug. The cure rate in patients receiving 12 weeks of therapy (nine of 15) was higher than that in patients receiving a single 10-d course (three of 15); difference was marginally significant (P = 0.06). Recurrences were usually with the same organism, and most (78%) occurred within 4 weeks of discontinuing therapy. This study indicates that a standard 10-d course of therapy usually fails to cure men with recurrent urinary tract infections with a positive antibody-coated bacteria test.     

Clinical evaluation of netilmicin therapy in serious infections.

Netilmicin, a new semisynthetic aminoglycoside, was evaluated in the therapy of 33 episodes of infection in 30 patients. Eighteen patients had documented bacteremia. Infection sites included pulmonary, urinary tract and soft tissue areas. A complete bacteriologic and clinical cure rate of 85 per cent was achieved. No treatment failures occurred in the bacteremic group. Although netilmicin is less effective than gentamicin in vitro against Pseudomonas, it was clinically and bacteriologically effective. Netilmicin bacteriologic cures occurred in patients whose organisms were inhibited by 6.2 microgram/ml or less of netilmicin. Despite a uniform dosing protocol, a wide range of netilmicin serum levels was obtained. Adverse effects were limited to one case of transient nephrotoxicity and one Candida urinary suprainfection. Netilmicin appears to be an effective, safe agent for the therapy of serious infections.     

Incidence and therapy of fungal infections of the efferent urinary pathways

Manifest infections with fungi of the urinary tract are rare in comparison with bacterial diseases and therefore they are often overseen. When this is concerned a funguria must always be clarified in chronic pyelonephritis. In patients with manifest infections with fungi without pronounced renal insufficiency 5-fluorocytosin is therapeutically very well suited on account of the renal elimination.     

Efficacy of teicoplanin for enterococcal infections: 63 cases and review.

Sixty-three cases of monomicrobial enterococcal infections treated with teicoplanin in two open clinical studies in Europe from 1982 to 1989 are presented. Infections were documented as endocarditis (n = 18); septicemia (n = 8); and urinary tract (n = 29), skin/soft-tissue (n = 6), or bone/joint (n = 2) infections. A total of 63 enterococcal strains were isolated; all of 29 strains tested were susceptible to teicoplanin (geometric mean MIC, 0.16 micrograms/mL; range, 0.06-0.5 micrograms/mL). Forty-eight patients were treated with teicoplanin alone and 15 were treated with teicoplanin in combination with an aminoglycoside. The rate of clinical cure was 84.1%; 4.8% of patients clinically improved, 7.9% had clinical recurrence, and 3.2% did not respond to therapy. Bacteriologic eradication was observed in 87.2% of patients; persistence, in 3.2%; recurrence, in 3.2%; and reinfection, in 4.8%. One case was not evaluable bacteriologically. Of 18 patients with endocarditis, 15 were cured with a mean daily dose of 5.4 mg/kg--six with monotherapy and nine with combination therapy. All patients with urinary tract infections were treated with monotherapy, and 89.7% were cured (mean daily dose, 4.6 mg/kg). Lower rates of clinical cure and bacteriologic eradication were observed in septicemic patients without endocarditis (62.5%). This study demonstrated a good efficacy of teicoplanin for the treatment of enterococcal infections due to susceptible strains, but further clinical studies would be useful for establishing optimal dosage and the indications for combination therapy, especially for severe infections.     

The effect of current management on morbidity and mortality in hospitalised adults with funguria

BACKGROUND: To compare morbidity and mortality in inpatients with asymptomatic funguria between those treated and those observed for funguria. METHODS: Retrospective analyses were performed in 149 consecutive adult tertiary care inpatients with asymptomatic funguria. The primary endpoints were death, length of hospitalisation and progression to invasive fungal infection (IFI). RESULTS: Of the 149 subjects, 70% were female, 55% were >65 years, recent antibiotic and urinary catheter use occurred in >70%, diabetes in 32%, recent ICU admission in 29%, and concomitant bacteriuria in 28%. Forty-seven percent did not receive active intervention. Of the remainder, 46% were managed by controlling or eliminating risk factors for funguria or progression to IFI; fluconazole or amphotericin B were used to treat the other 54%. Fourteen percent died and 2.7 % progressed to IFI, with no significant difference between the treated versus observed groups for either endpoint (p>0.2). Median length of hospitalisation was significantly greater in the treated group (p<0.01); multivariate analysis demonstrated an exclusive relationship to the greater number of risk factors present in the treated group. CONCLUSION: Asymptomatic funguric patients who were managed with risk reduction and/or antifungal therapy were older, had more risk factors for funguria and subsequent progression to IFI, and had a longer hospital admission than those managed with observation. Treatment of asymptomatic funguria with risk reduction and/or antifungal therapy did not impact adult inpatient morbidity or mortality in this review; rather, the presence of multiple risk factors for funguria or IFI appeared to serve as a 'sickness indicator'. SUMMARY: In this study, we found that treatment for asymptomatic funguria in hospitalised adults did not impact morbidity or mortality. Rather, the presence of multiple risk factors for funguria or IFI correlated with a longer duration of hospitalisation, suggesting that funguria may be a 'sickness indicator', similar to bacteriuria in the elderly.     

Urinary tract infection in long-term-care facility residents.

Urinary tract infection is the most frequent bacterial infection in residents of long-term-care facilities. Most infections are asymptomatic, with a remarkable prevalence of asymptomatic bacteriuria of 15%-50% among all residents. The major reasons for this high prevalence are chronic comorbid illnesses with neurogenic bladder and interventions to manage incontinence. Prospective, randomized, comparative trials of therapy and no therapy for asymptomatic bacteriuria among nursing home residents have repeatedly documented that antimicrobial treatment had no benefits. However, there is substantial diagnostic uncertainty in determining whether an individual with a positive urine culture has symptomatic or asymptomatic infection when there is clinical deterioration and there are no localized findings. In the noncatheterized resident, urinary infection is an infrequent source of fever but may not be definitively excluded. The use of antimicrobials for treatment of urinary infection is part of the larger concern about appropriate antimicrobial use in long-term-care facilities and the impacts of the selective pressure of antimicrobials on colonization and infection with resistant organisms.     

Evaluation of infectious etiology and prognostic risk factors of febrile episodes in neutropenic cancer patients

OBJECTIVES: Febrile neutropenic cancer patients are at risk for development of serious infections, morbidity and mortality. The aim of this study was to determine the type and frequency of infections and to evaluate some prognostic risk factors. METHODS: 220 episodes of neutropenic fever in 177 cancer patients have been reviewed. RESULTS: Infections could be documented microbiologically in 38 (17.3%) episodes and suspected clinically in 29 (13.2%). The most common focus of infection was the lower respiratory tract (11.4%) followed by the urinary tract (6.4%). The most frequently isolated pathogen was Escherichia coli (31%) followed by Klebsiella pneumoniae (18%), Pseudomonas aeruginosa (13%) and Streptococcus pneumoniae (13%). The median durations of neutropenia and fever were 4 and 3 days, respectively. Mortality was seen in 25 patients (11.4%). Its rate was higher in documented infections except for non-bacteremic microbiologic infections in which no death was seen. Hypotension and shock were the most significant determinants of poor prognosis. CONCLUSIONS: The management of these special patients should be given adequate attention and be considered important since the success of therapy depends on revealing of etiologic agents.     

Epidemiology of intensive care unit-acquired urinary tract infections

PURPOSE OF REVIEW: The development of urinary tract infections in critically ill adult patients is associated with considerable morbidity, prolonged hospitalization, and greater healthcare expenditures. We review the occurrence, microbiology, risk factors for acquisition, and outcomes associated with intensive care unit-acquired urinary tract infections. RECENT FINDINGS: Reports from several countries indicate that nosocomial urinary tract infections frequently complicate the course of patients admitted to intensive care units. Virtually all patients who develop an intensive care unit-acquired urinary tract infection have indwelling urinary catheters; other factors associated with the development of these infections include increased duration of urinary catheterization, female sex, intensive care unit length of stay, and preceding systemic antimicrobial therapy. The most frequent pathogens include Escherichia coli, Pseudomonas aeruginosa, enterococci, and Candida albicans; both the species distribution and rates of resistance vary considerably among institutions and regions. Secondary bloodstream infections are uncommon. Although acquisition of an intensive care unit-acquired urinary tract infection has been associated with a prolongation of intensive care unit length of stay, higher cost, and a higher crude case fatality rate, they do not appear to independently increase the risk for death. SUMMARY: Urinary tract infection is a common complication of critical illness that is associated with increased patient morbidity but not mortality. There is a relative paucity of research on nosocomial urinary tract infection specifically acquired in the intensive care unit and further studies are needed to better define the epidemiology and management of these infections.     

Hyperammonemic encephalopathy in urinary diversion with urea-splitting urinary tract infection

We present two cases of hyperammonemic encephalopathy secondary to urea-splitting urinary tract infection with urinary diversion. One patient had a ureterosigmoidostomy, the other an ileal loop diversion. Neither patient had significant underlying liver disease, but both had considerable muscle atrophy that may have predisposed them to develop hyperammonemia. Medical therapy did not provide long-term control of symptoms. In both cases, hyperammonemic encephalopathy resolved after revision of their urinary diversions. The probable mechanism of the metabolic derangements produced by urea-splitting urinary tract infections is reviewed. We suggest that patients with urinary diversion who develop hyperammonemic encephalopathy secondary to a urea-splitting urinary tract infection be treated with surgical revision of the urinary system to improve drainage and decrease bowel contact time.     

Candiduria: When and how to treat it

The clinical finding of candiduria is often an enigmatic problem for the evaluating physician. The significance of yeast in the urine can range from procurement contamination to a sign of a life-threatening, opportunistic fungal infection. Proper evaluation requires validation of funguria, consideration of the setting in which it occurs, and the status of the patient. Provided that the patient is clinically stable, asymptomatic candiduria usually need not be treated with an antifungal agent. Rather, management should be directed at the elimination of predisposing factors, if feasible. When treatment is required, appropriate agents include amphotericin B (AmB), various lipid preparations of AmB (L-AmB), azoles, and flucytosine. Parenteral AmB is most useful against life-threatening infections in which the urinary tract is but one component of a widespread infection, or when resistant Candida are causative. Shorter courses of therapy may be preferable in certain cases. L-AmB treatment has been less sucessful. Intravesical AmB is a time-honored approach, but is best employed diagnostically rather than therapeutically. Fluconazole is presently the agent of first choice for susceptible fungi, but dosage and duration of therapy have not been established. Flucytosine is a useful alternative, especially for resistant Candida, but its toxicity must be closely monitored.     

A study for candidemia during the six year period from 1993 to 1999 in St. Luke's International Hospital]

There were 71 patients with candidemia in our hospital from November 1, 1993 to October 31, 1999. We investigated the 59 patients from isolated species, route of infection, underlying disorders, risk factors, complications, treatment and prognosis. Candida albicans was the most commonly isolated species (52%), followed by Candida tropicalis (11%). Eighty eight percent of the patients developed candidemia from central venous catheter related infections. The risk factors to candidemia included keeping the catheter in place for more than 5 days, gastrointestinal tract malignancies, postoperative state of gastrointestinal tract surgery, administration of broad-spectrum or combination antibiotics for more than 5 days, and under corticosteroid therapy. About half of the patients (47%) had complications, including endophthalmitis (19 patients, 32%), septic shock (12 patients, 20%). Mortality rate associated with candidemia was 46%. Mortality rate was lower in 20 patients who were treated with amphotericin B (40%) than in 34 patients treated with only fluconazole (50%), but it was not statistically significant. In order to make an early diagnosis of candidemia, taking blood cultures and ophthalmologic examinations are essential, especially for patients who have those risk factors to candidemia mentioned above. If the patient was suspected of having catheter related infection, the catheter should be removed quickly and the catheter tip should be cultured. Once candidemia is found, ophthalmologic examination and systemic antifungal therapy are needed. Antifungal therapy with Amphotericin B should be used for patients with severe candidemia or with candidemia of non-albicans Candida species.     

Nosocomial infections among patients in a long-term care facility: spectrum, prevalence, and risk factors

During a 6-month period data were collected on 460 patients residing on the long-term care division of this 1200-bed county hospital. The purpose was to determine prevalence and spectrum and to identify risk factors for skin infections, urinary tract infections, respiratory infections, and sepsis. Overall, the prevalence of nosocomial infections among 460 patients was 12%. Patients with infections had an average of 2.8 diagnoses of their underlying disease compared to patients without infections, who only had 1.8 diagnoses. Specific risk factors were identified. Skin infections were more common in patients who were nonambulatory, diabetic, malnourished, and incontinent of urine and feces, whereas respiratory infections were more common in patients who were smokers or had chronic obstructive lung disease and had not received pneumococcal vaccine. Thirteen percent of patients with an indwelling urinary catheter had symptomatic urinary tract infections, whereas 100% had asymptomatic bacteriuria.     

Nosocomial infections in U.S. hospitals, 1975–1976: Estimated frequency by selected characteristics of patients

To obtain estimates of the frequency of nosocomial infections nationwide, those occurring at the four major sites—urinary tract, surgical wound, lower respiratory tract and bloodstream—were diagnosed in a stratified random sample of 169,526 adult, general medical and surgical patients selected from 338 hospitals representative of the “mainstream” of U.S. hospitals. We estimate that in the mid-1970s one or more infections developed in 5.23 percent (± 0.16) of the patients and that 6.62 (± 0.24) infections occurred among every 100 admissions. Risks were significantly related to age, sex, service, duration of total and of preoperative hospitalization, presence of previous nosocomial or community-acquired infection, types of underlying illnesses and operations, duration of surgery, and treatment with urinary catheters, continuous ventilatory support or immunosuppressive medications. Seventy-one percent of the nosocomial infections occurred in the 42 percent of patients undergoing surgery and 56 percent in the 38 percent financed by Medicare, Medicaid or other public health care plans.     

Epidemiologie und Therapie bakterieller Infektionen in der Geriatrie

As the elderly segment of our population expands, there is an increase of therapeutic problems considering this age group. The elderly patient is generally susceptible to infections because of the decline in host defense mechanisms that occurs with aging, and the underlying chronic diseases of these patients. Increasing numbers of elderly people are being treated in hospitals and are additionally at particular risk of acquiring nosocomial infections with antibiotic-resistant organisms. This article focuses on the epidemiological considerations, risk factors, types of infections that occur in elderly patients, and the guidelines for empiric therapy. The most common infections of the elderly are respiratory tract infection, urinary tract infection, and skin and soft tissue infection. Empirical therapy should be broader in spectrum for elderly patients since the variety of infecting bacteria tends to be greater and the choice of antimicrobial therapy must be based on risk stratification (age, medical illnesses, and severity of presentation). Many additional aspects, e.g., route of administration, drug pharmacokinetics and pharmacodynamics, drug toxicity and drug-drug interactions, compliance, and multiple underlying diseases (e.g., renal failure) must be considered in the rational selection of antibiotic regimen.     

Treatment of candiduria with micafungin: A case series

There has been a gradual increase in the incidence of non-Candida albicans-related nosocomial infections. Candida glabrata urinary tract infections have increased in frequency, and treating these infections can be difficult because the organism may be resistant to fluconazole. A newer antifungal agent, micafungin, which belongs in the class of echinocandins, provides an alternative and effective therapy against C glabrata. The present report describes three cases of C glabrata-associated urinary tract infections successfully treated with micafungin. To the authors' knowledge, this is the first report of successful treatment of C glabrata and azole-resistant C albicans-associated urinary tract infection with an echinocandin.     

Persistent Cryptococcus neoformans infection of the prostate after successful treatment of meningitis. California Collaborative Treatment Group

STUDY OBJECTIVE: To assess the frequency of persistent Cryptococcus neoformans infection in patients with the acquired immunodeficiency syndrome (AIDS) after receiving apparently adequate treatment for meningitis. DESIGN: Blood, urine, and cerebrospinal fluid were cultured at the conclusion of primary therapy to assess the adequacy of treatment. SETTING: Outpatient clinics at three medical centers. PATIENTS: Patients had C. neoformans grown in culture from cerebrospinal fluid. Primary therapy consisted of either 2.0 g of amphotericin B alone; 6 weeks of combination therapy with flucytosine; or, if flucytosine was poorly tolerated, an adjusted minimum total amphotericin B dose. To meet criteria for adequate treatment of meningitis all patients had two sequential cerebrospinal fluid samples which were culture negative. MEASUREMENTS AND MAIN RESULTS: Nine of forty-one patients grew C. neoformans from urine after completion of primary treatment, but none had urinary symptoms. Fungi were visualized in expressed prostatic secretions in 4 of these patients. One patient refused further treatment and developed cryptococcemia within 5 weeks. Three patients received additional amphotericin B; all had persistent funguria without systemic relapse. Six patients received fluconazole; 4 became urine culture negative, and 2 had systemic relapse. CONCLUSION: The persistence of urinary C. neoformans after adequate therapy for meningitis suggests that the urinary tract (probably the prostate) is a sequestered reservoir of infection from which systemic relapse may occur.     

Infection in the elderly

Many functional, demographic, and immunologic changes associated with aging are responsible for increasing the incidence and severity of infectious diseases in the elderly. Management is complicated by age-related organ system changes. Because many of the elderly are on multiple medications for underlying illnesses, antimicrobial therapy needs to be chosen keeping drug interactions and adverse events in mind. Common infections seen in the elderly are infections of skin and soft tissue, urinary tract, respiratory tract, and gastrointestinal tract. Organized and well-funded programs to address infectious disease issues in the elderly are the only way to improve care.     

Trial of oral fumagillin for the treatment of intestinal microsporidiosis in patients with HIV infection. ANRS 054 Study Group. Agence Nationale de Recherche sur le SIDA

OBJECTIVE: Intestinal microsporidiosis caused by Enterocytozoon bieneusi is a cause of chronic diarrhoea in patients with HIV infection for which there is no current therapy. This study was designed to assess the safety and efficacy of oral fumagillin in this infection. DESIGN: A dose-escalation trial. METHODS: Twenty-nine HIV-infected patients with E. bieneusi infection were consecutively enrolled in the trial. Oral doses of fumagillin were given to four groups of patients for 14 days: 10 mg/day (group 1), 20 mg/day (group 2), 40 mg/day (group 3), and 60 mg/day (group 4). Patients were seen at weeks 1, 2, 4 and 6 to assess safety and efficacy. Efficacy was assessed primarily by the clearance of microsporidia from stools and follow-up duodenal biopsies. RESULTS: Thirteen patients complained of abdominal cramps, vomiting or diarrhoea during the study, and three patients had fumagillin withdrawn because of adverse events. Thrombocytopenia, neutropenia and hyperlipasaemia were the most frequent biological adverse events. Twenty-one out of 29 patients transiently cleared microsporidia from their stools during the study. By week 6, however, all patients in groups 1, 2 and 3 had parasitic relapse. Interestingly, eight out of 11 (72%) patients treated with 60 mg/day (group 4) apparently cleared microsporidia from their gastrointestinal tract and gained weight. No parasitic relapse was documented in these eight patients during a mean follow-up of 11.5 months. CONCLUSION: Treatment with fumagillin at 60 mg/day for 14 days has promise as an effective oral treatment for E. bieneusi infections.     

Infections in a coronary care unit

All infections in patients in an active coronary care unit (CCU) over a 3-year period were analyzed to ascertain rates, outcomes, pathogens and sites of infections. Standard surveillance methods and definitions of the Center for Disease Control were used. A total of 236 infections were documented in 200 infected patients. Infection rates were 5 and 2% for total and CCU-acquired infections, respectively. CCU infections accounted for 11% of nosocomial infections that occurred within all critical care areas surveyed. Of all documented infections, 131 (56%) were community-acquired and 90 (38%) were acquired within the CCU. Lower respiratory and urinary tract infections were most frequently noted, with E. coli, S. aureus, and klebsiella-enterobacter-serratia most usually implicated. Mortality among patients with infections was 31%, compared with 8 to 12% in those who were not infected. Those with lower respiratory infections or primary bacteremias had a higher mortality rate than those with infections at other sites (p less than 0.001). Infections are seen in close to 5% of CCU patients and may adversely affect the survival rate. The mortality rate in infected patients may be 3 times higher than that in the general CCU population. This study also provides data against which other similar institutions can gauge their CCU infection rates.