Raul Raz

International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

A Controlled Trial of Intravaginal Estriol in Postmenopausal Women with Recurrent Urinary Tract Infections

BACKGROUND Recurrent urinary tract infections are a problem for many postmenopausal women. Estrogen replacement restores atrophic mucosa, lowers vaginal pH, and may prevent urinary tract infections. METHODS We enrolled 93 postmenopausal women with a history of recurrent urinary tract infections in a randomized, double-blind, placebo-controlled trial of a topically applied intravaginal estriol cream. Midstream urine cultures were obtained at enrollment, monthly for eight months, and whenever urinary symptoms occurred. Vaginal cultures and pH measurements were obtained at entry and after one and eight months. The women were assigned to receive either estriol (n = 50) or placebo (n = 43), both administered intravaginally; 36 and 24, respectively, completed the eight months of follow-up. RESULTS The incidence of urinary tract infection in the group given estriol was significantly reduced as compared with that in the group given placebo (0.5 vs. 5.9 episodes per patient-year, P < 0.001). Survival analysis showed that more of the women in the estriol group than in the placebo group remained free of urinary tract infection (P < 0.001). Lactobacilli were absent in all vaginal cultures before treatment and reappeared after one month in 22 of 36 estriol-treated women (61 percent) but in none of the 24 placebo recipients (P < 0.001). With estriol the mean vaginal pH declined from 5.5 to 3.8 (P < 0.001), whereas there was no significant change with placebo. The rate of vaginal colonization with Enterobacteriaceae fell from 67 percent to 31 percent in estriol recipients but was virtually unchanged (from 67 to 63 percent) in the placebo recipients (P < 0.005). Side effects were minor, but caused 10 estriol recipients (28 percent) and 4 placebo recipients (17 percent) to discontinue treatment. CONCLUSIONS The intravaginal administration of estriol prevents recurrent urinary tract infection in postmenopausal women, probably by modifying the vaginal flora.

Risk Factors for the Development of Extended-Spectrum Beta-Lactamase-Producing Bacteria in Nonhospitalized Patients

Although the risk factors for acquiring infection by extended-spectrum beta-lactamase (ESBL)-producing bacteria have been investigated in hospitalized patients, such risk factors have not been defined in the community setting. In this study, clinical data from a total of 311 nonhospitalized patients with community-acquired urinary tract infection (128 with ESBL-positive strains and 183 with ESBL-negative strains) were obtained. According to a multivariate analysis, the following were identified as independent risk factors: previous hospitalization in the past 3 months (OR=8.95, 95%CI, 3.77–21.25), antibiotic treatment in the past 3 months (OR=3.23, 95%CI, 1.76–5.91), age over 60 years (OR=2.65, 95%CI, 1.45–4.83), diabetes (OR=2.57, 95%CI, 1.20–5.51), male gender (OR=2.47, 95%CI, 1.22–5.01), Klebsiella pneumoniae infection (OR=2.31, 95%CI, 1.17–4.54), previous use of third-generation cephalosporins (P=0.014, OR=15.8, 95%CI, 1.7–143), previous use of second-generation cephalosporins (P<0.0001, OR=10.1, 95%CI, 4.2–24), previous use of quinolones (P=0.001, OR=4.1, 95%CI, 1.8–9.0), and previous use of penicillin (P=0.003, OR=4.0, 95%CI, 1.6–9.0).

Clinical, epidemiological, and microbiological features of Vibrio vulnificus biogroup 3 causing outbreaks of wound infection and bacteraemia in Israel

Summary Background Vibrio vulnificus is a gram-negative bacterium that causes septicaemia and wound infection. Cases occur sporadically, and no previous outbreaks due to a common source or a clonal strain have been reported. In the summer and autumn of 1996 and 1997, an outbreak of invasive V vulnificus infection occurred in Israel in people who had recently handled fresh, whole fish purchased from artificial fish-ponds. Methods We reviewed clinical and epidemiological information, and undertook an environmental investigation to assess disease characteristics, modes of transmission, phenotypic characteristics of the bacterium, and fish-marketing policy. The clonal nature of 19 isolates was studied by biotyping, pulsed-field gel electrophoresis, and restriction-fragment length polymorphism (RFLP) analysis of a PCR fragment. Findings During 1996–97, 62 cases of wound infection and bacteraemia occurred. 57 patients developed cellulitis, four had necrotising fasciitis, and one developed osteomyelitis. In all cases, the fish were cultivated in inland fish-ponds. In the summer of 1996, fish-pond managers initiated a new marketing policy, in which fish were sold alive instead of being packed in ice. Phenotypically, the isolates had five atypical biochemical test results. The isolates were non-typeable by pulsed-field gel electrophoresis, and all had the same PCR-RFLP pattern which had not been seen previously. Interpretation The cause of the outbreak was a new strain of V vulnificus , classified as biogroup 3. A new fish-marketing policy that began in 1996 may have exposed susceptible people to the organism.

Recurrent Urinary Tract Infections in Postmenopausal Women

To evaluate factors associated with recurrent urinary tract infection (UTI) in postmenopausal women, we conducted a case-control study comparing 149 postmenopausal women referred to an infectious diseases outpatient clinic who had a history of recurrent UTI (case patients) with 53 age-matched women without a history of UTI (control patients). Each woman completed a questionnaire providing demographic data, history and clinical characteristics of prior infections, and information regarding risk factors for UTI. In addition, each patient underwent a gynecologic evaluation, renal ultrasound and urine flow studies, and blood group and secretor status testing. Three urologic factors-namely, incontinence (41% of case patients vs. 9.0% of control patients; P<.001), presence of a cystocele (19% vs. 0%; P<.001), and postvoiding residual urine (28% vs. 2.0%; P=.00008)-were all strongly associated with recurrent UTI. Multivariate analysis showed that urinary incontinence (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.05-16.42; P=.0009), a history of UTI before menopause (OR, 4.85; 95% CI, 1.7-13.84; P=. 003), and nonsecretor status (OR, 2.9; 95% CI, 1.28-6.25; P=.005) were most strongly associated with recurrent UTI in postmenopausal women. Prospective studies are needed to confirm these observations and to develop approaches for prevention.

Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens

This study evaluated whether trimethoprim-sulfamethoxazole (TMP-SMX) is effective for treatment of uncomplicated urinary tract infections (UTIs) due to TMP-SMX-resistant (TMP-SMX-R) pathogens. Healthy nonpregnant premenopausal women with symptomatic lower UTI were assessed for the presence of pyuria and bacteriuria; if either was present, a urine sample was cultured and TMP-SMX was prescribed. Clinical and microbiologic cure was assessed at days 5-9 and 28-42 after cessation of therapy. For 71%, of patients, cultures grew TMP-SMX-susceptible (TMP-SMX-S) microorganisms, and for 29%, cultures grew TMP-SMX-R organisms. Escherichia coli remained the predominant bacteria in both groups of cultures. At visit 2, microbiological cure had been achieved in 86% of the patients in the TMP-SMX-S group and 42% of those in the TMP-SMX-R group. Similar differences were found at visit 3 by clinical evaluation. Treatment with TMP-SMX of uncomplicated UTI caused by TMP-SMX-R microorganisms results in microbiologic and clinical failure. In high-resistance areas, TMP-SMX should not be the empiric drug of choice for uncomplicated UTI.

Cranberry Juice and Urinary Tract Infection

Cranberries have long been the focus of interest for their beneficial effects in preventing urinary tract infections (UTIs). Cranberries contain 2 compounds with antiadherence properties that prevent fimbriated Escherichia coli from adhering to uroepithelial cells in the urinary tract. Approximately 1 dozen clinical trials have been performed testing the effects of cranberries on the urinary tract. However, these trials suffer from a number of limitations. Most importantly, the trials have used a wide variety of cranberry products, such as cranberry juice concentrate, cranberry juice cocktail, and cranberry capsules, and they have used different dosing regimens. Further research is required to clarify unanswered questions regarding the role of cranberries in protecting against UTI in general and in women with anatomical abnormalities in particular.

Factors Contributing to Susceptibility of Postmenopausal Women to Recurrent Urinary Tract Infections

Recurrent urinary tract infections (UTIs) account for substantial morbidity, losses in work time, and medical costs. Recent studies suggest that the major factors predisposing to recurrent UTIs differ by age and functional status. In premenopausal women, sexual intercourse, spermicide exposure, maternal history of UTI, and a history of UTI in childhood have been associated with recurrent infections. In postmenopausal women, lack of estrogen appears to be an important factor predisposing to recurrent UTI, as does nonsecretor status, a history of UTI in the premenopausal period, incontinence, presence of a cystocele, and postvoid residual urine. In older women who are institutionalized, catheterization, incontinence, antimicrobial exposure, and functional status are most strongly related to risk of recurrent UTI. Further research is needed to better identify measures for prevention of recurrent UTI, which likely differ by age group.

Procalcitonin as a marker of acute pyelonephritis in infants and children

Abstract In the absence of specific symptomatology in children, the early diagnosis of acute pyelonephritis is a challenge, particularly during infancy. In an attempt to differentiate acute pyelonephritis from lower urinary tract infection (UTI), we measured serum procalcitonin (PCT) levels and compared these with other commonly used inflammatory markers. We evaluated the ability of serum PCT levels to predict renal involvement, as assessed by dimercaptosuccinic acid (DMSA) scintigraphy. Serum C-reactive protein (CRP), leukocyte counts, and PCT levels were measured in 64 children admitted for suspected UTI. Renal parenchymal involvement was assessed by 99mTc-DMSA scintigraphy in the first 7 days after admission. In acute pyelonephritis, the median PCT level was significantly higher than in the lower UTI group (3.41, range 0.36–12.4 μg/l vs. 0.13, range 0.02–2.15 μg/l, P<0.0001). In these two groups, respectively, median CRP levels were 120 (range 62–249 mg/l) and 74.5 (range 14.5–235 mg/l, P=0.012) and leukocyte counts were 15,910/mm3 (range 10,200–26,900) and 14,600/mm3 (range 8,190–26,470, P=0.34). For the prediction of acute pyelonephritis, the sensitivity and specificity of PCT were 94.1% and 89.7%, respectively; CRP had a sensitivity of 100%, but a specificity of 18.5%. We conclude that serum PCT may be an accurate marker for early diagnosis of acute pyelonephritis.

Who Are You—Staphylococcus saprophyticus?

Staphylococcus saprophyticus is a leading cause of cystitis in young women. S. saprophyticus shares many clinical features of urinary tract infection caused by Escherichia coli, but differs in pathogenesis, seasonal variation, and geographic distribution. This review summarizes what is known and what still needs to be learned about this microorganism.