Community-acquired urinary tract infections (UTIs) are among the most common bacterial infections in women. Therapy for these infections is usually begun before results of microbiological tests are ...known. Furthermore, in women with acute uncomplicated cystitis, empirical therapy without a pretherapy urine culture is often used. The rationale for this approach is based on the highly predictable spectrum of etiologic agents causing UTI and their antimicrobial resistance patterns. However, antimicrobial resistance among uropathogens causing community-acquired UTIs, both cystitis and pyelonephritis, is increasing. Most important has been the increasing resistance to trimethoprim-sulfamethoxazole (TMP-SMX), the current drug of choice for treatment of acute uncomplicated cystitis in women. What implications do these trends have for treatment of community-acquired UTIs? Preliminary data suggest that clinical cure rates may be lower among women with uncomplicated cystitis treated with TMP-SMX when the infecting pathogen is resistant to TMP-SMX. Women with pyelonephritis also have less bacterial eradication and lower clinical cure rates when treated with TMP-SMX for an infection that is resistant to the drug. Therefore, in the outpatient setting, identifying risk factors for TMP-SMX resistance and knowing the prevalence of TMP-SMX resistance in the local community are important steps in choosing an appropriate therapeutic agent. When choosing a treatment regimen, physicians should consider such factors as in vitro susceptibility, adverse effects, cost-effectiveness, and selection of resistant strains. Using a management strategy that takes these variables into account is essential for maintaining the safety and efficacy of treatment for acute UTI.
BackgroundA prospective cohort study was conducted to characterize the temporal sequence of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection ...(rUTI) MethodsWomen with acute cystitis and a history of UTI within the previous year self-collected periurethral and urine samples daily and recorded measurements of urine leukocyte esterase, symptoms, and sexual intercourse daily for 3 months. rUTI strains were characterized by pulsed-field gel electrophoresis and genomic virulence profiling. Urinary cytokine levels were measured ResultsThere were 38 E. coli rUTIs in 29 of 104 women. The prevalence of periurethral rUTI strain carriage increased from 46% to 90% during the 14 days immediately preceding rUTI, with similar increases in same-strain bacteriuria (from 7% to 69%), leukocyte esterase (from 31% to 64%), and symptoms (from 3% to 43%), most notably 2–3 days before rUTI (P<.05 for all comparisons). Intercourse with periurethral carriage of the rUTI strain also increased before rUTI (P=.008). Recurrent UTIs preceded by bacteriuria, pyuria, and symptoms were caused by strains less likely to have P fimbriae than other rUTI strains (P=.002) ConclusionsAmong women with frequent rUTIs, the prevalences of periurethral rUTI strain carriage, bacteriuria, pyuria, and intercourse dramatically increase over the days preceding rUTI. A better understanding of the pathogenesis of rUTI will lead to better prevention strategies
CONTEXT Guidelines for the management of acute uncomplicated
cystitis in women that recommend empirical therapy in
properly selected patients rely on the predictability of the agents
causing cystitis ...and knowledge of their antimicrobial susceptibility
patterns. OBJECTIVE To assess the prevalence of and trends in antimicrobial
resistance among uropathogens causing well-defined episodes of acute
uncomplicated cystitis in a large population of women. DESIGN Cross-sectional survey of antimicrobial susceptibilities of
urine isolates collected during a 5-year period (January, May, and
September 1992-1996). SETTING Health maintenance organization. PATIENTS Women aged 18 to 50 years with an outpatient diagnosis of
acute cystitis. MAIN OUTCOME MEASURES Proportion of uropathogens demonstrating in
vitro resistance to selected antimicrobials; trends in resistance over
the 5-year study period. RESULTS Escherichia coli and Staphylococcus
saprophyticus were the most common uropathogens, accounting for
90% of the 4342 urine isolates studied. The prevalence of resistance
among E coli and all isolates combined was more than 20% for
ampicillin, cephalothin, and sulfamethoxazole in each year studied. The
prevalence of resistance to trimethoprim and
trimethoprim-sulfamethoxazole rose from more than 9% in 1992 to more
than 18% in 1996 among E coli, and from 8% to 16% among all
isolates combined. There was a statistically significant increasing
linear trend in the prevalence of resistance from 1992 to 1996
amongE coli and all isolates combined to ampicillin
(P<.002), and to cephalothin, trimethoprim, and
trimethoprim-sulfamethoxazole (P<.001). In contrast, the
prevalence of resistance to nitrofurantoin, gentamicin, and
ciprofloxacin hydrochloride was 0% to 2% among E coli and
less than 10% among all isolates combined, and did not change
significantly during the 5-year period. CONCLUSIONS While the prevalence of resistance to
trimethoprim-sulfamethoxazole, ampicillin, and cephalothin increased
significantly among uropathogens causing acute cystitis, resistance to
nitrofurantoin and ciprofloxacin remained infrequent. These in vitro
susceptibility patterns should be considered along with other factors,
such as efficacy, cost, and cost-effectiveness in selecting empirical
therapy for acute uncomplicated cystitis in women.
Over the past 5–10 years, zero-inflated (ZI) count regression models have been increasingly applied to the analysis of dental caries indices (e.g. DMFT, dfms). The main reason for that is linked to ...the broad decline in children’s caries experience, such that dmf and DMF indices more frequently generate low or even zero counts. This article specifically reviews the application of ZI Poisson and ZI negative binomial regression models to dental caries, with emphasis on the description of the models and the interpretation of fitted model results given the study goals. The review finds that interpretations provided in the published caries research are often imprecise or inadvertently misleading, particularly with respect to failing to discriminate between inference for the class of susceptible persons defined by such models and inference for the sampled population in terms of overall exposure effects. Recommendations are provided to enhance the use as well as the interpretation and reporting of results of count regression models when applied to epidemiological studies of dental caries.
This is part of the series of practice guidelines commissioned by the Infectious Diseases Society of America (IDSA) through its Practice Guidelines Committee. The purpose of this guideline is to ...provide assistance to clinicians in the diagnosis and treatment of two specific types of urinary tract infections (UTIs): uncomplicated, acute, symptomatic bacterial cystitis and acute pyelonephritis in women. The guideline does not contain recommendations for asymptomatic bacteriuria, complicated UTIs, Foley catheter-associated infections, UTIs in men or children, or prostatitis. The targeted providers are internists and family practitioners. The targeted groups are immunocompetent women. Criteria are specified for determining whether the inpatient or outpatient setting is appropriate for treatment. Differences from other guidelines written on this topic include use of laboratory criteria for diagnosis and approach to antimicrobial therapy. Panel members represented experts in adult infectious diseases and urology. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendation and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council, the sponsor and supporter of the guideline. The American Urologic Association and the European Society of Clinical Microbiology and Infectious Diseases have endorsed it. An executive summary and tables highlight the major recommendations. Performance measures are described to aid in monitoring compliance with the guideline. The guideline will be listed on the IDSA home page at http://www.idsociety.org It will be evaluated for updating in 2 years.
Objectives:Mycoplasma genitalium has been associated with cervicitis, endometritis, and tubal factor infertility. Because the ability of this bacterium to ascend and infect the fallopian tube remains ...undefined, we performed an investigation to determine the prevalence of M genitalium in fallopian tube, endometrial, and cervical specimens from women laparoscopically diagnosed with acute salpingitis in Nairobi, Kenya. Methods: Women presenting with pelvic inflammatory disease were laparoscopically diagnosed with salpingitis. Infection with M genitalium in genital specimens was determined by polymerase chain reaction (PCR). Results: Of 123 subjects with acute salpingitis, M genitalium was detected by PCR in the cervix and/or endometrium in nine (7%) participants, and in a single fallopian tube specimen. In addition, those infected with M genitalium were more often HIV infected than women not infected by M genitalium (seven of nine (78%) v 42 of 114 (37%), p<0.03). Conclusions:M genitalium is able to ascend into the fallopian tube, but its association with tubal pathology requires further investigation.
To evaluate factors associated with recurrent urinary tract infection (UTI) in postmenopausal women, we conducted a case-control study comparing 149 postmenopausal women referred to an infectious ...diseases outpatient clinic who had a history of recurrent UTI (case patients) with 53 age-matched women without a history of UTI (control patients). Each woman completed a questionnaire providing demographic data, history and clinical characteristics of prior infections, and information regarding risk factors for UTI. In addition, each patient underwent a gynecologic evaluation, renal ultrasound and urine flow studies, and blood group and secretor status testing. Three urologic factors-namely, incontinence (41% of case patients vs. 9.0% of control patients; P < .001), presence of a cystocele (19% vs. 0%; P < .001), and postvoiding residual urine (28% vs. 2.0%; P = .00008)-were all strongly associated with recurrent UTI. Multivariate analysis showed that urinary incontinence (odds ratio OR, 5.79; 95% confidence interval CI, 2.05-16.42; P = .0009), a history of UTI before menopause (OR, 4.85; 95% CI, 1.7-13.84; P = .003), and nonsecretor status (OR, 2.9; 95% CI, 1.28-6.25; P = .005) were most strongly associated with recurrent UTI in postmenopausal women. Prospective studies are needed to confirm these observations and to develop approaches for prevention.
The objective of this study was to examine genital tissue, vaginal fluid, and vaginal microbial flora at 3 phases of the menstrual cycle in asymptomatic women. Vaginal examinations were performed 3 ...times in 74 women: at the menstrual phase (days 1-5), the preovulatory phase (days 7-12), and the postovulatory phase (days 19-24). Flora of 50 women without bacterial vaginosis (BV) was analyzed separately from flora of 24 women with BV. The volume of vaginal discharge increased and the amount of cervical mucus decreased over the menstrual cycle. Among subjects without BV, the rate of recovery of any Lactobacillus changed little (range, 82% to 98%; P = .2); however, a small increase occurred in the rate of recovery of heavy (3+ to 4+ semiquantitative) growth of Lactobacillus over the menstrual cycle (P = .04). A linear decrease occurred in the rate of recovery of heavy growth of any non-Lactobacillus species, from 72% at days 1-5 to 40% at days 19-24 (P = .002). A linear decrease also occurred in the rate of recovery of Prevotella species, from 56% on days 1-5 to 28% on days 19-24 (P = .007), while a small linear increase occurred in the rate of recovery of Bacteroides fragilis (P = .05). Among subjects with BV, the only significant change was an increase in the rate of recovery of Lactobacillus, from 33% at days 1-5 to 54% at days 19-24 (P = .008). Among all subjects, the rate of recovery of heavy growth of Lactobacillus increased over the menstrual cycle and, in contrast, the concentration of non-Lactobacillus species tended to be higher at menses, which is evidence that the vaginal flora becomes less stable at this time.
Chlamydia trachomatis infections are the most common bacterial sexually transmitted disease in the United States. A substantial proportion of initial infections in both men and women are ...asymptomatic. Use of nucleic acid amplification-based diagnostic tests on first-void urine makes it possible to initiate community-based screening programs aimed at identifying asymptomatically infected men and women. Directly observed single-dose therapy with azithromycin is now available. Screening programs have been demonstrated to reduce the overall prevalence of chlamydial infection in the tested population and to reduce the incidence of subsequent pelvic inflammatory disease in previously screened women. The sequelae of chlamydial infections are likely due to immunopathologically mediated events in which both the chlamydial 60 kDa heat-shock protein and genetic predisposition of specific patients play a role. An improved understanding of immunologic events leading to upper genital tract scarring is needed to target specific interventions and facilitate development of a vaccine.
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