Urinary tract infections
Abstract number: S17
Urinary tract infections (UTI) are the most common bacterial infections in women. The spectrum includes an umpteenth, patient-familiar episode of a recurrent cystitis to a fatal UTI-linked gramnegative sepsis. In primary healthcare (PHC) three major clinical pictures are important: acute cystitis or uncomplicated lower UTI, recurrent cystitis and acute pyelonephritis.
Discussing treatment of cystitis in PHC regards essentially (1) the growing resistance of uropathogens against familiar drugs used in cystitis, (2) the place of newer drugs such as the oral chinolones, (3) and the duration of therapy. Therapeutic dilemmas in community acquired acute pyelonephritis are: (1) which patients can be treated ambulatory and (2) with which drug.
In acute and recurrent cystitis treatment choices are mostly empirical. This implies that bacterial species and resistance have to be anticipated reliably. In recent years alarming resistance data in uropathogens have persuaded physicians to choose broadspectrum antimicrobial agents. But most of these data come from surveillance studies on all uropathogens in regional bacteriological laboratories. Important selection of urine samples occur in this setting: most samples sent to the bacteriological laboratory came from complicated infections, immune-incompetent patients or people with urologic problems such as pyelum stones. In contrast, the majority of cystitis is encountered in healthy women, so extrapolation of these resistance data is speculative. We performed a surveillance in this healthy population with cystitis and found no alarming resistance at all; moreover, a new surveillance 10 years later showed no increase of resistance in uropathogens encountered in these women. This means that nitrofurantoin remains the first choice in the Belgian GP-guideline (the same applies to the Dutch and the French guideline) Trimethoprim can still be useful but in GB and in the Netherlands more resistance has been observed. Chinolones are efficient but not superior. Because of high resistance, amoxicillines cannot be given empirically, which is a major problem in pregnant women for whom it is the safest drug.
The ideal duration of treatment remains controversial, but a recent Cochrane review showed equivalence in success in treatment s of 3 days compared with 5 days or more in all studied drugs. In this case, we are more uncertain about the use of nitrofurans, they are frequently prescribed for five days because of lack of data for 3 days. Physicians have to be aware that with these short treatments most patients will still have symptoms at the moment in which drug intake is stopped.
The field of recurrent cystitis is very unpopular, so study data are scarse. Nitrofurans seem most active; of course renal impairment should be taken into account. By resulting in less drug intake for equal efficacity, self-treatment is more attractive than chronic use.
Acute pylonephritis is not so common as the former infections, but it is of course a potential life-threatening situation. Hospitalisation has been the rule until recently the chinolones has proven to be a safe ambulatory oral treatment in otherwise healthy individuals. Only by reserving chinolones for serious infections we do not induce chinolone-resistance in Gram-negative bacteria and spoil life-saving drugs in uncomplicated infections. UTI are an interesting field to develop and to study rational antbiotherapy.
|Session name:||18th European Congress of Clinical Microbiology and Infectious Diseases|
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