The comeback of trimethoprim in France

Already used in various countries, trimethoprim (TMP) was withdrawn from the French market in 1990, but should be soon available again. This article reviews the experience of TMP use around the world and its current use in Europe. Label use and guidelines only recommend the use of TMP for the treatment of urinary tract infections (UTI). Compared with co-trimoxazole (Co-T), a combination of TMP and sulfamethoxazole (SMX), TMP has (a) a similar resistance rate among Escherichia coli strains (estimated between 10 and 20% in uncomplicated cystitis), (b) a similar clinical efficacy for cystitis prevention and treatment, (c) a lower toxicity (as severe toxicity adverse effects of Co-T come from its sulfonamide component), (d) limited data for the treatment of pyelonephritis and male UTIs, and (e) an important impact on the microbiota. TMP should thus be indicated in the third-line empirical treatment of acute uncomplicated cystitis (sparing fluoroquinolones and nitrofurantoin), in the prevention of recurrent acute cystitis when an antibiotic prophylaxis is required (possibly in first line), and in the treatment of documented acute cystitis at risk of complications. Updated data on the epidemiology of resistance to TMP per clinical pictures is now required. The bactericidal effect of TMP should also be confirmed on recent strains (although limited recent data suggests a bactericidia similar to that of Co-T) and its clinical efficacy should be evaluated in pyelonephritis and male UTI.     

'Urinary tract infections'--revised CBO guideline. Dutch Institute for Quality Assurance

Recently the 'Kwaliteitsinstituut voor de gezondheidszorg CBO' (Dutch Institute++ for Health Care Improvement) published revised guidelines on urinary tract infections. In children less than one year old clinical signs of urinary tract infection are non-specific and the diagnosis should be ruled out by laboratory investigations: a nitrite test, followed by inspection of the urinary sediment for leucocytes and bacteria if the test is negative. If one of the investigations is positive an urinary culture is made and antimicrobial therapy is started as for pyelonephritis. The child should be referred to a paediatrician to examine the urinary tract for anatomical abnormalities with a view to possible preventive measures regarding renal function loss. Boys older than one year with urinary tract infections should be managed in the same way as younger children. In older girls examination of the urinary tract is indicated after recurrent infection. In adult women with complaints of urinary tract infection causes like vaginitis, pyelonephritis and genital herpes should be excluded. Urine is examined (nitrite test, if negative followed by urinary sediment) to confirm the diagnosis. A urine culture is not indicated. First-choice treatment for uncomplicated infection is trimethoprim or nitrofurantoin. Persistent infection may be treated blind with a second antimicrobial drug. Recurrent infection can be prevented by changing behaviour, antimicrobial prophylaxis or oestrogen cream in postmenopausal women. If a man with micturition complaints also suffers from pain in the perineum, the lower back or the lower abdomen or during ejaculation, a distinction should be made between bacterial prostatitis, non-bacterial prostatitis and prostatodynia. Uncomplicated urinary infections can be treated with trimethoprim or nitrofurantoin. Urinary catheters are a risk for infection and their use should be restricted in number and duration. Catheter care should follow the guidelines of the Workgroup Infection Prevention. Urinary cultures should only be made in the presence of signs of infection if there is an indication for antimicrobial therapy.     

Summary of the 'Urinary tract infections' guideline (first revision) of the Dutch College of General Practitioners

The important changes in the Dutch College of General Practitioners' revised guideline on urinary tract infections, with respect to the first edition, are as follows: In assessing a urine sediment the leucocyte count has been omitted due to its low specificity. In the case of a negative nitrite test, the number of bacteria is of diagnostic importance. If a microscopic count is difficult to carry out, a semi-quantitative culture with a dip-slide is a good alternative. In the case of uncomplicated urinary tract infections, nitrofurantoin or trimethoprim are the preferred antibiotics, whereas for pregnant women nitrofurantoin and amoxicillin without clavulanic acid should be used. The most important pathogen is often resistant to sulphonamides. In the case of complicated urinary tract infections, characterised by fever, and a still unknown sensitivity of the pathogen, amoxicillin-clavulanic acid is recommended except in the case of pregnant women. The usefulness of tracing and treating pregnant women with asymptomatic bacteriuria has yet to be demonstrated.     

Estudio de sensibilidad de Escherichia coli productores de infecciones del tracto urinario comunitarias en Galicia. Período: 2016-2017

ObjectiveEscherichia coli (E. coli) is responsible for the majority of community urinary tract infections. The objective of the study is to know the sensitivity spectrum of E. coli in urinary tract infections to be able to recommend the appropriate empirical antibiotic treatment.DesignCross-sectional, multicentric, retrospective study.LocationGalician 8 public hospitals, practically the entire population of Galicia (Spain).Participants43,137 outpatients with urinary tract infection due to E. coli isolated in urine in 2016/2017.Main measurementsAnalyzed variables: demographic, minimum inhibitory concentration and interpretation of sensitivity according to CLSI criteria and resistance mechanisms. The antibiotics studied were: ampicillin, amoxicillin-clavulanic acid, ciprofloxacin, cefotaxime, cefepime, gentamicin, nitrofurantoin, fosfomycin, cotrimoxazole, imipenem and ertapenem. The identification and sensitivity were made mainly by automated methods.ResultsThe percentages of non-sensitivity of E. coli isolates were: ampicillin 49.2%, amoxicillin-clavulanic acid 17.8%, cefotaxime 6.7%, cefepime 5.7%, ertapenem 0.04%, imipenem 0.05%, gentamicin 9,1%, ciprofloxacin 26.2%, fosfomycin 3.3%, nitrofurantoin 2.4% and cotrimoxazole 23.9%. The non-sensitivities were higher in men and as age increases. Six percent of E. coli were producers of extended-spectrum beta-lactamases.ConclusionsThe empirical treatment in Galicia for uncomplicated cystitis produced by E. coli in women continues to be nitrofurantoin and fosfomycin. In men under 15 years of age, fosfomycin is indicated and in men older than 15 years, treatment in our environment should include culture and administer a 3rd generation oral cephalosporin empirically. Cotrimoxazole and ciprofloxacin are not recommended as empirical treatment because of their high resistance rates.     

French results of the ARESC study: clinical aspects and epidemiology of antimicrobial resistance in female patients with cystitis. Implications for empiric therapy

Objective

Uncomplicated cystitis is one of the most frequent community infections. We report the French results of the international ARESC study on the clinical aspects, epidemiology, and antimicrobial susceptibility of uropathogens.

Patient and methods

Female patients between 18 and 65 years of age, with symptoms of uncomplicated cystitis, were investigated clinically with urinalysis and urine culture. Uropathogens were identified and their susceptibility was tested with nine antimicrobials.

Results

Four thousand and four hundred patients were included, 871 in France, forming the largest national cohort. Urine culture was positive (cfu ≥ 10⁴/ml) in 550 (63.1%); 533 (96.9%) presented with a single bacterium infection. 488 uropathogens, collected from 479 patients, were analyzed. The most frequent were: Escherichia coli (83.8%), Staphylococcus saprophyticus (4.3%), Proteus mirabilis (3.1%), enterococci (1.2%), and Klebsiella pneumoniae (1.0%). E. coli was highly susceptible to fosfomycin (99.0%) (97.1%), nitrofurantoin (97.3%), and ciprofloxacin (98.3%). The lowest susceptibility rates were found for ampicillin (60.9%) and cotrimoxazole (87.8%). Fosfomycin (97.8%), ciprofloxacin (98.3%), and nitrofurantoin (91.5%) had the highest susceptibility rate. The lowest susceptibility rates were observed with ampicillin (61.4%) and cotrimoxazole (86.5%).

Conclusions

Fosfomycin, pivmecillinam (not available in France), and nitrofurantoin have preserved their in vitro activity and are suitable for empiric therapy. Cotrimoxazole (trimethoprim + sulfamethoxazole) and fluoroquinolones are not usually recommended as first intention drugs for the empiric therapy of uncomplicated cystitis, because of increasing resistance rates.     

肿瘤患者尿路感染大肠埃希菌的分布及耐药性监测

目的 了解大肠埃希菌尿路感染的病种分布及对抗菌药物的耐药趋势,给临床合理用药提供参考.方法 对2005年1其-2010年12月尿路感染肿瘤患者尿培养分离出的301株大肠埃希菌进行病种分布及耐药性统计分析,用纸片扩散法表型确证试验检测ESBLs.结果 分离出大肠埃希菌前5位肿瘤疾病为宫颈癌、直肠癌、肺癌、子宫内膜癌及卵巢癌,分别占30.6％、13.3％、9.6％、5.6％及5.6％;301株大肠埃希菌产ESBLs检出率为74.1％,并有逐年升高趋势;对氨苄西林的耐药率达96.7％,喹诺酮类、头孢-～四代、庆大霉素耐药率＞70.4％;对哌拉西林/他唑巴坦、磷霉素及呋喃妥因耐药率＜10.1％.结论 肿瘤患者尿路感染产ESBLs大肠埃希菌的检出率呈逐年增高趋势,对多种抗菌药物具有高度耐药性;对哌拉西林/他唑巴坦、磷霉素及呋喃妥因的耐药率较低,可用于肿瘤患者尿路感染早期经验用药.     

医院呼吸道感染金黄色葡萄球菌的耐药性分析

目的 分析探讨医院呼吸道感染金黄色葡萄球菌的耐药性.方法 对医院2011年4-6月检出的金黄色葡萄球菌对常用抗菌药物的敏感性进行分析总结,同时分析比较甲氧西林敏感金黄色葡萄球菌(MSSA)与耐甲氧西林金黄色葡萄球(MRSA)的耐药性.结果 金黄色葡萄球菌对万古霉素、替考拉宁、利奈唑胺、呋喃妥因4种抗菌药物的敏感性较高,其敏感性分别为100.00％、100.00％、100.00％、94.56％;对另外16种抗菌药物均出现了高达50.00％的耐药率;MSSA对苯唑西林、阿莫西林、哌拉西林等抗菌药物的耐药率明显低于MRSA(P＜0.01).结论 医院呼吸道感染金黄色葡萄球菌对多种常见的抗菌药物均有较强的耐药性,给临床治疗带来了较大的困难,为减少耐药菌株的产生,合理的应用抗菌药物是重要的有效预防措施.     

2007-2009年ICU铜绿假单胞菌的耐药性变迁

目的 了解铜绿假单胞菌(PAE)在ICU医院感染的分布,以及对多种抗菌药物耐药率的变迁,为临床应用抗菌药物提供依据.方法 用K-B纸片扩散法对2007-2009年外科重症监护病房PAE进行药敏试验,分析其耐药性变化.结果 外科PAE主要来源于痰液、分泌物、尿液;同时,对所监测的13种抗菌药物均有较高程度的耐药,特别是头孢曲松、甲氧苄啶、头孢吡肟和左氧氟沙星耐药率有上升的趋势.结论 医院外科重症监护病房PAE感染主要在呼吸道、泌尿系统以及创面感染,其中呼吸道感染最为严重;PAE耐药性逐渐加剧,因此对它进行规范连续的耐药监测,及时发现耐药菌株,对临床调整治疗方案,预防医院感染的发生是十分重要.     

New paradigms on antibiotic recommendations for community-acquired infections in Spain

Over the last years, the susceptibility activity of the most common microorganisms causing community-acquired infections has significantly changed in Spain. Based on the susceptibility rates of Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, and Klebsiella pneumoniae collected from outpatients aged 15 or older with symptoms of respiratory or urinary tract infections in several Microbiology Departments in Catalonia in 2021, penicillin V should be first choice for most respiratory tract infections, amoxicillin and clavulanate for chronic obstructive pulmonary disease exacerbations and a single dose of fosfomycin or a short-course nitrofurantoin should remain first-line treatments for uncomplicated urinary tract infections. Updated information on antimicrobial resistance for general practitioners is crucial for achieving appropriate empirical management of the most common infections by promoting more rational antibiotic use.     

High sensitivity of Escherichia coli to antimicrobial agents used for first-line treatment of urinary tract infections; results of an examination of feces of healthy subjects in Friesland

OBJECTIVE: To determine the basic sensitivity of Escherichia coli in the province of Friesland, the Netherlands, to antimicrobial agents used by general practitioners to treat urinary tract infections. DESIGN: Inventory. METHOD: Fifty general practitioners in the province were asked in 1999 to have faeces submitted by patients who had not been using antibiotics for at least one month. E. coli was isolated from the faeces using an elective medium. The proportions of resistance were compared with those of strains isolated in urine sent for examination to Friesland Public Health Laboratory by a clinic, outpatient department, general practice or nursing home. RESULTS: The sensitivities were tested of 240 strains from 240 healthy subjects (73 males and 167 females; mean age 47 years (range 0-84)). The proportions of strains resistant to the agents tested were as follows: nitrofurantoin: 0.8%, trimethoprim: 10%, co-trimoxazole: 10%, amoxicillin: 15%, amoxicillin-clavulanic acid 0.4%. Forty-eight per cent of the strains showed intermediate susceptibility to amoxicillin, 63% to amoxicillin/clavulanic acid. The resistance was lower than in isolates submitted for examination from general and specialist practices. CONCLUSION: The antimicrobial agents mentioned are still useful for treatment of urinary tract infections in the general practice.     

老年患者泌尿道大肠埃希菌的耐药分析及基因型研究

目的 探讨老年患者泌尿系统感染的菌群分布、大肠埃希菌的耐药性及产超广谱β-内酰胺酶( ESBLs)的基因分型.方法 对731份泌尿道感染的老年患者尿液标本进行分离培养,用K-B法进行药敏分析,筛选产ESBLs菌株并用PCR的方法鉴定基因型.结果 培养出细菌共198株,以大肠埃希菌为主占52.5％;大肠埃希菌耐药严重,仅对亚胺培南、哌拉西林/他唑巴坦、阿米卡星及呋喃妥因较敏感,其中有54.8％的菌株产ESBLs,产ESBLs菌株耐药率较非产ESBLs菌株高;而且ESBLs基因型多以CTX-M- 14和CTX-M-1为主,且40.3％的菌株存在＞2种的基因型.结论 老年患者泌尿道感染的病原菌耐药性严重且机制复杂,应定期监测病原菌的耐药趋势,以指导临床医师合理应用抗菌药物.     

Summary of the practice guideline 'Urinary-tract infections' (second revision) from the Dutch College of General Practitioners

The 1999 practice guideline 'Urinary-tract infections' from the Dutch College of General Practitioners has been revised. Not only febrile urinary-tract infections are now regarded as 'complicated', but also all urinary-tract infections in men, pregnant women, children, and patients with kidney or urinary-tract disease, impaired immune response or an indwelling catheter. Under certain conditions, in women recognising the symptoms of an earlier uncomplicated urinary-tract infection, treatment may be instituted without performing supplementary urinalysis. The nitrite dipstick test and dipslide culturing are recommended for the diagnosis of urinary-tract infections; the value of the leukocyte esterase dipstick test is limited. A group-B streptococcal urinary-tract infection during pregnancy is an indication for intravenous antibiotic prophylaxis during the delivery. The recommended duration of treatment with nitrofurantoin is extended from three to five days. Both increased bacterial resistance to trimethoprim and the intention to reduce the use of fluoroquinolones in the treatment of uncomplicated urinary-tract infections were reasons for including phosphomycin in the guideline. In addition to antibiotic prophylaxis, cranberry products may be of value in the prevention of recurrent urinary-tract infections.     

472株大肠埃希菌分布及耐药性分析

目的 了解医院大肠埃希菌(ECO)的耐药性及其标本来源,为临床治疗及控制医院感染提供依据.方法 对2010年6月-2011年3月临床分离的472株大肠埃希菌的耐药率及标本来源进行回顾性分析.结果 收集的472株大肠埃希菌对亚胺培南、美罗培南、厄他培南的耐药率均为0;对哌拉西林/他唑巴坦、头孢西丁、阿莫西林/克拉维酸、头孢吡肟、头孢他啶、氨曲南、妥布霉素、庆大霉素、左氧氟沙星、环丙沙星、头孢噻肟的耐药率为7.8％～58.5％;对磺胺甲噁唑/甲氧苄啶、头孢唑林和氨苄西林的耐药率分别为63.3％、73.9％、82.0％,472株大肠埃希菌主要从痰液和尿液标本中检出,分别占33.1％和29.0％.结论 大肠埃希菌为呼吸道和泌尿道感染的常见病原随,临床上应根据耐药特点合理选用抗菌药物.     

尿路感染患者1112例中段尿细菌培养结果

目的探讨尿路感染患者清洁中段尿致病性细菌检出和耐药情况，以指导临床合理用药。方法对武汉大学人民医院2007年1月—2008年3月1112例尿路感染患者的清洁中断尿的病原体进行鉴定和体外药敏试验，细菌鉴定按照《全国临床检验操作规程》进行；药敏试验采用琼脂扩散法（K—B），对革兰阴性杆菌进行超广谱β内酰胺酶的检测。结果检出大肠埃希菌，占53．2％，其次是肠球菌（15．1％）、真菌（5．3％）、葡萄球菌（4．5％）。产超广谱β内酰胺酶大肠埃希菌检出率为24．0％，呈上升趋势。大肠埃希菌对喹诺酮类、复方新诺明、青霉素，除头孢西丁外的第1、2代头孢的耐药率〉40％，对碳青霉烯类、呋喃妥因、哌拉西林／他唑巴坦、头孢哌酮／舒巴坦的敏感率〉90％。产超广谱β内酰胺酶的大肠埃希菌对青霉素类，喹诺酮类及大多数头孢的耐药率大幅增高（P〈0．05），对碳青霉烯类、呋喃妥因、哌拉西彬他唑巴坦、头孢哌酮／舒巴坦、复方新诺明、庆大霉素的耐药率没影响（P〉0．05）。革兰阳性菌对喹诺酮类、庆大霉素耐药率〉50％，对万古霉素（92％）、氯霉素（82％）、呋喃妥因（75％）的敏感率较高。结论泌尿系统感染仍以肠杆菌科细菌为主，且病原菌耐药性较强，临床医生加强对泌尿系统感染病人的病原菌的检测及耐药性的监测，对指导合理使用抗生素有重要意义。     

胆道感染病原菌分布及耐药性分析

目的 研究和探讨胆道感染病原菌的分布及其耐药性,为临床使用抗菌药物提供依据.方法 收集医院2007年1月-2010年12月胆道感染患者的362份胆汁进行细菌培养,对分离病原菌进行鉴定及药敏试验,整理分析检测结果.结果 362份胆汁标本共检测到231株病原菌,阳性率为63.3％;革兰阴性杆菌占68.8％,革兰阳性球菌占26.0％,真菌占2.2％;引起胆道感染的常见病原菌有大肠埃希菌占29.0％、粪肠球菌占15.2％、肺炎克雷伯菌占10.8％、阴沟肠杆菌占9.5％、鲍氏不动杆菌占7.8％;革兰阴性杆菌对亚胺培南和哌拉西林/他唑巴坦耐药率低,分别为0.6％、6.9％,而对氨苄西林的耐药率为94.3％、头孢唑林为71.7％、磺胺甲噁唑/甲氧苄啶为51.6％;革兰阳性球菌对万占霉素的耐药率为0,其次呋喃妥因为1.7％、利条唑胺为3.3％,真菌药物敏感性较好.结论 胆道感染仍以革兰阴性杆菌为主,病原菌谱构成有所变迁,不动杆菌属和肠杆菌属增多,病原菌耐药性增强,需加强对病原菌的检测及耐药性分析,有针对性合理使用抗菌药物.     

泌尿系感染病原菌及耐药性分析

目的 调查分析泌尿系感染的细菌潜及耐药性,指导临床合理用药.方法 病原菌分离鉴定按卫生部《全国临床检验规程》进行,药敏试验采用K-B法.结果 泌尿系感染的主要病原菌是革兰阴性杆菌,占73.6％,依次为大肠埃希菌占49.2％、铜绿假单胞菌占10.4％、肺炎克雷伯菌占5.2％;革兰阳性菌占18.8％;真菌占7.6％;革兰阴性菌对亚胺培南、呋喃妥因、头孢哌酮/舒巴坦的敏感率比较高,而对头孢类.氨苄西林、氨曲南等耐药率较高,革兰阳性球菌对糖肽类、利奈唑胺的敏感性为100.0％.结论 细菌耐药性日趋严重,合理使用抗菌药物刻不容缓.     

小儿下呼吸道疾病病原菌感染情况及对常用抗生素的敏感性

目的 探讨引起小儿呼吸道感染的病原菌分布情况及其对常用抗生素的耐药性.方法 回顾性分析因呼吸道感染性疾病在某院治疗的376例患儿临床资料,分析咽拭子的细菌培养鉴定及其耐药性.结果 ①376例标本中共分离出细菌和真菌125株,阳性检出率为33.2％.革兰阴性菌为89株,占总数的71.2％,包括为流感嗜血杆菌27株,大肠埃希菌24株,肺炎克雷伯杆菌17株,鲍氏不动杆菌14株,其他细菌7株;革兰阳性球菌为29株,占23.2％,包括肺炎链球菌12株,金黄色葡萄球菌10株,溶血葡萄球菌5株以及其他2株;真菌共检出7株,占5.6％,以白色念珠菌为主,共检出5株.②流感嗜血杆菌对左左氧氟沙星、阿米卡星的耐药率较低,对红霉素、庆大霉素、头孢噻肟等三代的耐药率较高,在40％～60％之间.大肠埃希菌和肺炎克雷伯杆菌均对亚胺培南及美罗培南的高度敏感,对氨苄西林等均不敏感.③肺炎链球菌对呋喃妥因部分抗生素较敏感,对青霉素G,红霉素、克林霉素、磺胺甲噁唑/甲氧苄啶及四环素高度耐药.金黄色葡萄球菌及溶血葡萄球菌对呋喃妥因、万古霉素、利福平较为敏感,对左氧氟沙星、庆大霉素、红霉素等均呈现不同程度的耐药,尤其对青霉素G100％耐药.结论 临床治疗应根据致病菌耐药的情况,兼顾不同患儿的特殊情况和个体差异,提高治疗效果、尽量降低多重耐药的发生和减少医疗费用.