Acute uncomplicated cystitis: from surveillance data to a rationale for empirical treatment
Introduction
Acute uncomplicated cystitis (AUC) constitutes the real burden of urinary tract infections (UTIs) in the primary care setting and is usually treated empirically. The rationale for this approach is the predictable spectrum of uropathogens (Escherichia coli in 70–80% of cases) and the characteristic and distressing nature of the symptoms [1]. The choice of antimicrobial agent should be based on the in vitro susceptibility profiles of uropathogens in the geographic region of the practitioner, which are usually derived from laboratory-based surveillance systems. Ideally, for surveillance purposes physicians should send a urine sample from all patients with a clinical diagnosis of UTI. However, such a practice is not warranted by current guidelines [2]. Instead, a urine specimen is more likely to originate from a patient with a difficult-to-treat or recurrent infection or from patients with a complicated UTI, thus resulting in an overestimation of resistance rates among uropathogens in the community [3].
In the present study conducted in the Greek community, consecutive positive urine cultures were collected along with a questionnaire per culture, allowing classification (uncomplicated vs. complicated; cystitis vs. other types of UTI) and recording previous exposure to antibiotics. The present study represents a large-scale, multicentre surveillance study that was designed for the first time in Greece to explore epidemiology and resistance rates in AUC as well as to provide guidance on its empirical antibiotic treatment.
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Materials and methods
A multicentre surveillance network was formed by private and public microbiology laboratories for outpatients in Attica region (Athens, Piraeus and suburbs), Thessaloniki (Northern Greece), Peloponnese (Southwestern Greece—Patras, Tripoli and Argolis) and Sterea Ellada (Central Greece—Karpenisi and Nafpaktos). Isolated strains were shipped to the central laboratory (Research Laboratory of Infectious Diseases and Antimicrobial Chemotherapy, 4th Department of Internal Medicine, Athens University
Demographics
During the surveillance period (1 January 2005 to 1 March 2006) a total of 1936 non-duplicate positive urinary cultures were collected. Of those, 1648 (85.1%) were from female patients, with a mean ± standard deviation age of 48.5 ± 18.9 years. From the original sample, 889 cases of AUC were evaluated (53.9% of the original female population). In complicated cases 45.5% of patients were male. Demographic and clinical data per group of patients are presented in Table 1.
Distribution of species per type of infection, age and gender
Escherichia coli was the main
Discussion
In the present study, use of a simple structured questionnaire helped to differentiate groups of patients comprising the spectrum of UTIs acquired and treated in the community. This approach allowed a more focused interpretation of laboratory-generated data regarding the susceptibility profile of uropathogens isolated in cases of AUC [3], [6]. Of note, 24% of isolated uropathogens from the total study yield originated from patients reporting lack of urinary symptoms. In this group of
Conclusion
The choice of antibiotic in empirical treatment of AUC should result from a cautious balance between the available in vitro susceptibility data from the specific target population and the tolerability and ecological effects of the prescribed agent. For patients with AUC in Greece, increased co-trimoxazole resistance rates undermine its use as a first-line agent. Fluoroquinolones still display excellent in vitro activity against most uropathogens but the increasing resistance rates to nalidixic
Acknowledgments
The present study was a multicentre collaborative initiative (Collaborative Study Group on Antibiotic Resistance in Community-acquired Urinary Tract Infections) formed by the following centres (in brackets members per centre are presented): 4th Department of Internal Medicine, ATTIKON University General Hospital, Athens, Greece (Ioannis Katsarolis, Garyphallia Poulakou, Sofia Athanasia, Niki Lambri, Elias Karaiskos, Periklis Panagopoulos, Flora V. Kontopidou, Ioannis Deliolanis, Panagiota
References (22)
Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis
Urol Clin North Am
(2008)The etiology of urinary tract infection: traditional and emerging pathogens
Am J Med
(2002)- et al.
Outcomes associated with trimethoprim/sulphamethoxazole (TMP/SMX) therapy in TMP/SMX resistant community-acquired UTI
Int J Antimicrob Agents
(2002) Addressing antibiotic resistance
Am J Med
(2002)Fluoroquinolones and resistance in the treatment of uncomplicated urinary tract infection
Int J Antimicrob Agents
(2003)- et al.
Optimization of the use of ciprofloxacin
Pathol Biol (Paris)
(2009) - et al.
Emergence of fluoroquinolone resistance in outpatient urinary Escherichiacoli isolates
Am J Med
(2008) Pivmecillinam—therapy of choice for lower urinary tract infection
Int J Antimicrob Agents
(2003)- et al.
Surveillance study in Europe and Brazil on clinical aspects and antimicrobial resistance epidemiology in females with cystitis (ARESC): implications for empiric therapy
Eur Urol
(2008) - et al.
Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA)
Clin Infect Dis
(1999)
When do general practitioners request urine specimens for microbiology analysis? The applicability of antibiotic resistance surveillance based on routinely collected data
J Antimicrob Chemother
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Collaborators: Ioannis Deliolanis, Panagiota Rekatsina and Evangelos Koratzanis (4th Department of Internal Medicine, ATTIKON University General Hospital, Athens, Greece); Olympia Zarkotou and Paraskevi Gavra (Tzaneio General Hospital, Piraeus, Greece); Maria Pyrgioti and Carmen Moldovan (Sismanoglion General Hospital, Marousi, Greece); Helen Malamou-Lada and Panagiotis Gargalianos-Kakolyris (‘George Gennimatas’ General Hospital, Athens, Greece); Despina Halkiadaki (‘Korgialenion-Benakion’ Hellenic Red Cross General Hospital, Athens, Greece); Ekaterini Vogiatzi (Primary Health Care Centre of Nafpaktos, Nafpaktos, Greece); Mina Psychogiou and George L. Daikos (Laikon General Hospital, Athens, Greece); Charalampos Panou and Loukia Kalovoulou (Karpenisi General Hospital, Karpenisi, Greece); Stavroula Zervou, Katerina Geombre, Lemonia Krikou, Katerina Koroni, Aristea Varouta and Andreas Kabalonis (Biomedicine Laboratories, Athens-Thessaloniki, Greece); Charalampos Birbilis (Livadia General Hospital, Livadia, Greece); Christos Kalyvas (‘Hippocrates’ Diagnostic Centre, Nikaia, Greece); and George Veliotis (Interamerican-Eurico, Athens, Greece).