Acute uncomplicated cystitis: from surveillance data to a rationale for empirical treatment

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Abstract

The objectives of this study were to explore the epidemiological features and resistance rates in uropathogens isolated from cases of acute uncomplicated cystitis (AUC) in Greece, and subsequently to guide empirical treatment. Urine samples from outpatients aged >16 years were cultured and for each uropathogen isolated non-susceptibility to orally administered antimicrobial agents was defined. Demographic and clinical data were provided in questionnaire form. From January 2005 to March 2006 a total of 1936 non-duplicate positive urinary cultures were collected and 889 AUC cases were evaluated. Escherichia coli was the main aetiological agent (83%). In the AUC group, non-susceptibility rates for E. coli isolates were as follows: amoxicillin 25.8%; co-trimoxazole 19.2%; cefalothin 14.9%; nitrofurantoin 10.7%; amoxicillin/clavulanic acid 5.2%; nalidixic acid 6%; mecillinam 3.4%; ciprofloxacin 2.2%; cefuroxime 1.7%, and fosfomycin 1.6%. Amoxicillin and/or co-trimoxazole use in the previous 3 months was significantly associated with isolation of a co-trimoxazole-resistant E. coli isolate. The same applied for previous use of a fluoroquinolone agent and isolation of a ciprofloxacin-resistant E. coli isolate. In conclusion, increased co-trimoxazole non-susceptibility rates undermine its use as a first-line agent in empirical treatment, especially in cases of recent use of co-trimoxazole and/or amoxicillin. Fluoroquinolones display potent in vitro activity against community uropathogens, but prudent use is warranted for uncomplicated infections. Mecillinam and nitrofurantoin could serve as effective front-line agents in an effort to design fluoroquinolones-sparing regimens.

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.

Section snippets

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

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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).

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