Management of urinary tract infections: historical perspective and current strategies: Part 2--Modern management

PURPOSE: An understanding of the microbial origin of infectious diseases and the introduction of antimicrobial therapy stimulated more advances in the management of urinary tract infections (UTIs) in the 20th century than had occurred in the previous 5 centuries. MATERIALS AND METHODS: Numerous resources were used to collect the information described in this review. Medical texts from the 19th and 20th century contain information regarding the traditional contemporary treatment of UTI during those eras. Early volumes of the Journal of Urology from the beginning of the 20th century describe the first attempts at chemotherapy for UTI. MEDLINE searches were used to collect appropriate information after 1969. Modern medical journals and modern medical texts were used to collect information on antimicrobial therapy since the late 1960s through today. RESULTS: Numerous advances in the diagnosis and management of UTI were made during the 20th century. Advances in microbiological and chemical assays have facilitated the development of historical uroscopy into modern day urinalysis and culture techniques, which are the cornerstone of UTI diagnosis. Imaging technologies, including x-ray, ultrasound, nuclear imaging, magnetic resonance and computerized tomography, have been particularly helpful in the diagnosis of complicated or recurrent UTIs. Major innovations in nonpharmacological therapy include noninvasive shock wave lithotripsy and percutaneous drainage of kidney abscesses. The most profound advance in UTI management during the 20th century was the discovery of antimicrobial agents. Nitrofurantoin was the first truly effective and safe antimicrobial therapy for UTI but its spectrum of activity is limited. Broad use of amoxicillin (and other beta-lactams) after its introduction in the 1970s led to the development of resistance to this antimicrobial, prompting a gradual change to trimethoprim/sulfamethoxazole (TMP/SMX) as first line therapy for UTI. However, wide use of TMP/SMX also resulted in the progressive emergence of resistance, limiting the clinical usefulness of this therapy in the modern management of UTI. Fluoroquinolones offer an attractive alternative to TMP/SMX, and American and European guidelines recommend their empirical use in areas where TMP/SMX resistance is 10% or higher. CONCLUSIONS: The development of antimicrobial therapy was the defining moment of 20th century medicine and one of the key innovations in medical history. While the initial promise of antimicrobials has been validated in clinical practice, overuse of certain agents has led to the emergence of resistance, illustrating the importance of using evidence based strategies to select therapy.     

A pilot randomized double-blind placebo-controlled trial on the use of antibiotics on urinary catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin

OBJECTIVE: To assess if a short course of antibiotics starting at the time of the removing a short-term urethral catheter decreases the incidence of subsequent urinary tract infection (UTI). PATIENTS AND METHODS: Patients across specialities with a urethral catheter in situ for >/= 48 h and 相似文献   

Improved Classification of Urinary Tract Infection: Future Considerations

The current European Association of Urology and European Section of Infection in Urology classification of urinary tract infections (UTIs) is a working instrument useful for daily patient assessment and clinical research. This new classification of UTI is based on clinical presentation, risk factors, and severity scale. Symptomatic UTIs are classified as cystitis, pyelonephritis, and urosepsis, considering that the urosepsis syndrome is the most severe form and that pyelonephritis is more severe than cystitis. The risk factors are phenotyped according to the ORENUC system: O indicates no known risk factors; R, risk of recurrent UTIs but without risk of a more severe outcome; E, extraurogenital risk factors; N, relevant nephropathic diseases; U, urologic resolvable (transient) risk factors; C, permanent external urinary catheter and unresolved urologic risk factors. Although clinical findings, culture tests, and microscopy remain the standard methods for diagnosing UTIs, improved detection of bacteria by novel diagnostic technologies, such as metagenomic sequencing (MGS), might change this paradigm in the future. Applying a culture-independent MGS technology allows detection of rich bacterial communities in urologic patients with “sterile” urine. However, the clinical relevance of detecting difficult-to-culture bacteria needs to be established by well-designed clinical studies.Patient summaryThe current European Association of Urology Section of Infection in Urology classification of urinary tract infections (UTIs) is useful for patient assessment. Symptomatology and urine culture remain the standards for diagnosing UTIs. Novel technologies will further explore the interactions between the host and microorganisms in the urogenital tract.     

Urinary tract infections: what's new?

PURPOSE: This review provides practicing urologists with important basic information about urinary tract infections (UTIs) that can be applied to everyday clinical problems. MATERIALS AND METHODS: A review is presented of provocative and controversial concepts in the current literature. RESULTS: Bacterial virulence mechanisms are critical for overcoming the normal host defenses. Increasing antimicrobial resistance of uropathogens has led to reconsideration of traditional treatment recommendations in many areas. For effective patient management the first issue is to define complicating urological factors. Managing complicated urinary tract infections, particularly in urology, is determined by clinical experience to define the pertinent anatomy and to determine the optimal interventions. New clinical data are summarized on UTIs in long-term care patients, behavioral risks for UTI in healthy women and anatomical differences associated with an increased risk for UTI. The rationale is presented for UTI prophylaxis using cranberry juice, immunization and bacterial interference. Current treatment trends for UTI include empiric therapy (without urine culture and sensitivity testing), short-course therapy, patient-administered (self-start) therapy and outpatient therapy for uncomplicated pyelonephritis. CONCLUSIONS: Recommendations for treating patients with UTIs have changed based on basic science and clinical experience.     

Urologic diseases in america project: trends in resource use for urinary tract infections in men

PURPOSE: Various types of urinary tract infection (UTI) occur in men. In this study we examined health care use trends, including epidemiological and economic factors, for UTI in men in the United States. MATERIALS AND METHODS: The analytical methods used to generate these results have been described previously. RESULTS: Approximately 20% of all UTIs occur in men. Between 1988 and 1994 the overall lifetime prevalence of UTI was estimated to be 13,689/100,000 men. Orchitis rates, particularly in older men, are generally higher than those of cystitis or pyelonephritis. Approximately 10% of all inpatient care of men with UTI is for orchitis (12 to 14/100,000 population). Rates of outpatient hospital and physician office care for male UTI have increased in the last decade. Rates for emergency room care for UTI in elderly men (85 to 94 years old) were almost twice those in men younger than 85 years. The adjusted mean health care expenditure for privately insured men with UTI was 5,544 dollars in 1999 compared to 2,715 dollars for men without UTI. Total annual health care expenditures for men and women with UTI were 5,544 dollars and 5,407 dollars, respectively. Mean time lost from work was slightly higher for men. Based on composite data overall medical expenditures for men with UTI in the United States were estimated to be approximately 1.028 billion dollars in 2000. CONCLUSIONS: Health care use and economic data on UTIs in men revealed a number of intriguing trends. These results raise various important questions for future research.     

Hygiene and urinary tract infections after cystectomy in 452 Swedish survivors of bladder cancer

Study Type – Symptom prevalence (retrospective cohort)
Level of Evidence 2b

OBJECTIVES

To determine whether or not an improved hygiene can lessen the incidence of symptomatic urinary tract infections (UTIs) in patients treated by cystectomy for urinary bladder cancer.

PATIENTS AND METHODS

We attempted to contact during their follow‐up all men and women aged 30–80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. During a qualitative phase we identified hygienic measures and included them in a study‐specific questionnaire. The patients completed the questionnaire at home. Outcome variables were dichotomized and the results presented as relative risks (RR) with 95% confidence interval.

RESULTS

We received the questionnaire from 452 (92%) of 491 identified patients. The proportion of patients who had a symptomatic UTI in the previous year was 22% for orthotopic neobladder and cutaneous continent reservoir, and 23% for non‐continent urostomy diversion. The RR for a UTI was 1.1 (0.5–2.5) for ‘never washing hands’ before handling with catheters or ostomy material. Patients with diabetes mellitus had a RR of 2.1 (1.4–3.2) for having a symptomatic UTI.

CONCLUSIONS

We could not confirm lack of hygiene measures as a cause of UTI for men and women who had a cystectomy with urinary diversion. Patients with diabetes mellitus have a greater risk of contracting a UTI.     

Stones and urinary tract infections

The term infection stones refers to calculi that occur following urinary tract infections (UTIs) caused by urease-producing gram-negative organisms. They consist of magnesium ammonium phosphate, carbonate apatite and monoammonium urate. Alkaline urine is most favorable to their formation. Urinary tract obstruction, neurogenic bladder, voiding dysfunction, temporary or indwelling urinary catheters, distal renal tubular acidosis and medullary sponge kidney are considered the main risk factors for developing infection stones. Urinalysis and urine culture are essential for diagnosis. A typical finding on imaging is a moderately radiopaque, staghorn or branched stone. Curative treatment is possible only by eliminating all of the stone fragments and by eradicating UTI. A variety of operative and pharmaceutical approaches is available. Metaphylactic treatment is mandatory to prevent recurrences. The relationship between urinary stones and UTIs is well known and shows two different clinical pictures: (1) stones that develop following UTIs (infection stones) which play a key role in stone pathogenesis, and (2) stones complicated by UTIs (stones with infection) which are metabolic stones that passively trap bacteria from coexistent UTIs and may consist of calcium or non-calcium. This article presents an overview of infection stones, analyzing the epidemiology, composition, pathogenesis, diagnosis, treatment and prevention of this type of calculi.     

Patient assessment in urinary tract infections: symptoms, risk factors and antibiotic treatment options

Urinary tract infections (UTI) may present with rather distinct clinical pictures. However, being caused by invasion of billions of living organisms a UTI may progress into severe conditions leading to loss of kidney function or even death of the patient. Young urologists used to think that a UTI may be stopped at any time point by effective antibiotics. During the last decade an increasing number of signs have told us that UTIs are not what they used to be. Antibiotics have been prescribed so extensively that bacteria have developed resistance mechanisms to more and more drugs. Recently omni-resistant urinary tract pathogens were reported. The European Section for Infections in Urology (ESIU) has introduced a new concept of severity assessment of UTI. The assessment is based on three pillars; clinical presentation, patient risk factors and availability of effective antibiotics. This article presents the new concept of classification and gives practical advices on the use of antibiotics in urology.     

The changing pattern of antimicrobial resistance within 42,033 Escherichia coli isolates from nosocomial, community and urology patient-specific urinary tract infections, Dublin, 1999-2009

Study Type – Therapy (practice patterns cohort) Level of Evidence not applicable What's known on the subject? and What does the study add? Epidemiological and resistance patterns of bacterial pathogens in urinary tract infections show large inter‐regional variability, and rates of bacterial resistance are continually changing due to different regional antibiotic treatment regime. In Ireland and the UK, trimethoprim or nitrofurantoin is usually recommended for empirical treatment of uncomplicated cystitis in the community whilst parenteral cephalosporins, aminoglycosides, quinolones and co‐amoxyclav are reserved for complicated UTIs. Neither penicillins nor trimethoprim represent suitable empirical antimicrobial agents for UTI in this study population. The high rate of ciprofloxacin resistance in encountered is suggestive of an over‐reliance on this agent in this population and with resistance rates approaching 30%, empirical use of quinolones for urology patients is inadvisable. E. coli UTIs have remained extremely sensitive to nitrofurantoin across all three patient sample groups in this population and the resistance rate has not changed significantly over the eleven‐year study period.

OBJECTIVE

• ? To investigate the changing pattern of antimicrobial resistance in Escherichia coli urinary tract infection over an eleven year period, and to determine whether E. coli antibiotic resistance rates vary depending on whether the UTI represents a nosocomial, community acquired or urology patient specific infection.

PATIENT AND METHODS

• ? A retrospective analysis of the 42 033 E. coli urine isolates from the 11‐year period 1999–2009 in a single Dublin teaching hospital was performed.
• ? WHONET^TM software was used to analyse the changing pattern of sensitivity and resistance of E. coli to commonly used antibiotics over the study period.
• ? The origins of the urine samples were stratified into three groups: inpatients with nosocomial UTIs; urine originating from the emergency department and general practice (community UTIs); and UTIs in urology patients.

RESULTS

• ? Urinary tract infections in the urology patient population demonstrate higher antibiotic resistance rates than nosocomial or community UTIs.
• ? There were significant trends of increasing resistance over the 11‐year period for ampicillin, trimethoprim, gentamicin and ciprofloxacin, and significant differences in co‐amoxyclav, gentamicin, nitrofurantion and ciprofloxacin resistance rates depending on the sample origin.
• ? Ampicillin and trimethoprim were the least active agents against E. coli, with total 11‐year resistance rates of 58.3 and 33.8%, respectively.
• ? The overall gentamicin resistance rate was 3.4% and is climbing at a rate of 0.7% per year (P < 0.001). Within the urology patient population the resistance rate was 6.4%.
• ? Ciprofloxacin resistance approaches 20% in the nosocomial UTI population and approaches 30% in the urology population; however, it remains a reasonable empirical antibiotic choice in this community, with an 11‐year resistance rate of 10.6%.

CONCLUSIONS

• ? E. coli remains the commonest infecting uropathogen in the community and hospital setting with its incidence climbing from 50 to 60% of UTIs over the 11‐year period.
• ? Neither penicillins nor trimethoprim represent suitable empirical antimicrobials for UTI and ciprofloxacin resistance in this Dublin‐based study renders it unsuitable empirical therapy for nosocomial UTIs and UTIs in the urology population.
• ? The dramatic 11‐year rate increase in gentamicin resistance is of paramount concern.

     

Evidence of bladder oversensitivity in the absence of an infection in premenopausal women with a history of recurrent urinary tract infections

Study Type – Prevalence (case control) Level of Evidence 4 What's known on the subject? and What does the study add? Urinary tract infections (UTIs) have been implicated in the aetiology of interstitial cystitis/painful bladder syndrome (IC/PBS). Prior studies have described symptoms and laboratory tests suggestive of UTI at the onset of IC/PBS as well as a significant history of childhood recurrent UTIs. However, the mechanism by which recurrent UTIs contribute to the development of IC/PBS is not clear. Our study shows that women with recurrent UTI suffer from bladder oversensitivity. Our findings have useful clinical implications. Women with bladder oversensitivity complain of urinary frequency which is often misdiagnosed as an infection and treated with unnecessary antibiotics. Additionally, there are no effective therapies for bladder oversensitivity. Therefore, women with recurrent UTI should undergo prompt evaluation and treatment of episodes of infection to prevent the development of bladder oversensitivity. Our findings also provide a possible mechanism for the development of IC/PBS. Whether women with recurrent UTI are at increased risk for developing IC/PBS in the future will need to be confirmed in future studies.

OBJECTIVE

• ? To compare the mean voided volume and bladder sensation during filling cystometry in women with a history of recurrent urinary tract infection (UTI) and controls.

PATIENTS AND METHODS

• ? This was a case–control study including adult women seen in the urogynaecology clinic.
• ? The cases were 49 women with at least three documented positive urine cultures >105 colonies/mL in the previous 12 months and no active infection at the time of data collection.
• ? Controls were 53 women with stress urinary incontinence and no history of recurrent UTI or coexistent urge urinary incontinence.
• ? We compared bladder diary variables and filling cystometry data in the absence of an active infection.

RESULTS

• ? There was no significant difference in the median age, parity and body mass index of women with a history of recurrent UTI and controls.
• ? The median number of voids per day and median number of voids per litre of fluid intake was significantly greater in women with recurrent UTI than controls (12 vs 7 voids/day and 6 vs 4 voids/L, P= 0.005 and P= 0.004 respectively).
• ? The median average voided volume was significantly lower in women with recurrent UTI than controls (155 vs 195 mL, P= 0.008).
• ? On filling cystometry, median volumes of strong desire to void and maximum cystometric capacity were significantly lower in women with recurrent UTI than controls (all P < 0.05).

CONCLUSION

• ? In the absence of an infection, premenopausal women with a history of recurrent UTI have significantly greater urinary frequency, lower average voided volume and a lower threshold of bladder sensitivity than controls.

     

Prevention of recurrent bacterial cystitis by intravesical administration of hyaluronic acid: a pilot study

OBJECTIVES: To assess the effect of bladder instillations of hyaluronic acid (HA) on the rate of recurrence of urinary tract infection (UTI). PATIENTS AND METHODS: Forty women (mean age 35 years) with a history of recurrent UTI received intravesical instillations of HA (40 mg in 50 mL phosphate-buffered saline) once weekly for 4 weeks then once monthly for 4 months. The UTI status was assessed over a prospective follow-up of 12.4 months and compared with the rates of UTI before instillation, determined by a retrospective review of patient charts covering 15.8 months. RESULTS: After HA treatment no patients had a UTI during the 5-month treatment phase and 28 (70%) were recurrence-free at the end of the follow-up. The mean (sd) rate of UTI per patient-year was 4.3 (1.55) before treatment and 0.3 (0.55) afterward (P < 0.001). The median time to recurrence after HA treatment was 498 days, compared with 96 days beforehand (P < 0.001). The tolerability was excellent, as side-effects were limited to nine patients who reported mild bladder irritation; no patient interrupted the treatment. CONCLUSIONS: In this preliminary study, bladder instillations of HA had a significant effect on the rate of UTI in women with a history of recurrent UTIs. The bladder instillation of HA is an acceptable and promising therapeutic alternative in patients with recurrent UTI. Expanded placebo controlled clinical trials examining this application of HA are currently underway.     

Nitrofurantoin: the return of an old friend in the wake of growing resistance

OBJECTIVE

To re‐evaluate the first‐ and second‐line therapies for treating uncomplicated urinary tract infection (UTI), as although fluoroquinolones are commonly used for this purpose, its level of use is thought to be inappropriately excessive and will eventually have a detrimental impact; thus we hypothesise that nitrofurantoin might be the best choice for this indication, due to its low frequency of use and its high susceptibility rate in common UTI pathogens.

MATERIALS AND METHODS

We retrospectively analysed antimicrobial susceptibility patterns of urinary isolates from 2003 to 2007, taken from a community‐based institutional hospital in Brooklyn, NY, USA.

RESULTS

In all, 10 417 cultures grew Escherichia coli from 2003 to 2007. Overall, from 2003 to 2007, 95.6% of E. coli urine isolates were susceptible to nitrofurantoin, with an average 2.3% resistance rate. By contrast, E. coli uropathogens had a mean 75.6% and 75.9% susceptibility and 24.2% and 24% resistance rate to both ciprofloxacin and levofloxacin, respectively. Co‐trimoxazole (trimethoprim/sulfamethoxazole; ‘TMP/SMX’) had a mean 29% resistance rate to E. coli over the same 5‐year period.

CONCLUSIONS

We consider that nitrofurantoin is a good fluoroquinolone‐sparing alternative to co‐trimoxazole; this study shows that nitrofurantoin is bactericidal to a mean of 95% of E. coli UTIs. Nitrofurantoin also has a resistance rate of 2.3%, by contrast to the quinolones (ciprofloxacin and levofloxacin), with resistant rates of ≈24%, and Co‐trimoxazole, with a resistant rate of 29%. Nitrofurantoin is an acceptable treatment for uncomplicated UTIs and should now be considered the first‐line treatment. A reconsideration of UTI treatment guidelines might now be appropriate.     

Prophylactic antibiotics following radical cystectomy reduces urinary tract infections and readmission for sepsis from a urinary source

Introduction

Urinary tract infections (UTI) and sepsis contribute significantly to the morbidity associated with cystectomy and urinary diversion in the first 30 days. We hypothesized that continuous antibiotic prophylaxis decreased UTIs in the first 30 days following radical cystectomy.

The physiology and pharmacology of the urinary tract

The urinary bladder is a storage vessel for most of the time, when intravesical pressure remains low and the outflow resistance high. During voiding a switch occurs when intravesical pressure rises and the outflow relaxes. The control of this change of function is regulated by a complex interplay between sensations arising from the lower urinary tract (LUT), coordination of responses in the brain and sacral spinal cord and control over bladder and the outflow tract. LUT function can become disorganized and commonly shows as overactive bladder (OAB) with symptoms of urgency and frequency, with or without incontinence. Several pharmaceutical approaches to manage OAB are possible which rely predominantly on manipulating mechanisms that generate detrusor contraction, initiate sensations of bladder filling or reduce the magnitude of outflow obstruction. The introduction of successful agents requires knowledge of the mechanisms that generate contraction in LUT tissues both in the normal and overactive bladder. The upper urinary tract propels urine from the kidney to the bladder by peristalsis, a process modulated by agents such as prostaglandins, produced by the ureters. Urinary tract stones collect in the upper tract and cause considerable morbidity. They are commonly formed of Ca oxalate/phosphate or magnesium ammonium phosphate. Various endogenous and artificial agents promote or inhibit stone formation and along with various mechanical procedures are used to manipulate the formation of upper tract stones.     

Clinical features of community-acquired <Emphasis Type="Italic">Pseudomonas aeruginosa</Emphasis> urinary tract infections in children

This retrospective chart review sought to determine clinical, radiological, and gender-associated characteristics of community-acquired Pseudomonas aeruginosa (PA) urinary tract infections (UTIs) among children admitted to two medical centers. The records of 73 children with community-acquired PA UTIs were compared with records of 109 children with community-acquired UTIs caused by other pathogens. The mean age of both groups was similar. The PA UTI group included more boys. Features significantly more common in the PA UTI group were the number of patients who had undergone urinary tract surgery, patients with skeletal and/or neurological malformation, patients with >1 previous episode of UTI, patients on prophylactic antibiotic treatment on admission, and patients with pathological renal ultrasound and voiding cystourethrography (VCUG) findings. Multivariate logistic regression analysis revealed the following to be associated with PA UTI: >1 episode of UTI in the past [odds ratio (OR) = 35.5; 95% confidence interval (CI) 11.6–108.7], previous urinary tract surgery (OR = 34.1; 95% CI 7.00–166.2), and pathological VCUG results (OR = 2.62; 95% CI 0.96–7.15). In conclusion, PA UTI is associated with >1 previous UTI, urinary tract abnormalities, and past urinary tract surgery. We recommend that when UTI is suspected in children with these risk factors, a thorough radiologic investigation, including a VCUG, should be considered. Drs. Goldman and Rosenfeld-Yehoshua contributed equally to this work.     

Community-acquired enterococcal urinary tract infections

Enterococcal urinary tract infection (UTI) is usually hospital-acquired and affects individuals with predisposing conditions. The aim of this study was to evaluate the community-acquired enterococcal UTIs in otherwise well children. We reviewed all the 257 first UTI episodes in children hospitalized in a General Hospital during a 5-year period. Enterococcus faecalis was isolated in 13 episodes, accounting for 5.1% of the total UTIs. All strains were susceptible to ampicillin, vancomycin and nitrofurantoin. Imaging studies revealed major urinary tract abnormalities in 9 and parenchymal defects in 8 children. During a follow-up period from 2 to 6 years, 4 children suffered break-through infections despite antibiotic prophylaxis, 3 developed renal scarring and 4 underwent corrective surgical procedures. Children with enterococcal UTIs presented with significantly higher rates of anatomical abnormalities and worse prognosis in terms of renal scarring, recurrences and corrective surgery compared with the total cohort of children with Gram-negative UTIs. However children with enterococcal UTIs did not present with a worse prognosis when compared with a group of children with Gram-negative UTIs matched for age and degree of reflux. Enterococcal infection is not an independent risk factor for poor outcome, nevertheless positive urine culture including enterococci is highly indicative for underlying urinary tract abnormalities, recurrences, renal scarring, and need for surgical intervention.     

Management of Uncomplicated Recurrent Urinary Tract Infections

Mostly young but also postmenopausal women are often affected by recurrent urinary tract infections (rUTIs), defined as three or more symptomatic UTI episodes per year or two or more UTIs within 6 mo. Approximately 20–30% of women with a UTI have a recurrence. UTIs are associated with considerable morbidity. Treatable predisposing factors in uncomplicated rUTI are rare but have to be considered. According to the 2015 European Association of Urology guidelines, the recommendations for prophylaxis of rUTI are first, behavioral changes and second, nonantimicrobial measures. Antibiotic prophylaxis should only be considered if the former recommendations are not sufficiently effective, to avoid adverse events and the collateral damage of unnecessary long-term antibiotic use. General behavioral recommendations can lower the recurrence rate by about 30%. Of the nonantimicrobial measures, immunoprophylaxis and local estriol substitution are effective to lower the recurrence rate, especially in postmenopausal women. Cranberry products on the market are widely variable and seem to have too low a proanthocyanidin content to prevent rUTI effectively. Other promising modalities need to be tested in further controlled trials to prove their preventive benefit. For long-term antibiotic prophylaxis, oral fosfomycin, nitrofurantoin, trimethoprim, cotrimoxazole, and oral cephalosporins (especially during pregnancy) are recommended. Placebo-controlled studies show a high efficacy of long-term antibiotic prophylaxis, but this strategy does not appear to modify the natural history of rUTI, and most of the studies were performed at a time when antibiotic resistance was not an issue.Patient summaryWomen of all ages experience recurrent urinary tract infections (rUTIs) that cause considerable morbidity. Treatable predisposing factors in uncomplicated rUTI are rare but have to be considered. Guidelines for the prophylaxis of rUTI episodes recommend behavioral changes followed by nonantimicrobial measures and only then by antibiotic prophylaxis to avoid adverse events and the collateral damage of unnecessary long-term antibiotic use.     

Diagnosis of pediatric urinary tract infections

Urinary tract infection (UTI) is the second common infection in children. The diagnosis of UTI in infants and children can be difficult. Good history taking and physical examination are corner stones of good care of UTI. In addition, this article reviewed current evident on the methods of urine specimen collection and various diagnostic criteria to reach the diagnosis of UTI. Asian Guideline for UTI in children is highlighted to increase consensus of the diagnosis of UTI.     

What is the effect of circumcision on risk of urinary tract infection in boys with posterior urethral valves?

Purpose

Boys with posterior urethral valves (PUV) have increased risks of urinary tract infection (UTI) voiding dysfunction and ongoing renal damage. Circumcision has been shown epidemiologically to reduce UTIs, but no trial has yet confirmed this in PUV. Circumcision is not routinely performed in boys with PUV in our unit, but one quarter of our patients are circumcised for religious reasons. It may be hypothesized that circumcision reduces the risk of subsequent urinary tract infection in boys with PUV. This study aims to test this hypothesis by comparing the risk of UTI, and subsequent renal outcome, in PUV in uncircumcised boys with those who were circumcised.

Methods

A retrospective cross-sectional case note review of boys with PUV was performed, and the following were documented: age at presentation, method of diagnosis, method of treatment, initial renal status, and timing of treatment; use and timing of urinary tract diversion; timing of circumcision; and UTIs—date, organism, and treatment.

Results

Seventy-eight patients were identified, mean age 6.7 years (range, 1-18). These boys experienced 78 UTIs in the uncircumcised state. Subsequently, 27 were circumcised, experiencing 8 UTIs. Eighteen boys were diverted. The incidence of UTI was reduced from 0.50 ± 0.14 (mean ± SEM) UTIs annually uncircumcised to 0.09 ± 0.02 (mean ± SEM) circumcised (P < .01, Student's t test).

Conclusion

In PUV, circumcision reduces the incidence of UTI by 83%, every circumcision prevents 1 UTI on average. Early circumcision in all PUV is beneficial, but a larger randomised control trial should be considered to confirm this.     

Prophylactic single-dose prulifloxacin for catheter-associated urinary tract infection after tension-free vaginal tape procedure

The purpose of the study was to evaluate whether antibiotic prophylaxis with a single dose of prulifloxacin after tension-free vaginal tape (TVT) procedure decreases catheter-associated urinary tract infections (UTIs). Patients undergoing TVT procedure receiving a single dose of prulifloxacin (600 mg) 10 h before catheter removal (n = 54) were compared with historical controls who have had no treatment (n = 60). All patients had an indwelling urethral catheter in situ for 24 h. Urine specimens for culture were collected preoperatively, before Foley removal, and 7 days postoperatively in both groups. Main outcome measures were significant bacteriuria and symptomatic UTI at catheter removal and 1 week postoperatively. No patient had a positive urine culture in the prulifloxacin group compared with 14 (23.3%) in the control group at catheter removal (P = 0.0001). Ten out of 14 (71.4%) women with a positive catheter urine culture had a symptomatic UTI. One week after surgery no difference was found in the rate of significant bacteriuria between groups. Our data suggest that a prophylactic single dose of prulifloxacin could help to reduce the rate of symptomatic and asymptomatic UTIs after short-term urethral catheterization in women undergoing TVT procedure.