Antimicrobial resistance of clinical Enterobacterales isolates from urine samples, Germany, 2016 to 2021.

IntroductionEmpirical therapy for the treatment of urinary tract infections should be tailored to the current distribution and susceptibility of potential pathogens to ensure optimal treatment.AimWe aimed to provide an up-to-date overview of the epidemiology and susceptibility of Enterobacterales isolated from urine in Germany.MethodsWe retrospectively analysed antimicrobial susceptibility data from 201,152 urine specimens collected between January 2016 and June 2021 from in- and outpatients. Multiple logistic regression analysis was used to evaluate the association between year of investigation and antibiotic resistance, adjusted for age, sex and species subgroup. Subgroup analyses were performed for midstream urine samples obtained from (i) female outpatients aged 15 to 50 years, (ii) female outpatients older than 50 years and (iii) male outpatients.ResultsResistance rates of less than 20% were observed for nitroxoline (3.9%), fosfomycin (4.6%), nitrofurantoin (11.7%), cefuroxime (13.5%) and ciprofloxacin (14.2%). Resistance to trimethoprim/sulfamethoxazole (SXT) (20.1%), amoxicillin-clavulanic acid (20.5%), trimethoprim (24.2%), pivmecillinam (29.9%) and ampicillin (53.7%) was considerably higher. In the subgroup of outpatient women aged 15-50 years, resistance rates were generally lower. Resistance rates of all antibiotics decreased from 2016 to 2021. Multiple logistic regression revealed the lowest adjusted odds ratio (ORadj) of 0.838 (95% confidence interval (CI): 0.819-0.858; p < 0.001) for pivmecillinam and the highest ORadj of 0.989 (95% CI: 0.972-1.007; p = 0.226) for nitrofurantoin.ConclusionsResistance has generally decreased over the past years, independent of sex, age and causative pathogen. Our data provide an important basis for empirical antibiotic recommendations in various settings and patient collectives.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1.

OBJECTIVES: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, -EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention.

BACKGROUND: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

The revival of old antibiotics for treatment of uncomplicated urinary tract infections in the era of antibiotic stewardship.

PURPOSE OF REVIEW: In the era of increasing antibiotic resistance worldwide, this review highlights the advantages of revival of old antibiotics for treatment of uncomplicated urinary tract infections (uUTIs). RECENT FINDINGS: Recent studies have shown that these four oral old antibiotics, fosfomycin trometamol, nitrofurantoin, nitroxoline and pivmecillinam, show no increasing antibiotic resistance against uropathogens causing uUTI, are still effective for the treatment of uUTI and exhibit only minimal or no collateral damage as compared with fluoroquinolones or third-generation cephalosporines. SUMMARY: According to the principles of antibiotic stewardship, the prudent use of antibiotics is needed. Therefore, recent international and national guidelines already favour these old oral antibiotics as first-choice treatment of uUTI. Unfortunately, implementation of these guidelines is still suboptimal.

The Diagnosis, Treatment, and Prevention of Recurrent Urinary Tract Infection.

BACKGROUND: Urinary tract infection has a one-year prevalence of 11% in women and ranges among the most common reasons for consulting a primary care physician and for receiving a prescription for antibiotics. In the case of recurrent urinary tract infection (rUTI), there are questions about the further work-up, treatment, and preventive measures. METHODS: The systematic literature search performed for the update of the German clinical practice guideline on uncomplicated urinary tract infection (043-044) (up to February 2022) was supplemented with a selective search for clinical trials (up to August 2023). RESULTS: Urine culture and ultrasonography are reasonable steps in the diagnostic evaluation of rUTI. Further invasive testing is suggested for men but is not routinely indicated for women. Antibiotics are among the most effective preventive measures (risk ratio [RR] 0.15, 95% confidence interval [0.1; 0.3]) but carry a high risk of side effects. Non-antibiotic preparations such as cranberry juice (RR 0.74 [0.5; 0.99]), mannose (RR 0.23 [0.14; 0.37]), and vaginal estrogen (RR, 0.42 [0.30; 0.59]) can also reduce the infection rate, with a low risk of side effects. Increased daily fluid intake has been shown to lower infection rates in the short term (odds ratio [OR] 0.13 [0.07; 0.25]); the use of hygienically advisable wiping techniques after passing stool or urine has been little studied but can be implemented with no risk. CONCLUSION: rUTI poses a challenge for the treating physician. The measures to be taken must be considered on an individual basis. Vulnerable groups, such as older patients, need special attention.

Perceived risks of adverse effects and influenza vaccination: a survey of hospital employees.

BACKGROUND: Many hospital employees shun influenza immunization because they want to avoid adverse reactions. We surveyed hospital employees to elucidate whether the conception of the adverse effects of vaccination stems from correct or misperceived incidence rates of vaccine adverse effects. METHODS: We used an anonymous self-administered paper questionnaire at a tertiary-care university hospital in Germany, in 2006. Multiple-choice questions probed respondents' knowledge about influenza, influenza vaccine and about rates of 12 possible vaccine adverse effects. We correlated overestimation of each adverse effect with failure to obtain vaccination in 2005-06, stratified by professional group. RESULTS: The overall response rate was 34% (652/1898). Of the 304 respondents unvaccinated in 2005-06, 127 (42%) attributed their vaccination status mainly to concerns about adverse effects. Among physicians, failure to obtain influenza vaccination was associated with the overestimation of both non-severe and severe adverse effects. Non-vaccinated nurses were significantly more likely than the vaccinated nurses to overestimate the rates of five of six non-severe adverse effects, but differed significantly in rates of overestimation of merely one of the six severe adverse effects. Overestimation of vaccine-caused absenteeism from work was negatively associated with vaccination rates among all professionals. CONCLUSIONS: Overestimation of the actual low rates of influenza vaccine adverse effects was associated with non-receipt of the vaccine among hospital employees. Due to our finding of different misconceptions about adverse effects, educational and promotional programmes should be targeted differentially for nurses and physicians.

[HIV and AIDS patients in the ICU]. / HIV- und AIDS-Patienten auf der Intensivstation.

The number of HIV-infected patients in Germany has increased steadily over time. This is due to the positive development of decreasing death rates and a nearly stable rate of new infections. This development is based on the improved prognosis for HIV/AIDS patients due to the introduction of highly active antiretroviral therapy (HAART) in 1996. Considering this, a new look at the HIV patient as a potential ICU candidate is necessary. The most common referral for ICU therapy is respiratory failure, followed by neurological disorders. In rare cases, HAART-induced side-effects require therapy in the ICU. Very few clinical trials directly compare the outcome of HIV-positive and HIV-negative patients, and most of these data were collected in the pre-HAART era. The ICU outcome does not correlate with HIV-genuine parameters, such as the CD4 cell counts. Thus, a HIV patient can benefit from ICU treatment. Regarding HAART management, open questions still exist especially considering the mechanically ventilated patient. Actually only AZT (Retrovir®) is available as an i.v. formulation. Other antiretroviral medication can only be administered after grinding the tablets. The consequenses of the altered galenic composition with regard to efficacy and development of resistance has not been sufficiently studied. This also applies to risks and benefits of interrupted therapy versus a possibly inappropriate application of HAART. In this survey we also describe possible interactions between HAART and sedative/antiepileptic/tuberculostatic etc. medication. Finally special aspects of HIV exposure in the health care setting are discussed, including essential immediate measures after an injury. Current recommendations for post-exposure prophylaxis are given.