Antibiotic resistance in isolates recovered from women with community-acquired urinary tract infections presenting to a tertiary care emergency department

ABSTRACTIntroduction:We sought to determine the antibiotic susceptibility of organisms causing community-acquired urinary tract infections (UTIs) in adult females attending an urban emergency department (ED) and to identify risk factors for antibiotic resistance.Methods:We reviewed the ED charts of all nonpregnant, nonlactating adult females with positive urine cultures for 2008 and recorded demographics, diagnosis, complicating factors, organism susceptibility, and risk factors for antibiotic resistance. Odds ratios (ORs) and 95% confidence intervals (CIs) for potential risk factors were calculated.Results: Our final sample comprised 327 UTIs: 218 were cystitis, of which 22 were complicated cases and 109 were pyelonephritis, including 22 complicated cases. Escherichia coli accounted for 82.3% of all UTIs, whereas Staphylococcus saprophyticus accounted for 5.2%. In uncomplicated cystitis, 9.5% of all isolates were resistant to ciprofloxacin and 24.0% to trimethoprim-sulfamethoxazole (TMP-SMX). In uncomplicated pyelonephritis, 19.5% of isolates were resistant to ciprofloxacin and 36.8% to TMP-SMX. In UTI (all types combined), any antibiotic use within the previous 3 months was a significant risk factor for resistance to both ciprofloxacin (OR 3.34, 95% CI 1.16-9.62) and TMP-SMX (OR 4.02, 95% CI 1.48-10.92). Being 65 years of age or older and having had a history of UTI in the previous year were risk factors only for ciprofloxacin resistance. Conclusions:E. coli was the predominant urinary pathogen in this series. Resistance to ciprofloxacin and TMP-SMX was high, highlighting the importance of relevant, local antibiograms. Any recent antibiotic use was a risk factor for both ciprofloxacin and TMP-SMX resistance in UTI. Our findings should be confirmed with a larger prospective study.     

The etiology of urinary tract infection: traditional and emerging pathogens

The microbial etiology of urinary infections has been regarded as well established and reasonably consistent. Escherichia coli remains the predominant uropathogen (80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10% to 15%). Klebsiella, Enterobacter, and Proteus species, and enterococci infrequently cause uncomplicated cystitis and pyelonephritis.The pathogens traditionally associated with UTI are changing many of their features, particularly because of antimicrobial resistance. The etiology of UTI is also affected by underlying host factors that complicate UTI, such as age, diabetes, spinal cord injury, or catheterization. Consequently, complicated UTI has a more diverse etiology than uncomplicated UTI, and organisms that rarely cause disease in healthy patients can cause significant disease in hosts with anatomic, metabolic, or immunologic underlying disease. The majority of community-acquired symptomatic UTIs in elderly women are caused by E coli. However, gram-positive organisms are common, and polymicrobial infections account for up to 1 in 3 infections in the elderly. In comparison, the most common organisms isolated in children with uncomplicated UTI are Enterobacteriaceae. Etiologic pathogens associated with UTI among patients with diabetes include Klebsiella spp., Group B streptococci, and Enterococcus spp., as well as E coli. Patients with spinal cord injuries commonly have E coli infections. Other common uropathogens include Pseudomonas and Proteus mirabilis.Recent advances in molecular biology may facilitate the identification of new etiologic agents for UTI. The need for accurate and updated population surveillance data is apparent, particularly in light of concerns regarding antimicrobial resistance. This information will directly affect selection of empiric therapy for UTI.     

Risk factors for community-acquired ciprofloxacin-resistant Escherichia coli urinary tract infection

BACKGROUND: Fluoroquinolones are recommended for the empiric treatment of urinary tract infection (UTI) in communities in which uropathogen resistance to trimethoprim/sulfamethoxazole (TMP/SMX) is >or=10% to 20%. However, recent studies also have demonstrated an increase in the isolation of fluoroquinolone-resistant Escherichia coli. Identification of outpatients at increased risk for fluoroquinolone resistance would improve the selection of empiric treatment. OBJECTIVE: To identify risk factors for community-acquired UTIs due to ciprofloxacin-resistant E. coli (CREC). METHODS: All medical records from the University of California at San Francisco Medical Center from January to December 2001 were retrospectively reviewed to identify patients with community-acquired UTI due to CREC. Patients with community-acquired UTI due to ciprofloxacin-susceptible E. coli presenting during the same time period were randomly selected as the study group in a 1:2 ratio of case to controls. RESULTS: Independent risk factors for CREC included recurrent UTI (OR 8.13) and prior exposure to fluoroquinolones (OR 30.35). CONCLUSIONS: Fluoroquinolones continue to be appropriate empiric treatment in most patients with uncomplicated UTI. Nitrofurantoin or a cephalosporin may be better choices in patients with recurrent lower UTI and/or previous fluoroquinolone use.     

The ECO.SENS Project: a prospective, multinational, multicentre epidemiological survey of the prevalence and antimicrobial susceptibility of urinary tract pathogens--interim report

The ECO.SENS Project is the first international survey to investigate the prevalence and susceptibility of pathogens causing community-acquired, uncomplicated urinary tract infections (UTIs) in women. At 240 centres in 17 countries, female patients presenting with symptoms of uncomplicated UTIs were asked to provide a urine sample for testing for the presence of leucocytes and bacteria. The bacteria were identified and their susceptibility to 12 antibiotics commonly used in the treatment of UTIs was determined. The objective of the survey was to collect 5000 urine samples to obtain approximately 3500 isolates of defined uropathogens. This interim report includes the results from 1960 urine samples, 75% of which contained a uropathogen. Escherichia coli accounted for the majority (80%) of uropathogens isolated in all 17 countries. The rates of resistance among E. coli strains were: ampicillin and sulphamethoxazole, 30%; trimethoprim alone or with sulphamethoxazole, 15%; nalidixic acid, 6%; ciprofloxacin, 3%; amoxycillin-clavulanic acid, mecillinam, cefadroxil, nitrofurantoin and fosfomycin, < or =2%. The use of ampicillin, sulphonamides and trimethoprim alone or with sulphamethoxazole needs to be reconsidered. The seemingly rapid increase in quinolone resistance among community-acquired E. coli in some of the countries gives cause for concern.     

Addressing antibiotic resistance

Management of uncomplicated urinary tract infections (UTIs) has traditionally been based on 2 important principles: the spectrum of organisms causing acute UTI is highly predictable (Escherichia coli accounts for 75% to 90% and Staphylococcus saprophyticus accounts for 5% to 15% of isolates), and the susceptibility patterns of these organisms have also been relatively predictable. As a result, empiric therapy with short-course trimethoprim-sulfamethoxazole (TMP-SMX) has been a standard management approach for uncomplicated cystitis.However, antibiotic resistance is now becoming a major factor not only in nosocomial complicated UTIs, but also in uncomplicated community-acquired UTIs. Resistance to TMP-SMX now approaches 18% to 22% in some regions of the United States, and nearly 1 in 3 bacterial strains causing cystitis or pyelonephritis demonstrate resistance to amoxicillin. Fortunately, resistance to other agents, such as nitrofurantoin and the fluoroquinolones, has remained low, at approximately 2%. Preliminary data suggest that the increase in TMP-SMX resistance is associated with poorer bacteriologic and clinical outcomes when TMP-SMX is used for therapy. As a result, these trends have necessitated a change in the management approach to community-acquired UTI. The use of TMP-SMX as a first-line agent for empiric therapy of uncomplicated cystitis is only appropriate in areas where TMP-SMX resistance prevalence is <10% to 20%. In areas where resistance to TMP-SMX exceeds this rate, alternative agents need to be considered.     

Does urinary tract infection caused by extended-spectrum β-lactamase-producing Escherichia coli show same antibiotic resistance when it recurs?

This study was performed to evaluate what percentage of urinary tract infections (UTIs) caused by extended spectrum β-lactamase (ESBL)-producing strains recurs with ESBL-producing strains during follow up and to assess the risk factors for recurrence with ESBL-producing Escherichia coli strains on subsequent first recurrence episode. We enrolled female patients with UTIs caused by ESBL-producing E. coli between May 2012 and December 2015, who were longitudinally followed up for at least 24 months. Among the 206 patients with ESBL positive UTI, 180 completed the study. 60 (60/180, 33.3%) of patient with first episode of UTI caused by ESBL-producing E. coli experienced recurrent UTIs during follow up. Of 60 patients, 43 (43/60, 71.7%) recurred with ESBL-producing E. coli on the first UTI recurrence episode. On multivariate analysis, the time to recurrence and history of cephalosporin usage in the last 6 months were identified as risk factors for recurrence with ESBL-producing E. coli per se (odds ratio [OR] = 0.9, 95% confidence interval [CI] 0.8–1.0, p = 0.030 and OR = 27.0, 95% CI 2.4–299.8, p = 0.007, respectively). These findings show that high proportion of patient with UTI caused by ESBL-producing E. coli recurs with ESBL-producing E. coli on subsequent recurrence episode. While result of antibiotic susceptibility cannot be identified on the visit day empirical treatment should be referred to the antecedent antibiotic resistance profile in patients whose previous UTIs were due to ESBL-producing strains.     

The expanding role of fluoroquinolones

There has been a growing rate of resistance among common urinary tract pathogens, such as Escherichia coli, to traditional antimicrobial therapies including the "gold standard" trimethoprim-sulfamethoxazole (TMP-SMX). Consequently, fluoroquinolone antimicrobial agents have taken on an expanding management role for UTIs. In fact, the recent Infectious Diseases Society of America clinical management guidelines for UTI recommend fluoroquinolones as first-line therapy for uncomplicated UTI in areas where resistance is likely to be of concern. Fluoroquinolones have demonstrated high bacteriologic and clinical cure rates, as well as low rates of resistance, among most common uropathogens. There are currently 7 fluoroquinolones with indications for UTI in the United States. However, only 3 are commonly used: levofloxacin, ciprofloxacin, and, to a lesser extent, gatifloxacin. Many of the fluoroquinolone agents have once-daily dosing regimens, enhancing patient adherence. In addition, levofloxacin and gatifloxacin have same-dose bioequivalency between their intravenous and oral formulations, allowing for "switch" or step-down therapy from parenteral to oral formulations of the same agent at the same dose.Fluoroquinolones are indicated for the management of acute uncomplicated UTIs, as well as complicated and severe UTI and pyelonephritis, in adults. They are the first-line treatment of acute uncomplicated cystitis in patients who cannot tolerate sulfonamides or TMP, who live in geographic areas with known resistance >10% to 20% to TMP-SMX, or who have risk factors for such resistance. Fluoroquinolone properties include a broad spectrum of coverage, low rates of resistance, and good safety profiles.     

Risk factors for community-onset urinary tract infections due to Escherichia coli harbouring extended-spectrum beta-lactamases

OBJECTIVES: Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli have been increasingly recognized in the community. The aim of this study was to determine the prevalence, types of ESBLs and risk factors for community-onset ESBL-producing E. coli in urinary tract infections (UTIs). METHODS: Adults with community-onset UTIs due to ESBL-producing E. coli (cases) and non-ESBL-producing E. coli (controls) were identified through records of the clinical microbiology laboratory of the hospital. Two different periods were studied: from January 2000 to January 2001 and from October to December 2003. Controls were matched in a 3:1 ratio to case patients according to age, sex, date of isolation and residence in a long-term care facility. Potential risk factors were recorded. Isoelectric focusing as well as PCR and DNA sequencing were used to characterize the bla(TEM), bla(SHV) and bla(CTX-M) genes. A possible clonal relationship among the strains was determined by repetitive extragenic palindromic sequence PCR. RESULTS: The prevalence of infection due to ESBL-producing E. coli increased from 0.47% in 2000 to 1.7% in 2003 (P < 0.001). Community-onset ESBL-producing E. coli infection shifted from 50% in the first period to 79.5% in 2003 (P < 0.001). Nineteen cases and 55 matched controls of community-onset ESBL-producing E. coli UTI were included. ESBL-producing E. coli strains were clonally unrelated. On univariate analysis, genitourinary pathology (P < 0.03), previous bacterial infection (P = 0.01), intravenous antibiotic treatment (P = 0.01), hospitalization in the previous 12 months (P = 0.04) and previous exposure to oral second-generation cephalosporins (P < 0.05) were associated with community-onset infection due to ESBL-producing E. coli. In our regression model, only previous exposure to second-generation cephalosporins was strongly associated with E. coli harbouring ESBLs (OR, 21.42; CI 95%, 5.38-85.22; P < 0.05). In the first period, only TEM- and SHV-derived ESBLs were identified. The enzymes were characterized as members of the TEM group (60%), SHV group (16%) and CTX-M group (24%). CONCLUSIONS: We detected a marked increase in infections due to ESBL-producing E. coli, especially in the community, in the periods studied. Only previous exposure to the oxyimino cephalosporin cefuroxime, and not to ciprofloxacin, aminoglycosides or third-generation cephalosporins, was predictive of an ESBL-producing E. coli community-onset infection in our area. The emergence of the CTX-M type of beta-lactamase in E. coli follows closely the spread of ESBLs in community isolates.     

187例医院内尿路感染病原分布和抗生素耐药分析

目的 :了解医院内尿路感染的病原分布和对抗生素的耐药情况及其比较与院外尿路感染的差别 ,企图以此指导临床用药。方法 :收集 187例医院内尿路感染和同期住院的 14 5例院外尿路感染进行比较。结果 :医院内尿路感染的优势菌依次为 :大肠埃希菌 2 8.2 4 % ,肠球菌 2 1.37% ,念珠菌 14 .89% ,克雷伯杆菌 8.0 2 % ,假单胞菌 7.2 5 %和链球菌 4 .96 %。其中医院内念珠菌的感染率较院外显著升高 (P <0 .0 1)。有尿路操作者中大肠埃希菌 33.33% ,肠球菌 16 .92 % ,念珠菌 16 .4 1%和假单胞菌8.2 1%。其中念珠菌和假单胞菌的感染率显著高于无尿路操作者 (P <0 .0 5 ,P <0 .0 1)。在院内感染者中 ,大肠埃希菌对环丙沙星和头孢哌酮的耐药性 ,肠球菌对青霉素的耐药性药明显高于院外感染者 (P <0 .0 5 ,P <0 .0 5 ,P <0 .0 5 )。结论 :院内尿路感染中有较多尿路操作和广谱抗生素的使用史 ,念珠菌的感染率明显升高 ,细菌对抗生素耐药的情况较多 ,应注意调整治疗方案。     

Antimicrobial resistance in community-acquired urinary tract infections: results from the Korean Antimicrobial Resistance Monitoring System

The Korean Antimicrobial Resistance Monitoring System was established and the first nationwide surveillance of bacterial uropathogens was conducted during the period from January 2008 to June 2009. With the cooperation of 34 medical centers throughout South Korea, a total of 1994 strains belonging to clinically relevant bacterial uropathogens were collected from patients with community-acquired urinary tract infections (UTIs). To compare with past data, understand a trend of antimicrobial resistance, and ultimately determine new regimens for empirical treatment of uncomplicated cystitis, the antimicrobial susceptibilities against Escherichia coli in uncomplicated cystitis to commonly prescribed drugs were investigated. In uncomplicated cystitis, the most prevalent causative organism was E. coli (72.7%), followed by Enterococcus faecalis (10.7%) and Klebsiella pneumoniae (3.5%). Among E. coli isolates from acute uncomplicated cystitis, 38.5% were susceptible to ampicillin, 80.7% to amoxicillin/clavulanate, 67.3% to trimethoprim/sulfamethoxazole, 74.6% to ciprofloxacin, 77.5% to levofloxacin, 86.0% to cefazolin, 86.1% to cefuroxime, 93.6% to cefpodoxime, 94.7% to ceftriaxone, 99.5% to amikacin, 80.9% to tobramycin, and 76.6% to gentamicin. An increasing tendency of resistance to ciprofloxacin (24.8%) has been observed compared with the similar studies in 2006 (23.4%) and 2002 (15.2%) from patients with uncomplicated cystitis. These data provide much needed information on the prevalence of antimicrobial resistance in community-acquired UTIs in South Korea and will be a useful reference for future periodic surveillance studies.     

The resistance ofEscherichia coli strains isolated from community-acquired urinary tract infections

Urinary tract infections (UTIs) are the most common infections caused byEscherichia coli. Most recent research demonstrates that antibiotic resistance has reached a critical point throughout the world, as increased use of antibiotics among nonhospitalized patients encourages the growth of drug-resistant pathogens among that population. The goal of this study was to determine the antimicrobial drug resistance ofE coli strains isolated from community-acquired UTIs in 5 different regions in Turkey. The minimum inhibitory concentrations of ciprofloxacin, gentamicin, sulfamethoxazole, trimethoprim, trimethoprim-sulfamethoxazole, and ampicillin and forE coli were determined with the agar dilution method. Among the 480 strains isolated, 8.3% were resistant to ciprofloxacin, 3.3% to gentamicin, 35.4% to sulfamethoxazole, 33.3% to trimethoprim, 27.9% to trimethoprim-sulfamethoxazole, and 40.8% to ampicillin. These results show that the antibiotics currently most effective againstE coli are ciprofloxacin and gentamicin. Local epidemiologic trends should be considered when prescribing antibacterial therapy. More research in bacterial gene mapping will be necessary to elucidate the influence of regional antimicrobial drug use and resistance in epidemiologic trends among the general population.     

Trimethoprim/sulfamethoxazole resistance in urinary tract infections

Urinary tract infections (UTI) are among the most prevalent infectious diseases, and their financial burden on society is substantial. Management of UTIs has been complicated by the emergence of resistance to most commonly used antibiotics. Increasing prevalence of resistance has led to a gradual evolution in the antibiotics used to treat UTIs. The aims of this study were to determine the TMP/SMX (trimethoprim/sulfamethoxazole) resistance rate in patients with uncomplicated UTIs and to determine which empiric antibiotics are prescribed in the emergency department for the outpatient management of UTI. Between June 2004 and May 2005, archives of the emergency department were searched retrospectively and the files of patients diagnosed with UTI were reviewed. Patients' demographical data, urine culture results, pathogen microorganisms, and TMP/SMX and fluoroquinolone (FQ) resistance rates were recorded. We obtained information from 274 files of patients who had been diagnosed with UTI. The most frequently isolated pathogen was Escherichia coli (54%). Of the 274 patients diagnosed with UTI, 251 had been started on empiric antibiotics. The most frequently prescribed antibiotics were FQs (85%), and the first choice in this group was ofloxacin (58%). The resistance rate for TMP/SMX was 34% and all of the resistant microorganisms were E. coli. The resistance rate for the FQ group was 16.4% and resistant microorganisms were E. coli. In the treatment of UTIs in our patient population, the most prescribed antibiotics were FQs. At the same time it was found that resistance rates against FQ antibiotics are as high as 16.4%. Unfortunately, in our population, in the near future, empiric FQ use may result in bacterial resistance.     

Antimicrobial resistance among uropathogens that cause community-acquired urinary tract infections in Antananarivo, Madagascar

BACKGROUND: Urinary tract pathogens obtained from patients in Madagascar are becoming increasingly resistant to commonly used antibiotics that are readily available at a low price. This poses a real problem for the treatment of community-acquired urinary tract infections (UTIs) in Madagascar. OBJECTIVES: To obtain data on the pathogens responsible for community-acquired UTIs in Antananarivo and on their susceptibility patterns to the antimicrobial agents that are currently used to treat UTIs. METHODS: We conducted a retrospective study on bacteria isolated from the urine of patients at the Institut Pasteur of Madagascar between January 2004 and April 2006. RESULTS: We isolated 903 pathogens from 673 women and 213 men. The most commonly isolated bacteria were Escherichia coli (607 strains), Klebsiella pneumoniae (87 strains), Staphylococcus aureus (35 strains) and Proteus mirabilis (32 strains). Seventy-seven per cent of Gram-negative bacilli were resistant to amoxicillin, 65.7% were resistant to trimethoprim/sulfamethoxazole and more than 15% were resistant to ciprofloxacin. Strains were rarely resistant to more expensive antibiotics (ceftriaxone 5.9%, fosfomycin 4.6%). Most bacteria showed intermediate susceptibility to nitroxolin. Resistance rates of E. coli to ceftriaxone and gentamicin increased significantly between 2005 and 2006, due to the increase in strains harbouring an extended-spectrum beta-lactamase. Gram-positive bacteria, Streptococcaceae and Staphylococcus spp. were rarely resistant, but 9.5% of streptococci were resistant to penicillin A and 8% of staphylococci were resistant to oxacillin. CONCLUSIONS: The rate of amoxicillin- and trimethoprim/sulfamethoxazole-resistant Enterobacteriaceae implies that another antibiotic should be used for empirical treatment and that there is a need for new generic drugs in developing countries, especially in Madagascar.     

Urinary tract infection: traditional pharmacologic therapies

Urinary tract infections (UTIs) are common bacterial infections, particularly in women. Antimicrobial therapy is seldom indicated for asymptomatic infection, but antimicrobial therapy is usually indicated for amelioration of symptoms. Management of acute uncomplicated UTI (cystitis) is generally straightforward, with a predictable distribution of uropathogens isolated. First-line treatment of acute uncomplicated UTI has traditionally involved a 3-day regimen of trimethoprim-sulfamethoxazole (TMP-SMX) or TMP alone for patients with sulfa allergies. Increasing resistance among community-acquired Escherichia coli to TMP-SMX worldwide has led to a reassessment of the most appropriate empiric therapy for these infections. Alternative first-line agents include the fluoroquinolones, nitrofurantoin, and fosfomycin.Factors to be considered in the selection of appropriate antimicrobial therapy include pharmacokinetics, spectrum of activity of the antimicrobial agent, resistance prevalence for the community, potential for adverse effects, and duration of therapy. Ideal antimicrobial agents for UTI management have primary excretion routes through the urinary tract to achieve high urinary drug levels. In addition, there are special considerations in the management of UTI among selected populations, including postmenopausal and pregnant women, and for women with frequent recurrent UTIs.     

An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO.SENS Project

The ECO.SENS study is the first international survey to investigate the prevalence and susceptibility of pathogens causing community-acquired acute uncomplicated urinary tract infections (UTIs). Midstream urine samples were taken for culture and for testing for the presence of leucocytes from 4734 women not older than 65 years presenting with symptoms of acute UTI at 252 community health care centres in 17 countries. Recognized urinary tract pathogens were identified and the susceptibility to 12 antimicrobials determined. Pathogens were present in 3278 (69.2%) patients, Escherichia coli accounting for 77.0% of isolates. In E. coli, 42% of the isolates were resistant to one or more of the 12 antimicrobial drugs investigated. Resistance was most common to ampicillin (29.8%) and sulfamethoxazole (29.1%), followed by trimethoprim (14.8%), trimethoprim/sulfamethoxazole (14.1%) and nalidixic acid (5.4%). Resistance in E. coli to co-amoxiclav, mecillinam, cefadroxil, nitrofurantoin, fosfomycin, gentamicin and ciprofloxacin was <3%. However, co-amoxiclav resistance was apparent in Portugal (9.3%) as was resistance to the quinolones, nalidixic acid and ciprofloxacin, in Portugal (11.6% and 5.8%, respectively) and Spain (26.7% and 14.7%, respectively). Overall, Proteus mirabilis were less resistant to ampicillin (16.1%) and more resistant to trimethoprim (25.5%) than E. coli, whereas Klebsiella spp. were more resistant to ampicillin (83.5%) and fosfomycin (56.7%). 'Other Enterobacteriaceae' were more resistant to the broad spectrum beta-lactams (ampicillin 45.9%, co-amoxiclav 21.3% and cefadroxil 24.6%), nitrofurantoin (40.2%) and fosfomycin (15.6%). In Staphylococcus saprophyticus resistance development was rare. Overall, antimicrobial resistance was lowest in the Nordic countries and Austria and highest in Portugal and Spain.     

老年尿路感染产超广谱β-内酰胺酶大肠埃希菌耐药性分析

目的探讨老年尿路感染患者中产超广谱β-内酰胺酶（ESBLs）大肠埃希菌的耐药性。方法回顾性分析2008年至2009年117例ESBLs（＋）老年尿路感染患者中段尿标本结果。结果大肠埃希菌产ESBLs率自2008年的49.1%上升到2009年的53.9%。产ESBLs大肠埃希菌对氨基糖苷类,二、三代头孢菌素以及酶抑制剂抗生素的耐药性呈上升趋势。产ESBLs大肠埃希菌对第二、三代头孢菌素,氨苄西林,环丙沙星耐药率高,对头孢哌酮舒巴坦、丁胺卡那敏感,对碳青酶类无耐药。结论老年尿路感染患者中产ESBLs大肠埃希菌检出率和耐药性非常高,头孢哌酮舒巴坦是此类患者较为理想的选择。     

Comparison of once-daily extended-release ciprofloxacin and conventional twice-daily ciprofloxacin for the treatment of uncomplicated urinary tract infection in women

BACKGROUND: Trimethoprim/sulfamethoxazole (TMP/SMX) is currently the first choice for empiric therapy of acute uncomplicated urinary tract infection (UTI) in women. In areas where resistance to TMP/SMX is known to be high, ciprofloxacin and other fluoroquinolones are recommended as first-line choices for the empiric therapy of UTI. OBJECTIVE: This study compared the efficacy and safety profile of once-daily extended-release ciprofloxacin 500 mg (referred to hereafter as ciprofloxacin QD) with those of conventional ciprofloxacin 250 mg BID, each administered orally for 3 days, in the treatment of uncomplicated UTI in women. METHODS: In this multicenter, prospective, randomized, double-blind, double-dummy, Phase III trial, adult women with clinical signs and symptoms of acute uncomplicated UTI, pyuria, and a positive pretherapy urine culture (>/=10(5) colony-forming units/mL) received ciprofloxacin QD or ciprofloxacin BID. Bacteriologic and clinical outcomes were assessed at the test-of-cure visit (4-11 days after completion of therapy) and the late follow-up visit (25-50 days after completion of therapy). RESULTS: The intent-to-treat population consisted of 891 patients (444 ciprofloxacin QD, 447 ciprofloxacin BID); 422 patients were evaluable for efficacy (199 ciprofloxacin QD, 223 ciprofloxacin BID). At the test-of-cure visit, bacteriologic eradication was achieved in 94.5% (188/199) of the ciprofloxacin QD group and 93.7% (209/223) of the ciprofloxacin BID group (95% CI, -3.5 to 5.1). Clinical cure was achieved in 95.5% (189/198) of the ciprofloxacin QD group and 92.7% (204/220) of the ciprofloxacin BID group (95% CI, -1.6 to 7.1). Bacteriologic and clinical outcomes at the late follow-up visit were consistent with the test-of-cure findings. The rate of eradication of Escherichia coli, the most prevalent organism, was >97% in each treatment group. Rates of drug-related adverse events were similar with the once- and twice-daily ciprofloxacin regimens (10% and 9%, respectively). CONCLUSION: Extended-release ciprofloxacin 500 mg given once daily for 3 days was as effective and well tolerated as conventional ciprofloxacin 250 mg given twice daily for 3 days in the treatment of acute uncomplicated UTI in women.     

Incidence and risk factors for acquiring nosocomial urinary tract infection in the critically ill

PURPOSE: A urinary tract infection (UTI) is the most common hospital-acquired infection. However, the epidemiology of intensive care unit (ICU)-acquired UTIs is not well defined. The objective of this study was to describe the incidence, risk factors, and clinical outcomes of ICU-acquired UTIs. MATERIALS AND METHODS: All patients admitted to adult multidisciplinary ICUs in the Calgary Health Region (CHR, population approximately 1 million) during May 1, 1999 to April 30, 2000 were studied using a cohort design. RESULTS: A total of 1,158 admissions to a CHR ICU were 48 hours in duration or more. A total of 111 episodes of ICU-acquired UTI (defined as >10(5) CFU/mL of 1 or 2 organisms >48 hours after ICU admission) occurred in 105 (9%) patients and 5 (0.4%) had ICU-acquired bacteremic/fungemic UTIs for incidences of 11.3 and 0.5 UTIs per 1,000 ICU days, respectively. Significant independent risk factors for developing an ICU-acquired UTI as determined by a logistic regression model were female gender (adjusted odds ratio [OR(adj)], 2.31; 95% confidence interval [CI], 1.48-3.59) and natural logarithmic transformation of ICU length of stay (OR(adj), 3.96; 95% CI, 3.02-5.17). No differences in admitting vital signs, routine blood tests, APACHE II and TISS scores, or overall hospital mortality rate were observed among patients who developed an ICU-acquired UTI as compared with those who did not. The most common UTI etiologies were Enterococcus spp. (24%), Candida albicans (21%), and Escherichia coli (15%). Only 4 (3%) of the organisms were highly antibiotic resistant. CONCLUSIONS: Nosocomial UTIs develop commonly in the critically ill and women and those with an extended ICU stay are at increased risk. Although ICU-acquired UTIs are markers of morbidity, they do not significantly increase mortality.     

In vitro susceptibility of enterococci strains isolated from urine samples to fosfomycin and other antibiotics

Enterococci are mostly isolated from urinary tract infections (UTIs). Increasing antibiotic resistance affects the success rate in empirical treatment, thus makes antibiotic susceptibility tests important. The aim of this study was to determine the species distribution and resistance patterns of Enterococcus strains isolated from urine samples to antibacterial agents including fosfomycin in a teaching hospital, Istanbul. The identification of 100 Enterococcus strains were determined by using conventional methods and API 20 Strep (bioMerieux France). The susceptibility testing was performed by disk diffusion and Etest. The majority of isolates were E. faecalis (67%), followed by E. faecium (33%). The ratio of E. faecalis to E. faecium was 2.03/1. E. faecalis and E. faecium strains were resistant to penicillin (38.8, 93.9%), ampicillin (4.8, 84.8%), vancomycin (1.5, 18.2%), teicoplanin (1.5, 18.2%), gentamicin (13.4, 58%), ciprofloxacin (34.3, 84.8%), levofloxacin (34.3, 87.9%), norfloxacin (38.8, 84.8%), tetracycline (89.6, 48.5%), nitrofurantoin (1.5, 39.4%), and fosfomycin (2.3, 0%) (p < 0.0001), respectively. Resistance to fosfomycin was observed in neither E. faecium strains, nor vancomycine-resistant enterococci strains. It was concluded that, enterococci are important pathogens for UTI; species identification and periodic evaluation of antibiotic susceptibility pattern would be guide for early empirical treatment and in uncomplicated UTI, fosfomycin could be an alternative option for therapy.