Appropriateness of Antibiotic Prescriptions for Urinary Tract Infections.

INTRODUCTION: Urinary tract infections (UTI) are a common indication for antibiotic use in the emergency department (ED). With antibiotic resistance on the rise, it is essential that antibiotics be prescribed appropriately for UTIs. Our objective was to evaluate the appropriateness of antibiotic prescriptions by ED providers for uncomplicated cystitis and pyelonephritis. METHODS: We conducted a retrospective study of females ages 2-50 years seen in an academic ED from January 2017 to April 2018 diagnosed with UTI. We assessed the appropriateness of discharge antibiotic prescriptions, as determined by adherence to clinical practice guidelines, best evidence for the particular indication (cystitis vs pyelonephritis for children and adults), and the local antibiogram. RESULTS: A total of 421 patients were included in this study. Of these, 60 children and 198 adults were diagnosed with cystitis, and 47 children and 116 adults were diagnosed with pyelonephritis. Treatment in the absence of true infection was common, with culture-confirmed UTI occurring in only 17/50 (34%) of children and 60/129 (47%) of adults diagnosed with cystitis, and 23/40 (58%) of children and 58/87 (67%) of adults diagnosed with pyelonephritis, among patients who had urine cultures. The type of antibiotic prescribed was appropriate in 53/60 (88%) of children and 135/198 (68%) of adults with cystitis, and 38/47 (81%) of children and 53/116 (46%) of adults with pyelonephritis. The most common inappropriate antibiotic types were beta-lactams in adults (n = 92), nitrofurantoin for pyelonephritis (n = 16), and amoxicillin (n = 15). Dosing and duration errors were also common, occurring in 122/279 (44%) of prescriptions of an appropriate antibiotic type. The frequency of errors in the type of antibiotic prescribed was similar among provider types (attending physician, resident physician, and advanced practice clinician; p = 0.926). CONCLUSION: This study reveals room for improvement in antibiotic prescription practices across provider cohorts in the ED for the management of uncomplicated cystitis and pyelonephritis in females.

Hemorrhagic Cystitis: Treatment With Hyperbaric Oxygen Therapy in Patients With Acute Lymphoblastic Leukemia.

BACKGROUND: Hyperbaric oxygen therapy is a rare treatment modality for hemorrhagic cystitis (HC) following BK virus reactivation in the immunosuppressed population. Clinicians need to be aware of the etiology, preventive measures, complications, and various management techniques in HC while treating patients undergoing bone marrow transplantation. OBJECTIVES: This study details the pathologic progression of HC in a patient with acute lymphoblastic leukemia harboring BK virus after cytotoxic induction chemotherapy and haploidentical marrow transplantation. METHODS: A search of PubMed for literature published from 1973-2018 was conducted using keywords. FINDINGS: Hyperbaric oxygen therapy in chemotherapy-induced and BK virus-associated HC is a viable management option in parallel with tapering of immunosuppressives, bladder irrigation, and IV resuscitation within the post-transplantation acute lymphoblastic leukemia population.

[Comparative effectivenesss of standard antibiotic therapy and Canephron N asymptomatic bacteriuria in pregnant women].

Current international and Russian clinical guidelines recommend treating asymptomatic bacteriuria in pregnancy to prevent acute gestational pyelonephritis. At the same time, the growing resistance of uropathogens and the risks associated with antibiotic therapy in pregnancy dictate the need to limit the use of antibiotics and seek alternative approaches to antibacterial therapy. MATERIALS AND METHODS: A retrospective analysis was performed on 60 pregnant women who received either a standard antibiotic regimen (n=32) or the herbal preparation Canephron N (n=28). The primary outcomes were the incidence of symptomatic infections (cystitis or pyelonephritis), premature birth and low birth weight delivery, and incidence of persistent/recurrent bacteriuria. RESULTS: In the group of antibiotic therapy, one patient developed cystitis and three had pyelonephritis; in the Canephron N group, cystitis occurred in one patient, no pyelonephritis cases were observed. Among the whole study cohort (n=60), the incidence of symptomatic infections and pyelonephritis was 8.3 and 5.0%, respectively. The incidence of symptomatic infections (cystitis, pyelonephritis) did not differ statistically significantly between the study groups (p=0.2157). There were three and one premature births in the group of antibiotic therapy and the Canephron N group, respectively (p=0,373), and two low birth weight deliveries in each group (p=0.891). Recurrent bacteriuria was registered in 17 patients from the group of antibiotic therapy and in three in the Canephron N group (p=0.0006). CONCLUSIONS: The management of asymptomatic bacteriuria in pregnancy using Canephron N is not inferior to standard antibiotic therapy regarding the incidence of symptomatic infection, premature birth, and low birth weight delivery. Persistent/recurrent bacteriuria was more common in women receiving the antibiotic therapy.

A contemporary review about the management of radiation-induced hemorrhagic cystitis.

PURPOSE OF REVIEW: There are various specific therapeutic intervention available to treat hemorrhagic cystitis, once emergency treatment has been carried out. The lack of prospective studies, because of the relative rarity of this condition, makes it difficult to hierarchize the therapeutic sequence. The present review presents and summarizes the literature published on radiation-induced hemorrhagic cystitis from April 2015, date of a precedent exhaustive review, to March 2018. RECENT FINDINGS: During our period of interest, 13 clinical studies and two new clinical trials protocols were published. Most of the clinical studies were retrospective and presented data about hyperbaric oxygen (HBO) therapy, comforting its place as a well tolerated and effective first-line treatment. Other studies reported the outcomes of treatments with alum, formalin, silver nitrate, fulguration with laser or definitive surgery. SUMMARY: Although authors seem to agree that formalin and surgery have their role as effective but potentially morbid last-line treatments, there is no consensus on primary approach to management of radiation-induced hemorrhagic cystitis beyond symptomatic measures. Several treatments have proven excellent response rates and few side effects. The results of on-going prospective studies on mesenchymal stromal cells or tacrolimus instillations are awaited, but the main discriminating factor to choose between treatments remains local availability.

Inappropriate Empirical Treatment of Uncomplicated Cystitis in Thai Women: Lessons Learned.

A prospective study conducted in a Thai general practice clinic demonstrated a high prevalence (91.3%) of inappropriate empirical antibiotic use in women with uncomplicated cystitis and 42.6% Escherichia coli fluoroquinolone resistance. An annual update of antimicrobial resistance surveillance data of uropathogens may permit targeted treatment of patients in hospital care.

Feasibility study of toxicity outcomes using GEC-ESTRO contouring guidelines on CT based instead of MRI-based planning in locally advanced cervical cancer patients.

PURPOSE: To report late rectal and bladder toxicity outcomes of a CT-based image-guided brachytherapy (IGBT) technique for treatment of cervical cancer. METHODS AND MATERIALS: Between 2008 and 2014, 95 women with International Federation of Gynecology and Obstetrics stage IB to IVA cervical carcinoma treated with definitive concurrent cisplatin-based chemotherapy and external beam radiation therapy 50.4 Gy in 28 fractions followed by planned prescription dose of 7 Gy × 4 fractions of high-dose-rate IGBT was retrospectively reviewed. At each implantation, all patients had a urinary catheter in situ and received bowel enema before undergoing planning CT simulation. A high-risk clinical target volume (HRCTV) as per GEC-ESTRO guidelines and the entire cervix, rectum, and bladder was contoured on the simulation CT according to Radiation Therapy Oncology Group Gynaecology Contouring Atlas. Reported doses to HRCTV and organs at risk were recorded. Toxicities were recorded using National Cancer Institute Common Terminology Criteria for Adverse Events version 3. RESULTS: The median followup time was 29 months. The mean HRCTV equivalent dose in 2 Gy fractions (EQD2) of external beam radiation therapy combined with brachytherapy was 80 Gy (standard deviation [SD], 11), and the rectal doses to 2 cm3 (D2cc) EQD2 and bladder D2cc EQD2 were 74 Gy (SD, 6) and 79 Gy (SD, 15), respectively. Twenty-two patients (23%) had grade 2 proctitis and 10 patients (11%) had grade 3 proctitis. Four patients (4%) had grade 2 cystitis and two patients (2%) had grade 3 cystitis. No patients had ≥ grade 4 toxicity. CONCLUSIONS: Despite CT-based brachytherapy planning, reported organ at risk toxicity was still significant compared with reported MRI-based planning series. Coimplementation of interstitial IGBT using the European Study on MRI-guided Brachytherapy in Locally Advanced Cervical Cancer (EMBRACE) protocol or using intensity-modulated radiation therapy during the external beam phase treatment might help to limit these late toxicities.

[Diagnosis and treatment of cystitis: more questions than answers?]

INTRODUCTION: Despite the prevalence of acute cystitis, there are still many unsolved problems of diagnosis and treatment of this disease. MATERIAL AND METHODS: To determine the nosological structure of dysuria, 126 female patients who sought medical attention for frequent painful urination were examined. To determine the incidence of outpatient visits to an urologist for patients with cystitis, medical records of 6753 patients of municipal outpatient clinic were analyzed. The results of treating cystitis in 85 patients also were evaluated. RESULTS: Among 126 patients with dysuria, 31 (24.6%), 42 (33.3%) and 47 (37.3%) patients had acute uncomplicated cystitis, recurrent (chronic) cystitis without the complicating factors and recurrent (chronic) cystitis with complicating factors, respectively. Three (2.4%), 2 (1.6%) and 1 (0.8%) patients had trichomoniasis, urogenital herpes and tuberculosis, respectively. As a result of 6753 visits to the urologist, inflammatory diseases of the genitourinary system were detected in 3194 (47.3%) patients, of which 64.7%, 19.6%, 5.3% and 2.7% had chronic pyelonephritis, chronic cystitis, chronic prostatitis and acute cystitis, respectively. Selecting the optimal drugs increases the treatment effectiveness of acute uncomplicated and chronic cystitis by 6% and 17%, respectively. CONCLUSIONS: Most of clinical guidelines and scientific publications aimed at acute uncomplicated cystitis, while the proportion of the disease does not exceed 26% among the patients presenting with dysuria, and comprise only 2.7% among outpatient urologist visits for infectious and inflammatory diseases of the urogenital tract. Selecting the optimal drugs increases the treatment effectiveness of acute uncomplicated and chronic cystitis by 6% and 17%, respectively.

A Practical Approach to the Management of Radiation-Induced Hemorrhagic Cystitis.

Radiation-induced hemorrhagic cystitis (HC) is a complication of pelvic radiotherapy, mainly for prostate and uterine cancers. In the acute phase, patients feel urinary urgency and bladder pain. This phase is reversible after radiotherapy. In the chronic stage, an irritative syndrome is coupled with hematuria during the 2-10 years following radiotherapy. Cystoscopy shows white and frosted mucosa with telangiectasia. The incidence is estimated at 5 % or less. It is suggested that the radiation oncologist reviews the dosimetry plan to validate that the lesions coincide with significant radiation exposure confirming diagnosis of radiation-induced HC. The treatment for HC is first symptomatic, with bladder lavage, clot evacuation, coagulation via cystoscopy and blood transfusions if necessary. Subsequently, hyaluronic acid bladder instillation can be done with little toxicity. Hyperbaric oxygen therapy delivers pure oxygen to patients in a pressurized cabin, promoting angio-neogenesis and lowering hypoxia to the irradiated tissues. The clinical response rate is estimated to be around 80 %. Nevertheless, this approach is limited by the low availability, and length of treatment. While surgery remains an effective treatment for HC, it is the last option because of the high morbidity and mortality risks. Prospective studies need to be conducted to identify and evaluate new interventions, particularly for HC.

Hyperbaric oxygen therapy for chronic radiation-induced tissue injuries: Australasia's largest study.

AIM: Chronic radiation injuries, although uncommon, are associated with poor quality of life in oncology patients. The present study assesses the efficacy and safety of hyperbaric oxygen therapy in the management of chronic radiation-induced tissue injuries. METHODS: A retrospective analysis was performed in 276 consecutive patients treated with hyperbaric oxygen therapy for chronic radiation-induced tissue injuries at the Hyperbaric Medicine Unit, Townsville, Queensland, between March 1995 and March 2008. Of these patients, 189 (68%) had complete follow-up data and were assessed. RESULTS: A total of 265 events of chronic radiation tissue injury were experienced by the 189 patients treated with hyperbaric oxygen therapy. Osteoradionecrosis prophylaxis due to radiation-induced dental disease had an overall response rate of 96% (P=0.00003; Wilcoxon matched-pairs signed-rank test). The overall response rates for established osteoradionecrosis of mandible, soft tissue necrosis of head and neck, and xerostomia were 86% (P=0.00001), 85% (P=0.002) and 64% (P=0.0001), respectively. The overall response rates for soft tissue necrosis at other sites, chronic radiation proctitis and hemorrhagic cystitis were 84% (P=0.03), 95% (P=0.0001) and 85% (P=0.03), respectively. The total complication rate after hyperbaric oxygen therapy was 15.9%, comprising reversible ear barotrauma (10.6%), reversible ocular barotrauma (4.2%), dental complications (0.5%) and myocardial infarction (0.5%). CONCLUSION: Our study demonstrates that hyperbaric oxygen therapy can be effectively used in a variety of chronic radiation-induced tissue injuries; its favorable risk profile suggests it should be considered for patients with radiation-induced tissue injuries.

Escherichia coli sequence type 131: epidemiology and challenges in treatment.

Escherichia coli ST131 has emerged as a global epidemic, multidrug-resistant clone of E. coli causing extra-intestinal infections. It is now highly prevalent among fluoroquinolone-resistant and CTX-M ESBL-producing E. coli isolates worldwide. Humans are likely the primary reservoir of ST131. Factors associated with its acquisition include residence in long-term care facilities and recent receipt of antimicrobial agents. E. coli ST131 causes a wide array of infections ranging from cystitis to life-threatening sepsis. Fluoroquinolones and trimethoprim-sulfamethoxazole are no longer adequate options for empiric therapy when E. coli ST131 is suspected from risk factors and local epidemiology. Expanded-spectrum cephalosporins, piperacillin-tazobactam and carbapenems are options to treat serious non-ESBL-producing E. coli ST131 infections, while carbapenems are indicated for ESBL-producing infections. There is a growing interest in reevaluating oral agents including fosfomycin and pivmecillinam for less serious infections such as uncomplicated cystitis.

Antibiotic treatment of acute uncomplicated cystitis based on rapid urine test and local epidemiology: lessons from a primary care series.

BACKGROUND: Acute uncomplicated cystitis (AUC) is an ideal target of optimization for antibiotic therapy in primary care. Because surveillance networks on urinary tract infections (UTI) mix complicated and uncomplicated UTI, reliable epidemiological data on AUC lack. Whether the antibiotic choice should be guided by a rapid urine test (RUT) for leukocytes and nitrites has not been extensively studied in daily practice. The aim of this primary care study was to investigate local epidemiology and RUT-daily use to determine the optimal strategy. METHODS: General practitioners included 18-65 years women with symptoms of AUC, performed a RUT and sent urines for analysis at a central laboratory. Different treatment strategies were simulated based on RUT and resistance results. RESULTS: Among 347 enrolled patients, 78% had a positive urine culture. Escherichia coli predominated (71%) with high rates of susceptibility to nitrofurantoin (100%), fosfomycin (99%), ofloxacin (97%), and even pivmecillinam (87%) and trimethoprim-sulfamethoxazole (87%). Modelization showed that the systematic use of RUT would reduce by 10% the number of patients treated. Fosfomycin for patients with positive RUT offered a 90% overall bacterial coverage, compared to 98% for nitrofurantoin. 95% for ofloxacin, 86% for trimethoprim-sulfamethoxazole and 78% for pivmecillinam. CONCLUSION: Local epidemiology surveillance data not biased by complicated UTI demonstrates that the worldwide increase in antibiotic resistance has not affected AUC yet. Fosfomycin first line in all patients with positive RUT seems the best treatment strategy for AUC, combining good bacterial coverage with expected low toxicity and limited effect on fecal flora. TRIAL REGISTRATION: The current study was registered at clinicaltrials.gov (NCT00958295).

Cranberry and recurrent cystitis: more than marketing?

Epidemiologic studies indicate that millions of people suffer from recurrent cystitis, a pathology requiring antibiotic prophylaxis and entailing high social costs. Cranberry is a traditional folk remedy for cystitis and, which, in the form of a variety of products and formulations has over several decades undergone extensive evaluation for the management of urinary tract infections (UTI). The aim of this retrospective study is to summarize and review the most relevant and recent preclinical and clinical studies on cranberries for the treatment of UTIs. The scientific literature selected for this review was identified by searches of Medline via PubMed. A variety of recent experimental evidence has shed light on the mechanism underlying the anti-adhesive properties of proanthrocyanidins, their structure-activity relationships, and pharmacokinetics. Analysis of clinical studies and evaluation of the cranberry efficacy/safety ratio in the prevention of UTIs strongly support the use of cranberry in the prophylaxis of recurrent UTIs in young and middle-aged women. However, evidence of its clinical use among other patients remains controversial.

[Features of the incidence of cystitis depending on the type of contraception].

For the purpose of evaluation the effect of contraceptive methods on the incidence of recurrent bacterial cystitis in women, 215 clinical records of patients with cystitis were analyzed. In addition, incidence of recurrent cystitis in three groups of sexually active women of reproductive age was compared: 26 patients (Group 1) received conventional therapy and used condom as a method of contraception; 31 patients (Group 2) received combined oral contraceptives (COC), and 32 patients (Group 3) received COC and two courses of treatment with canephrone. A negative correlation between COC use and the risk of cystitis was detected. After conventional therapy, recurrences were observed in 43.3% of patients in Group 1, in 25.8% of patients in Group 2, and only in 15.6% of women in Group 3. Thus, the choice of COCs for contraception lead to 2-fold reduction of risk of recurrence of bacterial cystitis, and additional use of canephrone--to 3-fold reduction.

The use of hyperbaric oxygen for treating delayed radiation injuries in gynecologic malignancies: a review of literature and report of radiation injury incidence.

PURPOSE: The purposes of this paper are to review the best evidence supporting the use of hyperbaric oxygen therapy (HBOT) in delayed radiation injuries in gynecologic malignancies and report the incidence of radiation injuries at two large medical centers in southeastern Wisconsin. METHODS: A literature search was performed on Google Scholar, PubMed, and Ovid for studies evaluating the use of HBOT radiation cystitis, proctitis, and necrosis. The studies were then reviewed for the highest quality evidence using American Academy of Neurology guidelines. To evaluate radiation injuries, cancer databases at Froedtert Memorial Lutheran Hospital (FMLH) and Aurora St. Luke's Hospital (ASLH) were accessed. RESULTS: Several studies support the use of HBOT in treating radiation cystitis, proctitis, and necrosis, with proctitis having the strongest evidence in its favor. The average annual incidence of radiation injury at FMLH was 13.8%. Patients with cervical cancer and vulvar cancer had rates of 23% each. The average annual incidence of radiation injury among gynecologic cancer patients at ASLH was 5.5%. CONCLUSIONS: There is level A evidence for using HBOT to treat radiation proctitis. There is level B evidence for using HBOT to treat radiation cystitis and necrosis. The incidence delayed radiation injuries can be as high as 23%. This has relevance in practice guidelines for the treatment of delayed radiation injuries in gynecologic malignancies.

[Uncomplicated lower urinary tract infections in females--clinical aspects, aetiology and antimicrobial resistance epidemiology. Results of the ARESC (Antimicrobial Resistance Epidemiological Survey on Cystitis) study in Poland and their implications for empiric therapy]. / Niepowiklane zakazenia dolnych dróg moczowych u kobiet- -obraz kliniczny, etiologia i wrazliwosc na antybiotyki najczestszych patogenów. Wyniki badania Aresc (Antimicrobial Resistance Epidemiological Survey on Cystitis) w Polsce i ich znaczenie w wyborze terapii empirycznej.

UNLABELLED: The Polish results of the international ARESC study are reported concerning clinical aspects, epidemiology, and antimicrobial susceptibility of uropathogens. METHODS: Patients between 18 and 65 years with symptoms of uncomplicated cystitis were consecutively enrolled and investigated clinically including urinalysis and urine culture. Uropathogens were identified and their susceptibility was tested for nine antimicrobials RESULTS: In Poland a total of 212 patients were enrolled and 119 uropathogens from 118 patients were identified. Escherichia coli was the most frequent (90; 75.6%), followed by Staphylococcus saprophyticus (5; 4.2%), Staphylococcus aureus (4; 3.4%), Proteus mirabilis (4; 3.4%), Klebsiella pneumoniae (3; 2.5%), E. coli showed the highest rate of susceptibility to fosfomycin (98.9%) followed by mecillinam (97.8%), nitrofurantoin (92.2%), and ciprofloxacin (92.2%). The lowest rate was found for ampicillin (40.0%) followed by cotrimoxazole (80.0%). For the total spectrum the order was fosfomycin (97.1%), ciprofloxacin (93.1%), and nitrofurantoin (85.2%). The lowest rates were found again for ampicillin (43.2%) and cotrimoxazole (80.7%). CONCLUSIONS: The results indicate that fosfomycin, ciprofloxacin, nitrofurantoin and amoxicillin/clavulanate have preserved their good in vitro activity (> 80%) against both E. coli and the total spectrum of uropathogens.

Acute uncomplicated cystitis: from surveillance data to a rationale for empirical treatment.

The objectives of this study were to explore the epidemiological features and resistance rates in uropathogens isolated from cases of acute uncomplicated cystitis (AUC) in Greece, and subsequently to guide empirical treatment. Urine samples from outpatients aged >16 years were cultured and for each uropathogen isolated non-susceptibility to orally administered antimicrobial agents was defined. Demographic and clinical data were provided in questionnaire form. From January 2005 to March 2006 a total of 1936 non-duplicate positive urinary cultures were collected and 889 AUC cases were evaluated. Escherichia coli was the main aetiological agent (83%). In the AUC group, non-susceptibility rates for E. coli isolates were as follows: amoxicillin 25.8%; co-trimoxazole 19.2%; cefalothin 14.9%; nitrofurantoin 10.7%; amoxicillin/clavulanic acid 5.2%; nalidixic acid 6%; mecillinam 3.4%; ciprofloxacin 2.2%; cefuroxime 1.7%, and fosfomycin 1.6%. Amoxicillin and/or co-trimoxazole use in the previous 3 months was significantly associated with isolation of a co-trimoxazole-resistant E. coli isolate. The same applied for previous use of a fluoroquinolone agent and isolation of a ciprofloxacin-resistant E. coli isolate. In conclusion, increased co-trimoxazole non-susceptibility rates undermine its use as a first-line agent in empirical treatment, especially in cases of recent use of co-trimoxazole and/or amoxicillin. Fluoroquinolones display potent in vitro activity against community uropathogens, but prudent use is warranted for uncomplicated infections. Mecillinam and nitrofurantoin could serve as effective front-line agents in an effort to design fluoroquinolones-sparing regimens.

[Norfloxacine efficacy in acute cystitis in the region with 10% resistance of E. coli to fluoroquinolones: a comparative randomized study].

We have conducted a clinicomicrobiological study the first stage of which consisted in collection of information on uropathogens resistance to fluoroquinolones in 89 females with uncomplicated urinary infections (UI). Sensitivity to antibacterial drugs was determined by the agar dilution test (CLSI, 2007). At stage two of the study we made a prospective multicenter randomized trial including 108 females aged 18-55 years with acute uncomplicated cystitis. The patients were randomized into two groups: group 1 (n = 55) received norfloxacin (400 mg twice a day for 3 days); group 2 (n = 53) received phosphomycin (a single 3.0 g dose). Clinical and microbiological assessment of efficacy and safety was performed before the treatment, on treatment day 5, 10 and 28. Isolation of E. coli strains in the region highly and moderately resistant to cyprofloxacine was rather high--10 and 1.1%, respectively. Before the treatment E. coli was isolated from the urine in 82.4% cases, E. faecalis--5.9%, S. saprophyticus--3.9%, Staphylococcus spp--2.0%, others--< 1%. No significant differences by bacteriological and clinical efficacy were found between the groups. Eradication of the agent and persistent bacteriological response were seen in 100 and 95.2%, 95.8 and 100% patients of groups 1 and 2, respectively. Complete and partial responses were registered in 68.5 and 76%, 76 and 98% patients of groups 1 and 2, respectively. Thus, treatment with norfloxacin in a dose 400 mg twice a day for 3 days and with phosphomycin in a 3.0 g single dose have high clinical and microbiological efficacy in uncomplicated cystitis. Norfloxacin retains clinical and microbiological efficacy in acute uncomplicated cystitis even in conditions of 10% prevalence of fluoroquinolone-resistant strains. We think that there are reasons for revision of criteria of interpretation of uropathogens sensitivity to fluoroquinolones in the treatment of uncomplicated UI.

Rational use of antibiotics in acute uncomplicated cystitis: a pharmaco-epidemiological study.

Uncomplicated community-acquired urinary tract infections are among those most commonly found in clinical practice, resulting in significant morbidity and health care costs. Current management is usually empirical because of the narrow and predictable spectrum of etiologic agents that cause acute cystitis and their susceptibility patterns. However, since antimicrobial resistance is increasing, the use narrow-spectrum, inexpensive antimicrobial agents becomes less feasible. In our study we have evaluated the effectiveness of amoxicillin, a narrow-spectrum, inexpensive and non toxic drug, against non-complicated acute cystitis in 34 patients, and compared the results with the antibiotic therapy previously employed by the physicians of the Health Care Unit of Paola (CS), Italy. Amoxicillin was found to be effective for the treatment of community-acquired cystitis, thus suggesting that the development of bacterial resistance does not represent a limit to its use. Furthermore, our study demonstrates that besides providing an effective alternative to broad-spectrum antibiotics, the use of amoxicillin significantly reduced health care costs.

Prolongation of response to DMSO by heparin maintenance.

Dimethylsulfoxide (DMSO) is an effective treatment of symptomatic patients with detrusor mastocytosis but it is associated with frequent relapses. A group of patients (N = 25) followed for twelve months showed a relapse rate of 59 percent. Our experience with a combination of DMSO and heparin has suggested that the relapse rate may be lower. Heparin is a glycosaminoglycan that may afford protection to the urothelium and may reduce the relapse rate. It is better tolerated than DMSO or a combination of DMSO and heparin and does not produce garlic halitus. It is not associated with coagulation anomalies when administered intravesically. To determine whether or not maintenance therapy with intravesical heparin may reduce relapses we have treated a similar cohort of 25 patients with monthly instillations of 10,000 IU of heparin over a twelve-month period. Both groups were comparable in age, duration of symptoms, severity of symptoms, and response to DMSO. At twelve months only 20 percent of the heparin-treated group had relapsed versus 52 percent of the control group. Furthermore 6 patients (24%) in the follow-up group failed to respond to retreatment with DMSO while all of the heparin maintenance group continued to respond to one or more treatments with DMSO. Thus, it seems that heparin maintenance produces a significant reduction in the relapse rate of patients who respond to DMSO and reduces the number of patients requiring alternative therapy.