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.

Trend of antibiotics usage for acute pyelonephritis in Korea based on national health insurance data 2010-2014.

BACKGROUND: The objective of this study is to describe the changes in prescribing practices of antibiotics to treat acute pyelonephritis (APN) in Korea. METHODS: The claim data base of the Health Insurance Review and Assessment Service in Korea was used to select patients with ICD-10 codes N10 (acute tubulo-interstitial nephritis) or N12 (tubulo-interstitial nephritis, not specified as acute nor chronic) as the primary discharge diagnosis during 2010-2014. Consumption of each class of antibiotics was converted to Defined Daily Dose (DDD)/event. RESULTS: Throughout the five-year period, the average antibiotic consumption were 11.3 DDD per inpatient event and 6.0 DDD per outpatient event. The annual average antibiotic consumption increased for inpatients (P = 0.002), but remained stable for outpatients (P = 0.066). The use of parenteral antibiotics increased for inpatients (P < 0.001), but decreased for outpatients (P = 0.017). As for the the antibiotic classes, 3rd generation cephalosporins (3rd CEPs) was the most commonly prescribed (41.4%) for inpatients, followed by fluoroquinolones (FQs) (28.5%); for outpatient, FQs (54.8%) was the most commonly prescribed, followed by 3rd CEPs (13.1%). The use of 3rd CEPs (P < 0.001), beta-lactam/beta-lactamase inhibitors (P = 0.007), and carbapenems (P < 0.001) increased substantially for the treatment of hospitalized APN patients. In particular, carbapenems use increased 3.1-fold over the 5 years. CONCLUSIONS: Prescription of broad-spectrum antibiotics increased much for the treatment of APN in Korea during 2010-2014.

[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.

[Profile of bacterial resistance in pediatric urinary tract infections in 2014]. / Étude du profil des résistances bactériennes dans les pyélonéphrites de l'enfant en 2014.

In pediatric units, bacteria-producing extended-spectrum-betalactamase (ESBL) have an increasing prevalence among bacteria causing febrile urinary tract infections (UTIs). The purpose of this study was to evaluate the epidemiology of bacteria resistance patterns observed in UTIs, in order to assess the current antibiotic treatment protocols. This study is based upon a single-center retrospective chart review of the cytobacteriological urine cultures performed in UTIs between 1 January and 31 December 2014, in the medical pediatric unit of the Caen University Hospital. Out of the total of 219 cases of UTI, 26.9% were recurrences of UTI, 18.3% were infections in infants less than 3 months old, 21% of the patients suffered from underlying uropathy, and 16.4% of the patients had recently been exposed to antibiotics. In 80.3% of the cases, Escherichia coli was found, while Enterococcus faecalis was found in 5.6%. The antibiograms proved that 33.5% of the bacteria were sensitive. Half of E. coli were resistant to ampicillin, 4.9% to cefixime, 4.9% to ceftriaxone, 1.1% to gentamicin, and 27.8% to trimethoprim-sulfamethoxazole. Nine E. coli and one Enterobacter cloacae produced ESBL, accounting for 4.6% of the UTIs. We did not find any bacteria-producing high-level cephalosporinase. Cefixime resistance was statistically linked to ongoing antibiotic treatment (OR=5.98; 95% CI [1.44; 24.91], P=0.014) and underlying uropathy (OR=6.24; 95% CI [1.47; 26.42], P=0.013). Ceftriaxone resistance was statistically related to ongoing antibiotic treatment (OR=6.93; 95% CI [1.45; 33.13], P=0.015). These results argue in favor of maintaining intravenous ceftriaxone for probabilistic ambulatory treatment. However, in case of hospitalization, cefotaxime can replace ceftriaxone, due to its lower ecological impact. Moreover, it is necessary to continue monitoring bacterial resistance and regularly review our treatment protocols.

Asymptomatic Bacteriuria and Bacterial Interference.

Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.

Factors associated with ciprofloxacin- and cefotaxime-resistant Escherichia coli in women with acute pyelonephritis in the emergency department.

BACKGROUND: High rates of antimicrobial resistance in Escherichia coli isolated from patients with urinary tract infections have been reported worldwide. The aim of this study was to identify risk factors for resistance to ciprofloxacin (CIP) and cefotaxime (CTX) in E. coli isolated from patients with acute pyelonephritis (APN). METHODS: We prospectively identified women over 18 y of age who visited the emergency department of one of 10 hospitals with APN and whose urine culture grew E. coli. The study was conducted from April 16 to June 10, 2012. RESULTS: Of the 229 patients identified, 173 (75.5%) had community-associated (CA) infections and 56 (24.5%) had healthcare-associated (HCA) infections. Sixty-seven isolates (29.3%) were resistant to CIP, 45 (19.7%) to CTX, and 29 (12.7%) to both CIP and CTX. Multivariate analyses revealed that hematologic disease, chronic kidney disease, a bed-ridden state, indwelling urinary catheter, antibiotic treatment in the preceding 3 months, and isolation of CIP-resistant E. coli in the urine within the preceding 3 months, were significantly associated with resistance to both CIP and CTX. CONCLUSIONS: Chronic conditions and healthcare-associated factors were related to resistance to both fluoroquinolones and third-generation cephalosporins in women with APN. Continued and vigilant surveillance is necessary to monitor the dissemination of antimicrobial resistance in uropathogens.

Impact of preoperative immunonutrition on morbidity following cystectomy for bladder cancer: a case-control pilot study.

PURPOSE: To compare postoperative complications in patients with or without preoperative immunonutrition before cystectomy. METHODS: A prospective, multicenter, pilot, case-control study was conducted during 6 months. Patients with 7-day preoperative immunonutrition were prospectively included and compared with a retrospective, matched control group without immunonutrition. Early complication rates and the length of hospital stay were analyzed. The bilateral type I error was <0.05; the power was 90%. Thirty patients in each group were required. RESULTS: Thirty patients were included in each group, on a comparable basis. In the immunonutrition group, fewer postoperative complications (40 vs. 76.7%; p = 0.008), less paralytic ileus at D7 (6.6 vs. 33.3%; p = 0.02), fewer infections (23.3 vs. 60%; p = 0.008), and in particular less pyelonephritis (16.7 vs. 46.7%; p = 0.03) occurred. Clavien's grades for complications were higher in the control group (p = 0.04). Mortality, pulmonary embolism, anastomotic fistulae, and wound dehiscence were similar between two groups. The length of stay was reduced by 3 days in the immunonutrition group. CONCLUSIONS: In this pilot case-control study, immunonutrition is associated with a decrease in postoperative complications, urinary tract infections, Clavien's grade for complications, and paralytic ileus in patients undergoing cystectomy for bladder cancer. Prospective randomized placebo control studies are needed to confirm these promising results.

Acute pyelonephritis in pregnancy: an 18-year retrospective analysis.

OBJECTIVE: We sought to describe the incidence of acute pyelonephritis in pregnancy, and to assess its association with perinatal outcomes in an integrated health care system. STUDY DESIGN: A retrospective cohort study was performed using medical records on 546,092 singleton pregnancies delivered in all Kaiser Permanente Southern California hospitals from 1993 through 2010. These medical records include the perinatal service system along with inpatient and outpatient encounter files. Adjusted odd ratios (ORs) and 95% confidence intervals (CIs) were used to estimate associations. RESULTS: The incidence of acute antepartum pyelonephritis was 0.5% (2894/543,430). Women with pyelonephritis in pregnancy were more likely to be black or Hispanic, young, less educated, nulliparous, initiate prenatal care late, and smoke during pregnancy. Pregnancies of women with pyelonephritis compared to those without were more likely to be complicated by anemia (26.3% vs 11.4%; OR, 2.6; 95% CI, 2.4-2.9), septicemia (1.9% vs 0.03%; OR, 56.5; 95% CI, 41.3-77.4), acute pulmonary insufficiency (0.5% vs 0.04%; OR, 12.5; 95% CI, 7.2-21.6), acute renal dysfunction (0.4% vs 0.03%; OR, 16.5; 95% CI, 8.8-30.7), and spontaneous preterm birth (10.3% vs 7.9%; OR, 1.3; 95% CI, 1.2-1.5). Most of the preterm births occurred between 33-36 weeks (9.1%). CONCLUSION: We characterize the incidence of pyelonephritis in an integrated health care system where routine prenatal screening for asymptomatic bacteriuria is employed. Maternal complications are commonly encountered and the risk of preterm birth is higher than the baseline obstetric population.

Pyelonephritis in pregnancy. How adequate is empirical treatment?

OBJECTIVE: To ascertain the adequacy of empirical antimicrobial treatment in pregnant women with acute pyelonephritis. MATERIAL AND METHODS: We have conducted a retrospective observational study of women admitted to the hospital with acute pyelonephritis between May 2004 and April 2011. Patients were included if the results of urine cultures and susceptibility testing to antibiotics were available. Epidemiological, clinical, therapeutical and outcome variables were collected from chart review. We considered inappropriate empirical antimicrobial treatment (IEAT) as the occurrence of microorganism that were not effectively treated at the time when the causative microorganism and its antibiotic susceptibility were known. RESULTS: Fifty women with appropriate microbiological data from a total of 93 cases of acute pyelonephritis were included in the study. The women's mean age was 26.4 years, and 58% were nulliparous. Pyelonephritis was developed in the 2nd and 3rd trimester in 88% of cases. Previous urinary tract infections were recorded in 34%. Escherichia coli was the most frequent microorganism (70%). The proportion of patients who received IEAT was 10%. Amoxicillin-clavulanate and cephalosporines were the most predominant antibiotics used, with a proportion of IEAT of 10.3% and 5.9%, respectively. CONCLUSIONS: Pregnant women with pyelonephritis received IEAT in a small but significant number of cases. Amoxicillin-clavulante and cephalosporines were adequate in most cases. More studies are needed to define the clinical impact of IEAT on prognosis.

[Prophylaxis and prognosis of preeclampsia in patients with chronic pyelonephritis and chronic glomerulonephritis].

The investigations performed showed that pregnant women with chronic pyelonephritis (CP) and chronic glomerulonephritis (CG) have certain response to therapy done in accordance with level of kidney function activity. In the pregnant women with CP and CG and kidney functional reserve KFR > 10% and from 5 to 10% the treatment efficacy was higher and practically absent in pregnant women with KFR < 5%.

Neutral and acidic oligosaccharides in preterm infants: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Serious infectious morbidity is high in preterm infants. Enteral supplementation of prebiotics may reduce the incidence of serious infections, especially infections related to the gastrointestinal tract. OBJECTIVE: The objective was to determine the effect of enteral supplementation of a prebiotic mixture consisting of neutral oligosaccharides ((SC)GOS/(LC)FOS) and acidic oligosaccharides (AOS) on serious infectious morbidity in preterm infants. DESIGN: In a randomized controlled trial, preterm infants (gestational age <32 wk and/or birth weight <1500 g) received enteral supplementation of 80% (SC)GOS/(LC)FOS and 20% AOS (1.5 g . kg(-1) . d(-1)) or placebo (maltodextrin) between days 3 and 30 of life. Serious infectious morbidity was defined as a culture positive for sepsis, meningitis, pyelonephritis, or pneumonia. The analysis was performed by intention-to-treat and per-protocol, defined as > or =50% supplementation dose during the study period. RESULTS: In total, 113 preterm infants were included. Baseline and nutritional characteristics were not different between groups. In the intention-to-treat analysis, the incidence of > or =1 serious infection, > or =1 serious endogenous infection, or > or =2 serious infectious episodes was not significantly different in the (SC)GOS/(LC)FOS/AOS-supplemented and placebo groups. In the per-protocol analysis, there was a trend toward a lower incidence of > or =1 serious endogenous infection and > or =2 serious infectious episodes in the (SC)GOS/(LC)FOS/AOS-supplemented group than in the placebo group (P = 0.09 and P = 0.07, respectively). CONCLUSIONS: Enteral supplementation of (SC)GOS/(LC)FOS/AOS does not significantly reduce the risk of serious infectious morbidity in preterm infants. However, there was a trend toward a lower incidence of serious infectious morbidity, especially for infections with endogenous bacteria. This finding suggests a possible beneficial effect that should be evaluated in a larger study. This trial was registered at isrctn.org as ISRCTN16211826.

[Acupuncture in the combined treatment of pyelonephritis]. / Akupunktura v kompleksnom lechenii pielonefrita.

In the treatment of pyelonephritis which continues to cause problems in practical uronephrology, the main efforts of the clinicians are now directed at enhancement of the patients resistance, improvement of renal blood flow and urodynamics. Acupuncture (AP) is thought capable to meet the above requirements. It was used in combined treatment of 102 pyelonephritis cases (51 with acute and 51 with chronic manifestations) showing intact renal function. According to radionuclide renography, a positive trend in the secretion and urodynamics of the upper urinary tract was demonstrable in 50% of the patients. Dynamic nephroscintigraphy reported a positive response in 60% of cases versus 25% in those treated without AP. AP promotion of earlier recovery or remission, reduction of the scope of chemotherapy, good short- and long-term response permit this modality to be recommended for application in urological and nephrological practice.