Brian Minnillo

Trimethoprim In Vitro Antibacterial Activity is Not Increased by Adding Sulfamethoxazole for Pediatric Escherichia coli Urinary Tract Infection

PURPOSE The combination of trimethoprim/sulfamethoxazole is often used to treat uncomplicated urinary tract infections in children. The rationale for combining trimethoprim and sulfamethoxazole is that they may act synergistically to increase antibacterial activity. However, approximately 3% of patients show allergic reactions to sulfamethoxazole, of which some are serious (liver failure and Stevens-Johnson syndrome). We determined whether adding sulfamethoxazole is necessary to increase in vitro antibacterial activity for pediatric urinary tract infection compared to that of trimethoprim alone. MATERIALS AND METHODS We prospectively identified 1,298 children with urinary tract infection (greater than 100,000 cfu/ml Escherichia coli) from a total of 4 American regions. In vitro susceptibility of bacterial isolates to sulfamethoxazole, trimethoprim and trimethoprim/sulfamethoxazole was determined using disk diffusion. Ampicillin susceptibility was tested at 2 sites. At 1 site all uropathogens from consecutive urinary isolates were evaluated. RESULTS E. coli susceptibility to trimethoprim was 70%, comparable to the 70% of trimethoprim/sulfamethoxazole (p = 0.9) and higher than the 56.9% of sulfamethoxazole (p <0.05). This susceptibility pattern was without regional differences. At 2 sites susceptibility to trimethoprim was significantly higher than to ampicillin. At 1 site the susceptibility of other uropathogens to trimethoprim and trimethoprim/sulfamethoxazole was similar to that of E. coli. CONCLUSIONS In children with urinary tract infection in vitro susceptibility to trimethoprim was comparable to that to trimethoprim/sulfamethoxazole and significantly higher than to sulfamethoxazole. This finding was similar at all sites. Adding sulfamethoxazole appears unnecessary and may represent a risk to patients. Trimethoprim can be used as an alternative to trimethoprim/sulfamethoxazole based on in vitro antibacterial susceptibility. Routine trimethoprim/sulfamethoxazole use for urinary tract infection should be carefully reevaluated.

Trends of Systemic Therapy Use for Renal Cell Carcinoma in the United States.

OBJECTIVE To assess the utilization of immunotherapy after the advent of tyrosine-kinase inhibitors and mammalian target of rapamycin inhibitors for metastatic renal cell carcinoma (RCC) in the United States, as well as to better understand the variables associated with the implementation of these systemic therapies. METHODS The National Cancer Data Base Participant User File for Renal Cancer was queried. Patients diagnosed with metastatic RCC were identified. From that group, patients who received either immunotherapy or chemotherapy (single or multiagent), given as a first-course therapy from 1998 to 2011 were selected. Multivariate analysis was used to assess patient, disease, and provider factors associated with immunotherapy or chemotherapy overall usage between 2003 and 2011. RESULTS A total of 25,186 patients diagnosed with metastatic RCC were identified; 3107 received immunotherapy and 8640 received chemotherapy. The use of immunotherapy decreased from 30.3% in 1998 to 3.8% in 2011. The use of chemotherapy increased from 16.2% in 1998 to 54.0% in 2011. The most dramatic period of change was from 2004 to 2006. Independent negative predictors of receiving immunotherapy included progressive years of diagnosis (P <.0001), increasing age (P <.0001), female gender (P = .001), and African American race (P = .04). CONCLUSION There has been a significant decrease in the use of immunotherapy for metastatic RCC in the United States since the introduction of targeted chemotherapeutic agents in the past decade.

Robot-Assisted Laparoscopic Bilateral Ureteroureterostomies

Abstract Introduction: We demonstrate a technique for robot-assisted laparoscopic bilateral ureterouretero-stomies of upper pole to lower pole ureters through a single approach. The patient is a 2-year-old girl with a history of bilateral reflux who was found to have bilateral ectopic ureters. Historically, repair of these ureters would have required two separate incisions. To our knowledge, this is the first published report describing a single-approach technique. Materials and Methods: The surgery was performed transperitoneally using four ports, approaching the ureters through the broad ligament at the level between the bladder and the uterus. A “hitch stitch” was used to suspend each lower pole ureter to facilitate anastomosis.1 Results and Conclusions: Operative time was 230 min, and there were no major intraoperative or postoperative complications. The patient was doing well at her 2-month follow-up, with no urinary tract infections or other complaints. Follow-up ultrasonography showed resolving hyd...