Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections.
TL;DR: The problem of antimicrobial resistance in acute uncomplicated community-acquired UTI is highlighted, focusing on TMPSMX resistance, and the few available data regarding clinical outcomes associated with in vitro resistance are summarized.
Abstract: The authors highlight the problem of antimicrobial resistance in acute uncomplicated community-acquired urinary tract infection (UTI), summarize the few available data on clinical outcomes associat...
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TL;DR: Underappreciated features include the wide variety of extraintestinal infections E. coli can cause, the high incidence and associated morbidity, mortality, and costs of these diverse clinical syndromes, and increasing antimicrobial resistance.
701 citations
TL;DR: Decisions regarding antibiotic agents should be individualized based on patients' allergies, tolerability, community resistance rates, cost, and availability.
Abstract: Clinical presentation helps differentiate between upper and lower urinary tract infections (UTIs). UTIs are classified as either complicated or uncomplicated. A complicated UTI is associated with an underlying condition that increases the risk of failing therapy. Primary laboratory tests for UTIs consist of urinalysis and urine culture. The most common pathogen for uncomplicated cystitis and pyelonephritis is Escherichia coli. Nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are first-line therapies for acute uncomplicated cystitis. Decisions regarding antibiotic agents should be individualized based on patients' allergies, tolerability, community resistance rates, cost, and availability.
693 citations
TL;DR: Nitrofurantoin, trimethoprim–sulfamethoxazole, fosfomycin, and pivmecillinam are considered first-line agents for cystitis, but fluoroquinolones should not be routine first- line choices for cysts.
Abstract: Nitrofurantoin, trimethoprim–sulfamethoxazole, fosfomycin, and pivmecillinam are considered first-line agents for cystitis. Fluoroquinolones should not be routine first-line choices for cystitis, although they are first-line empirical therapy for pyelonephritis.
613 citations
TL;DR: In this paper, the CTX-M-15 extended-spectrum beta-lactamase-associated Escherichia coli sequence type ST131 (O25:H4) has emerged internationally as a multidrug-resistant pathogen but has received little attention in the United States.
Abstract: Background Escherichia coli sequence type ST131 (O25:H4), associated with the CTX-M-15 extended-spectrum beta-lactamase, has emerged internationally as a multidrug-resistant pathogen but has received little attention in the United States. Methods From the SENTRY and Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) surveillance programs, 127 E. coli clinical isolates from hospitalized patients across the United States in 2007, stratified by extended-spectrum cephalosporin and fluoroquinolone phenotype and bla(CTX-M-15) genotype, were assessed for phylogenetic group, ST131 status, susceptibility profile, virulence genotype, gyrA and parC sequence, and pulsed-field gel electrophoresis profile. Results The 54 identified ST131 isolates (all fluoroquinolone resistant) accounted for an estimated 17% of the source populations, including 67%-69% of isolates resistant to extended-spectrum cephalosporins or fluoroquinolones, 55% of those resistant to both fluoroquinolones and trimethoprim-sulfamethoxazole, and 52% of multidrug-resistant isolates. Their distinctive virulence profiles were more extensive compared with other antimicrobial-resistant isolates but similarly extensive compared with antimicrobial-susceptible isolates. Pulsed-field profiling suggested ongoing dissemination among locales, with concentration of bla(CTX-M-15) within specific ST131 lineages. A historical ST131 isolate lacked the 2007 ST131 isolates' conserved fluoroquinolone resistance-associated single-nucleotide polymorphisms in gyrA and parC. Conclusions A single E. coli clonal group, ST131, probably caused the most significantly antimicrobial-resistant E. coli infections in the United States in 2007, thereby constituting an important new public health threat. Enhanced virulence and/or antimicrobial resistance compared with other E. coli, plus ongoing dissemination among locales, may underlie ST131's success. Urgent investigation of the sources and transmission pathways of ST131 is needed to inform mitigation efforts.
516 citations
Cites background from "Increasing antimicrobial resistance..."
...Because fluoroquinolones are increasingly relied on for empirical therapy of urinary tract infections [2, 27], fluoroquinolone resistance in E....
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TL;DR: Clinical microbiology laboratories need to communicate results of antibacterial susceptibility testing to prescribers and it is mandatory that breakpoints be reviewed when antibacterial agents have been in clinical use for some time, particularly if mechanisms of bacterial resistance to the drug have been described.
Abstract: Clinical microbiology laboratories need to communicate results of antibacterial susceptibility testing to prescribers. Sophisticated prescribers who are knowledgeable of the pharmacokinetics and pharmacodynamics of antibacterials may desire no more information than the MIC of the drug in question. However, most prescribers require interpretation of antibacterial susceptibility testing results. Breakpoints can assist in determining if an antibacterial is potentially useful in the treatment of a bacterial infection. Breakpoints should be set prior to an antibacterial being used clinically. Breakpoint setting requires integration of knowledge of the wild-type distribution of MICs, assessment of the pharmacokinetics/pharmacodynamics of the antibacterial, and study of the clinical outcome of infections when the antibacterial is used. It is mandatory that breakpoints be reviewed when antibacterial agents have been in clinical use for some time, particularly if mechanisms of bacterial resistance to the drug have been described. In general, greater amounts of information on the pharmacokinetics and pharmacodynamics of an antibacterial are available when breakpoints need to be revised. However, the opportunity to conduct randomized clinical studies of an antibacterial declines after the drug has been released commercially. Well-designed observational clinical studies are therefore necessary in order to provide reliable data to inform those reevaluating breakpoints. Breakpoint-setting organizations may also play a role in developing phenotypic tests for detection of resistance mechanisms, as this information may complement use of the breakpoint in some circumstances.
473 citations
Cites background from "Increasing antimicrobial resistance..."
...Those studies that do examine this have found that the current CLSI breakpoints for trimethoprim-sulfamethoxazole, which are based on systemic PK, effectively separate clinical and microbiological successes and failures or relapse (20, 77, 113) and that failure rates with strains defined as resistant using systemic PK are the same as those seen with placebo (100)....
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Book•
01 Mar 1989
TL;DR: This updated and expanded edition now offers 297 chapters that cover the basic principles of diagnosis and management, major clinical syndromes, all important pathogenic microbes and the diseases they cause, plus a number of specialised topics useful to the practitioner.
Abstract: This updated and expanded edition now offers 297 chapters that cover the basic principles of diagnosis and management, major clinical syndromes, all important pathogenic microbes and the diseases they cause, plus a number of specialised topics useful to the practitioner. It contains 24 totally-new chapters, offers a whole section on AIDS with seven chapters and a chapter "Microsporidium Disease", which deals with a new disease just discovered because of AIDS. The text is designed for clinical pathologists, microbiologists, virologists, medical scientists, mycologists, allergists, general practitioners and lecturers of medicine.
13,514 citations
TL;DR: This guideline is to provide assistance to clinicians in the diagnosis and treatment of two specific types of urinary tract infections (UTIs): uncomplicated, acute, symptomatic bacterial cystitis and acute pyelonephritis in women.
Abstract: This is part of the series of practice guidelines commissioned by the Infectious Diseases Society of America (IDSA) through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians in the diagnosis and treatment of two specific types of urinary tract infections (UTIs): uncomplicated, acute, symptomatic bacterial cystitis and acute pyelonephritis in women. The guideline does not contain recommendations for asymptomatic bacteriuria, complicated UTIs, Foley catheter-associated infections, UTIs in men or children, or prostatitis. The targeted providers are internists and family practitioners. The targeted groups are immunocompetent women. Criteria are specified for determining whether the inpatient or outpatient setting is appropriate for treatment. Differences from other guidelines written on this topic include use of laboratory criteria for diagnosis and approach to antimicrobial therapy. Panel members represented experts in adult infectious diseases and urology. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendation and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council, the sponsor and supporter of the guideline. The American Urologic Association and the European Society of Clinical Microbiology and Infectious Diseases have endorsed it. An executive summary and tables highlight the major recommendations. Performance measures are described to aid in monitoring compliance with the guideline. The guideline will be listed on the IDSA home page at http://www.idsociety.org It will be evaluated for updating in 2 years.
1,154 citations
"Increasing antimicrobial resistance..." refers background in this paper
...However, the cure rates would be lower than those expected with a 3-day regimen of a fluoroquinolone among fluoroquinolonesusceptible cases of cystitis (1, 9)....
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...In a setting with no TMP–SMX resistance, bacterial eradication and clinical cure rates with a 3-day course of TMP–SMX are expected to approach 93% and 95%, respectively (1, 9)....
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...Uncomplicated community-acquired urinary tract infections (UTIs) are among the most common infections in women, accounting for more than 8 million office visits per year in the United States as well as significant morbidity and health care costs (1)....
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...However, because of increasing in vitro resistance, as well as lower efficacy and more adverse effects than are seen with other available UTI antimicrobial agents, the b-lactams in general are no longer recommended for empirical UTI therapy (1)....
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...In certain settings, such as during pregnancy or when enterococci are suspected, ampicillin or amoxicillin may still be an appropriate choice for acute UTI (1)....
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TL;DR: This review will highlight recent advances in the treatment of patients in each of these categories, emphasizing cost-effective strategies that may be particularly important in the coming era.
Abstract: Urinary tract infections account for more than 7 million visits to physicians' offices and necessitate or complicate well over 1 million hospital admissions in the United States annually1,2. It is helpful to categorize adult patients with urinary infection into five groups: young women with acute uncomplicated cystitis, young women with recurrent cystitis, young women with acute uncomplicated pyelonephritis, all adults with complicated urinary infection, and all adults with asymptomatic bacteriuria. This review will highlight recent advances in the treatment of patients in each of these categories, emphasizing cost-effective strategies that may be particularly important in the coming era . . .
834 citations
"Increasing antimicrobial resistance..." refers background in this paper
...Although less well studied, the spectrum of agents causing uncomplicated pyelonephritis is similar to that causing acute cystitis (10, 11)....
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TL;DR: The optimal treatment duration for acute uncomplicated pyelonephritis has not been established, but 10- to 14-day regimens are recommended, and patients prefer to use antimicrobials that attain high renal tissue levels, such as a fluoroquinolone, trimethoprim-sulfamethoxazole, or an aminoglycoside for pyel onephritis.
716 citations
"Increasing antimicrobial resistance..." refers background in this paper
...The rationale for this approach is based on the narrow and predictable spectrum of etiologic agents that cause acute cystitis and their susceptibility patterns (2)....
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...Most gram-negative uropathogens are still susceptible to the combination of amoxicillin– clavulanate, but the expense and gastrointestinal side effects of this drug make it a less desirable choice for empirical treatment of uncomplicated UTI (2)....
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...negative rods, such as Klebsiella species and Proteus mirabilis, account for the remaining 5% to 10% (2, 9)....
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TL;DR: While the prevalence of resistance to trimethoprim-sulfamethoxazole, ampicillin, and cephalothin increased significantly among uropathogens causing acute cystitis, resistance to nitrofurantoin and ciprofloxacin remained infrequent.
Abstract: ContextGuidelines for the management of acute uncomplicated
cystitis in women that recommend empirical therapy in
properly selected patients rely on the predictability of the agents
causing cystitis and knowledge of their antimicrobial susceptibility
patterns.ObjectiveTo assess the prevalence of and trends in antimicrobial
resistance among uropathogens causing well-defined episodes of acute
uncomplicated cystitis in a large population of women.DesignCross-sectional survey of antimicrobial susceptibilities of
urine isolates collected during a 5-year period (January, May, and
September 1992-1996).SettingHealth maintenance organization.PatientsWomen aged 18 to 50 years with an outpatient diagnosis of
acute cystitis.Main Outcome MeasuresProportion of uropathogens demonstrating in
vitro resistance to selected antimicrobials; trends in resistance over
the 5-year study period.ResultsEscherichia coli and Staphylococcus
saprophyticus were the most common uropathogens, accounting for
90% of the 4342 urine isolates studied. The prevalence of resistance
among E coli and all isolates combined was more than 20% for
ampicillin, cephalothin, and sulfamethoxazole in each year studied. The
prevalence of resistance to trimethoprim and
trimethoprim-sulfamethoxazole rose from more than 9% in 1992 to more
than 18% in 1996 among E coli, and from 8% to 16% among all
isolates combined. There was a statistically significant increasing
linear trend in the prevalence of resistance from 1992 to 1996
amongE coli and all isolates combined to ampicillin
(P<.002), and to cephalothin, trimethoprim, and
trimethoprim-sulfamethoxazole (P<.001). In contrast, the
prevalence of resistance to nitrofurantoin, gentamicin, and
ciprofloxacin hydrochloride was 0% to 2% among E coli and
less than 10% among all isolates combined, and did not change
significantly during the 5-year period.ConclusionsWhile the prevalence of resistance to
trimethoprim-sulfamethoxazole, ampicillin, and cephalothin increased
significantly among uropathogens causing acute cystitis, resistance to
nitrofurantoin and ciprofloxacin remained infrequent. These in vitro
susceptibility patterns should be considered along with other factors,
such as efficacy, cost, and cost-effectiveness in selecting empirical
therapy for acute uncomplicated cystitis in women.
624 citations
"Increasing antimicrobial resistance..." refers background in this paper
...The fluoroquinolones have had consistently high activity against essentially all gram-negative uropathogens seen in women with uncomplicated community-acquired UTI but are active against only 60% to 70% of enterococci, depending on the study (3, 6)....
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...coli was 9% in 1992 but had increased to 18% by 1996, the last year of the study (3)....
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...coli gram-negative rods (3, 6) and inactive against Proteus and Pseudomonas species....
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...coli and other uropathogens to b-lactams, such as ampicillin, and the first-generation cephalosporins has continued to increase in the past decade and now approaches 40% in most studies (3, 6)....
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