Richard Colgan

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.

Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults

1. The diagnosis of asymptomatic bacteriuria should be based on results of culture of a urine specimen collected in a manner that minimizes contamination (A-II) (table 1). • For asymptomatic women, bacteriuria is defined as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts 10 cfu/mL (B-II). • A single, clean-catch voided urine specimen with 1 bacterial species isolated in a quantitative count 10 cfu/mL identifies bacteriuria in men (BIII). • A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count 10 cfu/mL identifies bacteriuria in women or men (A-II). 2. Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment (A-II). 3. Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive (A-I). • The duration of antimicrobial therapy should be

Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.

Risk Factors for Trimethoprim-Sulfamethoxazole Resistance in Patients with Acute Uncomplicated Cystitis

ABSTRACT Emerging antimicrobial resistance among uropathogens makes the management of acute uncomplicated cystitis increasingly challenging. Few prospective data are available on the risk factors for resistance to trimethoprim-sulfamethoxazole (TMP-SMX), the drug of choice in most settings. In order to evaluate this, we prospectively enrolled women 18 to 50 years of age presenting to an urban primary care practice with symptoms of cystitis. Potentially eligible women provided a urine sample for culture and completed a questionnaire regarding putative risk factors for TMP-SMX resistance. Escherichia coli isolates were tested for clonal group A (CGA) membership by a fumC-specific PCR. Of 165 women with cystitis symptoms, 103 had a positive urine culture and were eligible for participation. E. coli was the predominant uropathogen (86%). Fifteen (14.6%) women had a TMP-SMX-resistant (TMP-SMXr) organism (all of which were E. coli). Compared with the women who had a TMP-SMX-susceptible organism, women in the TMP-SMXr group were more likely to have traveled (odds ratio [OR], 15.4; 95% confidence interval [CI], 4.4 to 54.3; P < 0.001) and to be Asian (OR, 6.1; 95% CI, 1.0 to 36.4; P = 0.048). CGA was also independently associated with TMP-SMX resistance (OR, 105; 95% CI, 6.3 to 1,777.6; P = 0.001). No association with TMP-SMX resistance was demonstrated for the use of either TMP-SMX or another antibiotic in the past 3 months or with having a child in day care. Among these women with acute uncomplicated cystitis, Asian race and recent travel were independently associated with TMP-SMX resistance. TMP-SMXr isolates were more likely to belong to CGA. Knowledge of these risk factors for TMP-SMX resistance could facilitate the accurate selection of empirical therapy.

Time to symptom relief for uncomplicated urinary tract infection treated with extended-release ciprofloxacin: a prospective, open-label, uncontrolled primary care study

ABSTRACT Objective: Few studies have investigated symptom relief in urinary tract infections. This innovative exploratory trial aimed to measure the time to improvement of the signs and symptoms of uncomplicated urinary tract infection (UTI) in women receiving extended-release ciprofloxacin. Time to return to normal daily activities was also evaluated. Research design and methods: An open-label, multicenter US study in adult female outpatients with uncomplicated UTI. Patients completed serial questionnaires: the Urinary tract infection Symptom Assessment [USA], tracking time to symptom improvement, and the Activity Impairment Assessment [AIA], measuring the time to return to normal daily activities, using hand-held electronic diaries. Severity on the USA questionnaire was categorized using a 4‐point Likert-type scale, with improvement defined as a reduction of at least one degree of symptom severity. All patients received once-daily extended-release ciprofloxacin 500 mg tablets for 3 days. Results: Of 276 female patients aged 18−78 years who enrolled at 28 sites, 273 (99%) were safety-valid, 264 (96%) completed at least 24 h of questionnaires and were valid for symptom relief analysis, and 170 (62%) had pre-therapy pathogen(s) ≥ 103 CFU/mL and were valid for efficacy analysis. Six hours after the first dose of study drug, 50% of patients reported symptom improvement; 87% by 24 h and 91% by 48 h. At study entry, 54% of patients reported considerably decreased time at work or other activities; reduced to 23% by Day 2 and 10% by Day 3. At the test-of-cure visit (5−11 days post-therapy), 96% (163/170) of patients were clinical cures. Drug-related adverse events were reported by 18 (7%) patients and were consistent with previous extended-release ciprofloxacin studies (e.g., gastrointestinal disturbance, fungal superinfections). There were no serious adverse events or discontinuations due to adverse events. Conclusion: This open-label, non-comparative trial in adult women demonstrated a rapid improvement in uncomplicated UTI symptom severity (6−24 h) and the ability to return to work within 24 h following extended-release ciprofloxacin treatment. Clinical cure rate and tolerability profile were similar to results of previous extended-release ciprofloxacin studies.

I Remember…It Was December

William Osler is quoted as saying, “Nothing will sustain you more potently than the power to recognize in your humdrum routine, as perhaps it may be thought, the true poetry of life—the poetry of the commonplace, of the plain, toil-worn woman, with their loves and their joys, their sorrows and their griefs.”1 A family physician reflects how he continues to derive sustenance from having cared for a dying woman and her family over several home visits in his earliest years of private practice. The author’s memory of these house calls continues to reinforce his love for medicine. Today, when physicians are overburdened with countless numbers of interruptions, requirements, and measures we are reminded that one of the things which can maintain our passion for medicine is in realizing that caring for others is the focus of our sacred vocation. By appreciating the impact we have on the lives of those less fortunate, we may find meaning in our own lives.

Survival Tips for the Young Physician

Practical advice for the young physician is offered in this chapter. How to effectively present a patient is a critical talent, which all artists of medicine should have. Succinct directives are given on how to convey medical information with clear examples so that the reader may easily understand what is expected of them. The young physician is taught that the best way to get better at the practice of medicine is to see more patients, while learning from each one. You will be let in on a truism in medicine that is rarely discussed: all great clinicians started out in their careers just as you are doing—young, green, and inexperienced. Good communication techniques are highlighted. A simple mnemonic is reviewed which will help every reader focus on how to best show that the care of the patient intended is communicatedeffectively.

Advice to the Young Physician

For everybody, if you want to start joining with others to read a book, this advice to the young physician is much recommended. And you need to get the book here, in the link download that we provide. Why should be here? If you want other kind of books, you will always find them. Economics, politics, social, sciences, religions, Fictions, and more books are supplied. These available books are in the soft files.

A Modern Family

A Modern Family I FIRST MET JOE ON THE 13TH FLOOR OF AN INNER-CITY hospital. He was lying comfortably in his hospital bed, granted refuge as an unassigned medical admission for chest pain the night before by the inpatient team. Joe was a 73-year-old white man with uncombed hair, bushy eyebrows, and a severely stooped posture noticeable even as he sat upright in the bed. He had a gravelly voice—from years of smoking, I soon learned. On the chair beside him were his clothes, which were worn well beyond their life expectancy. Joe looked like someone who had worked hard all his life and appeared much older than his actual age. Aside from his appearance, I was struck by the tattered text by his bedside. It was an old edition of Age of Enlightenment, with “Enoch Pratt Library” stamped on the first page. While taking his history and performing a physical examination, I noticed that Joe spoke brusquely with many facial twitches and gross motor disturbances. He did not use many big words. I asked him politely about his book, to which he replied, oddly, “Oh, you know. I enjoy reading works of philosophy, particularly about Erasmus and the Reformation.” I had heard of Erasmus before, but was not very familiar with his history or theories. Joe knew all about this subject. He told me that he loved to read. I asked him about the last book he read. “Mein Kampf,” he replied. I asked him what he read before this, and he answered, “The Rise and Fall of the Third Reich.” I wondered to myself, Who is this guy? As it turned out he wasn’t a Nazi at all but absolutely loved all types of military history. His most recent reads had focused on the world wars. Joe’s favorite was the 1895 war novel The Red Badge of Courage by Stephen Crane. Joe continued, “But what I am really looking for, Doc, is a book about World War II by an American author—not a British author—but an American author.” Given my first impression of Joe, I was surprised to learn of his scholarly pursuits. Joe was born and raised on the east side of Baltimore and had made it through seventh grade. When I asked him why he didn’t go further in school, he said, “I quit school the day my father died, so I could go to work at a warehouse to help support my mother.” He had always loved reading and learning and tried his best to make time for these activities. At the age of 21, he married. It was also at this time that he developed schizophrenia. Unfortunately, this factor, as he explained it, was likely in part why his marriage failed after only two months and resulted in no children. That same year Joe was admitted to a state psychiatric hospital, followed by another stay at a different state hospital. These were the first of what were many psychiatric admissions; longer and longer each time and which ultimately became a 30-year period of institutionalization. His twisted facial expressions and thrashing body movements were caused by the cumulative adverse effects of years of powerful antipsychotic medications, which only dampened his disturbing thoughts and the obtrusive voices he experienced. Despite all this Joe was beloved by the hospital staff, where he held the reputation as an exemplary patient. Eventually he earned the privileges to work as an employee, supervising others in the boiler room. The institution became his home. In 1981, President Ronald Reagan rescinded the Mental Health Systems Act of 1980, which resulted in reduced federal funding to community mental health centers. Many patients, who were no longer thought to be a threat to themselves or to others, were released from intensive psychiatric care. This included Joe. After leaving the facility, Joe was offered and accepted a job to continue working at the hospital as a paid employee, with room and board included. Inexplicably, after a year of compensated service, he left. For years after his departure from psychiatric institutionalization, Joe was dutifully cared for by Miss Elsie, a 60-year-old African American woman. Elsie was herself no stranger to difficult times. She had married twice during her life; both marriages ended in divorce from abusive husbands. For more than 25 years she worked long hours as a correctional officer. After retirement from this career, she opened up an adult care service in her twostory four-bedroom home in a working class suburb of Baltimore. Elsie was contacted in 2004 by an admiring social worker from a local hospital, who asked if she would accept a new client under her care. She was told this gentleman had resided in substandard housing under horrible conditions—essentially in a room that was little more than a mattress on a basement floor and virtually void of human contact. This is how Joe first met Miss Elsie, a stranger who would walk beside him for the rest of his life. Joe had neither living relatives nor close friends. He often spent his time alone. On a weekly basis Joe took the local bus to the Enoch Pratt Library, where he would read for hours. On a good day he would walk away with free books in hand. “I can’t believe they give these things away!” he excitedly told me. His prized collection com-

Urinary tract infections. Current approaches, future directions.

Urinary tract infection (UTI) is a common problem that is distressing for patients and costly for the healthcare system. UTIs commonly affect young, sexually active women; the elderly; and patients who have predisposing factors, such as catheterization. Recurrent infections are likely to occur in all these patients groups. Patients who are pregnant or have predisposing factors are at increased risk for complications related to untreated UTIs, such as long-term renal damage. Given these risks and the public health burden associated with the condition, it is important that clinicians have up-to-date information regarding the classification, symptoms, pathogenesis, and empiric treatment of UTIs.