Medline ® Abstracts for References 9-12
of 'Acute uncomplicated cystitis and pyelonephritis in women'
Voided midstream urine culture and acute cystitis in premenopausal women.
Hooton TM, Roberts PL, Cox ME, Stapleton AE
N Engl J Med. 2013 Nov;369(20):1883-91.
BACKGROUND: The cause of acute uncomplicated cystitis is determined on the basis of cultures of voided midstream urine, but few data guide the interpretation of such results, especially when gram-positive bacteria grow.
METHODS: Women from 18 to 49 years of age with symptoms of cystitis provided specimens of midstream urine, after which we collected urine by means of a urethral catheter for culture (catheter urine). We compared microbial species and colony counts in the paired specimens. The primary outcome was a comparison of positive predictive values and negative predictive values of organisms grown in midstream urine, with the presence or absence of the organism in catheter urine used as the reference.
RESULTS: The analysis of 236 episodes of cystitis in 226 women yielded 202 paired specimens of midstream urine and catheter urine that could be evaluated. Cultures were positive for uropathogens in 142 catheter specimens (70%), 4 of which had more than one uropathogen, and in 157 midstream specimens (78%). The presence of Escherichia coli inmidstream urine was highly predictive of bladder bacteriuria even at very low counts, with a positive predictive value of 10(2) colony-forming units (CFU) per milliliter of 93% (Spearman's r=0.944). In contrast, in midstream urine, enterococci (in 10% of cultures) and group B streptococci (in 12% of cultures) were not predictive of bladder bacteriuria at any colony count (Spearman's r=0.322 for enterococci and 0.272 for group B streptococci). Among 41 episodes in which enterococcus, group B streptococci, or both were found in midstream urine, E. coli grew from catheter urine cultures in 61%.
CONCLUSIONS: Cultures of voided midstream urine in healthy premenopausal women with acute uncomplicated cystitis accurately showed evidence of bladder E. coli but not of enterococci or group B streptococci, which are often isolated with E. coli but appear to rarely cause cystitis by themselves. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.).
From the Department of Medicine, School of Medicine, University of Miami, Miami (T.M.H.); and the Department of Medicine, School of Medicine, University of Washington, Seattle (P.L.R., M.E.C., A.E.S.).
Prevalence and antimicrobial susceptibility of pathogens in uncomplicated cystitis in Europe. The ECO.SENS study.
Int J Antimicrob Agents. 2003;22 Suppl 2:49.
The ECO.SENS study investigated the prevalence and antimicrobial susceptibility of pathogens causing community-acquired acute uncomplicated urinary tract infections (UTIs) in 4734 women aged 18-65 years presenting with symptoms of acute UTI, at 252 community healthcare centres in 16 countries in Europe plus Canada. Resistance in Escherichia coli occurred most frequently to ampicillin (30%) and sulphonamides (29%), followed by trimethoprim (15%), trimethoprim/sulphamethoxazole (14%) and nalidixic acid (5%) but was low to co-amoxiclav, mecillinam, cefadroxil, nitrofurantoin, fosfomycin, gentamicin and ciprofloxacin, all at<3%. Consumption of antibiotics in 1997 varied more than 4-fold within Europe and from 9 to 37 DDD/1000 inhabitants/day, the consumption being highest in Southern Europe. The consumption of broad-spectrum penicillins correlated with resistance to ampicillin and there was a clear correlation between quinolone consumption and resistance to ciprofloxacin and nalidixic acid. The 4-fold difference in antibiotic consumption within Europe and the correlation to resistance emphasises the importance of controlling antibiotic usage.
Department of Clinical Microbiology, Central Hospital, SE-351 85, Växjö, Sweden. email@example.com
An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO.SENS Project.
Kahlmeter G, ECO.SENS
J Antimicrob Chemother. 2003;51(1):69.
The ECO.SENS study is the first international survey to investigate the prevalence and susceptibility of pathogens causing community-acquired acute uncomplicated urinary tract infections (UTIs). Midstream urine samples were taken for culture and for testing for the presence of leucocytes from 4734 women not older than 65 years presenting with symptoms of acute UTI at 252 community health care centres in 17 countries. Recognized urinary tract pathogens were identified and the susceptibility to 12 antimicrobials determined. Pathogens were present in 3278 (69.2%) patients, Escherichia coli accounting for 77.0% of isolates. In E. coli, 42% of the isolates were resistant to one or more of the 12 antimicrobial drugs investigated. Resistance was most common to ampicillin (29.8%) and sulfamethoxazole (29.1%), followed by trimethoprim (14.8%), trimethoprim/sulfamethoxazole (14.1%) and nalidixic acid (5.4%). Resistance in E. coli to co-amoxiclav, mecillinam, cefadroxil, nitrofurantoin, fosfomycin, gentamicin and ciprofloxacin was<3%. However, co-amoxiclav resistance was apparent in Portugal (9.3%) as was resistance to the quinolones, nalidixic acid and ciprofloxacin, in Portugal (11.6% and 5.8%, respectively) and Spain (26.7% and 14.7%, respectively). Overall, Proteus mirabilis were less resistant to ampicillin (16.1%) and more resistant to trimethoprim(25.5%) than E. coli, whereas Klebsiella spp. were more resistant to ampicillin (83.5%) and fosfomycin (56.7%). 'Other Enterobacteriaceae' were more resistant to the broad spectrum beta-lactams (ampicillin 45.9%, co-amoxiclav 21.3% and cefadroxil 24.6%), nitrofurantoin (40.2%) and fosfomycin (15.6%). In Staphylococcus saprophyticus resistance development was rare. Overall, antimicrobial resistance was lowest in the Nordic countries and Austria and highest in Portugal and Spain.
Department of Clinical Microbiology, Central Hospital, SE-351 85 Växjö, Sweden. firstname.lastname@example.org
Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy.
Naber KG, Schito G, Botto H, Palou J, Mazzei T
Eur Urol. 2008;54(5):1164.
BACKGROUND: Uncomplicated cystitis in females is among the most frequent infections in community.
OBJECTIVE: To determine clinical aspects, epidemiology, and antimicrobial susceptibility of uropathogens.
INTERVENTION: Patients were investigated clinically and with urinalysis and urine culture.
MEASUREMENTS: This survey started in 2003 and ended in 2006 including 68 centres in nine European countries and in Brazil. Female patients between 18 and 65 yr with symptoms of uncomplicated cystitis were consecutively enrolled and clinically evaluated. Uropathogens were identified and their susceptibility tested for nine antimicrobials.
RESULTS AND LIMITATIONS: Clinical data of 4264 eligible patients were analysed. A positive urine culture was found in 74.6%. Within the 3018 pathogens, Escherichia coli (E. coli) was most frequent (76.7%), followed by Enterococcus faecalis (4.0%), Staphylococcus saprophyticus (3.6%), Klebsiella pneumoniae (3.5%), and Proteus mirabilis (3.5%). E. coli showed the highest rate of susceptibility to fosfomycin (98.1%) followed by mecillinam (95.8%), nitrofurantoin (95.2%), and ciprofloxacin (91.8%). The lowest rate was found for ampicillin (45.1%). For the total spectrum the order was fosfomycin (96.4%), mecillinam (95.9%), ciprofloxacin (90.3%), and nitrofurantoin (87.0%). In all countries a susceptibility rate to E. coli above 90% was found only for fosfomycin, mecillinam, and nitrofurantoin. The susceptibility rates varied significantly from country to country (p<0.0001), except for fosfomycin, mecillinam, and nitrofurantoin.
CONCLUSIONS: Despite wide cross-country variability of bacterial susceptibility/resistance rates to the other antimicrobials tested, fosfomycin, mecillinam, and nitrofurantoin have preserved their in vitro activity in all countries investigated. They may represent good options for the empiric therapy of female patients with uncomplicated cystitis.
Technical University of Munich, Munich, Germany.