Co-Amoxiclav as empiric treatment of UTI in children: importance of surveillance in ensuring optimal empiric treatment choice

Background Urinary tract infections are common and require prompt treatment. Objective To examine the resistance rates of co-amoxiclav in children with urinary tract infection and whether antimicrobial resistance is influenced by other variables. Methods The records and antibiotic susceptibility data of 209 patients admitted with symptomatic urinary tract infection between January 2018 and December 2019 were reviewed. Results We examined 209 patients [mean (SD) age 23.73 (32.86) months], of whom 176 (84.2%) had first urinary tract infection. Escherichia coli was isolated in 190 (90.1%). Uropathogens were sensitive to co-amoxiclav in 47.8% of patients and gentamicin in 95.2%. Combined co-amoxiclav with gentamicin demonstrated antimicrobial sensitivity in 96.2%. Antimicrobial resistance was associated with longer hospital stay (p-value < 0.02). An association was identified between co-amoxiclav resistance and recurrent urinary tract infections. Uropathogens were resistant to co-amoxiclav in 80/176 (45.5%) and 29/33 (87.9%) patients with first and recurrent urinary tract infections, respectively (p-value 0.001). No link was observed between antimicrobial resistance and atypical urinary tract infection. Conclusion Approximately half of children in this cohort had urinary tract infection due to uropathogens resistant to co-amoxiclav. Co-amoxiclav resistance is associate with recurrent infections and longer hospital stays. A combination of co-amoxiclav and gentamicin demonstrates > 96% susceptibility.

Hematuria in Children with Spinal Injury

The presence of red blood cells (RBCs) in urine is hematuria, even in microscopic amounts alarms the patient and parents of the patient, and often prompts physician for many laboratory investigations. Hematuria can be red, dark or cola-colored, or brown known as macroscopic hematuria, and when it is not visible to the unaided eye, it is known as microscopic hematuria. RBCs in urine is one of the most important signs of genitourinary tract disease; however, it is almost never a cause of anemia, since few drops (1 mL) of blood can turn 1 L of urine into red-colored urine. Overall the physician should be alert enough not to overlook serious conditions like neoplasms and underlying bleeding disorder, to avoid unnecessary and often expensive laboratory studies. This article provides an approach to the evaluation and management of hematuria in children, and the detection of preventable and treatable conditions at the earliest to limit the disease progression, and an overall reduction in cost, energy, and anxiety. The patients are spinal cord injured patients with lower urinary tract dysfunction; special consideration of pediatric and elderly populations is presented separately. The target audience is healthcare providers who are engaged in the medical care of patients with spinal cord injury. The mandatory assessment includes medical history, physical examination, frequency-volume chart, urinalysis, blood chemistry, transabdominal ultrasonography, measurement of postvoid residual urine, uroflowmetry, and video-urodynamic study. Optional assessments include questionnaires on the quality of life, renal scintigraphy, and cystourethroscopy. The presence or absence of risk factors for renal damage and symptomatic urinary tract infection affects urinary management, as well as pharmacological treatments. Further treatment is recommended if the maximum conservative treatment fails to improve or prevent renal damage and symptomatic urinary tract infection. In addition, management of urinary incontinence should be considered individually in patients with risk factors for urinary incontinence and decreased quality of life. Keywords: Children; Kidneys, bladder, neurogenic, injuries, spinal cord, spinal cord disorders, ; RBC cast; Red blood cells; Urine, ASIA (American Spinal Injury Association)

High dose versus low dose standardized cranberry proanthocyanidin extract for the prevention of recurrent urinary tract infection in healthy women: a double-blind randomized controlled trial

Purpose Our objective was to assess the efficacy of a high dose cranberry proanthocyanidin extract for the prevention of recurrent urinary tract infection. Material and methods We recruited 145 healthy, adult women with a history of recurrent urinary tract infection, defined as ≥ 2 in the past 6 months or ≥ 3 in the past 12 months in this randomized, controlled, double-blind clinical trial. Participants were randomized to receive a high dose of standardized, commercially available cranberry proanthocyanidins (2 × 18.5 mg daily, n = 72) or a control low dose (2 × 1 mg daily, n = 73) for a 24-week period. During follow-up, symptomatic women provided urine samples for detection of pyuria and/or bacteriuria and received an appropriate antibiotic prescription. The primary outcome for the trial was the mean number of new symptomatic urinary tract infections during a 24-week intervention period. Secondary outcomes included symptomatic urinary tract infection with pyuria or bacteriuria. Results In response to the intervention, a non-significant 24% decrease in the number of symptomatic urinary tract infections was observed between groups (Incidence rate ratio 0.76, 95%CI 0.51–1.11). Post-hoc analyses indicated that among 97 women who experienced less than 5 infections in the year preceding enrolment, the high dose was associated with a significant decrease in the number of symptomatic urinary tract infections reported compared to the low dose (age-adjusted incidence rate ratio 0.57, 95%CI 0.33–0.99). No major side effects were reported. Conclusion High dose twice daily proanthocyanidin extract was not associated with a reduction in the number of symptomatic urinary tract infections when compared to a low dose proanthocyanidin extract. Our post-hoc results reveal that this high dose of proanthocyanidins may have a preventive impact on symptomatic urinary tract infection recurrence in women who experienced less than 5 infections per year. Trial registration: Clinicaltrials.gov, identifier NCT02572895

Impact of Treating Asymptomatic Bacteriuria in Kidney Transplant Recipients: A Prospective Cohort Study

This study aims to define the epidemiologic, clinical, and microbiological features of asymptomatic bacteriuria (AB) and cystitis in kidney transplantation recipients (KTRs), and to determine the impact of antimicrobial therapy of AB and the risk factors of cystitis. We conducted a prospective observational study of AB and cystitis in KTRs from January to June 2017. One-hundred ninety seven KTRs were included: 175 (88.8%) with AB and 22 (11.2%) with cystitis. The most frequent etiologies were Escherichia coli, Klebsiellapneumoniae, Enterococcusfaecalis, and Pseudomonas aeruginosa. No differences were observed regarding the etiologies, antimicrobial susceptibility patterns, and microbiologic outcomes in AB vs. cystitis. The treatment of AB diminished the microbiological cure and increased the rates of microbiologic relapses and reinfections; in addition, treated AB patients showed a trend of developing symptomatic urinary tract infection in the following six months. The analysis of the data identified the following independent risk factors for cystitis during the six months of follow-up: AB treatment, thymoglobulin induction, previous acute pyelonephritis, and time since transplantation < 1 year. In summary, considering the lack of clinical benefits of treating AB and its impact on cystitis development in the follow-up, we support the recommendation of not screening for or treating AB.

Antimicrobial Prophylaxis for Children With Vesicoureteral Reflux

This chapter summarizes the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial, a landmark trial that randomized children with vesicoureteral reflux diagnosed after a first or second febrile or symptomatic urinary tract infection to receive trimethoprim–sulfamethoxazole (TMP-SMX) prophylaxis versus placebo. It found that antibiotic prophylaxis reduced the incidence of recurrent febrile or symptomatic urinary tract infection but had little effect on renal scarring. Recurrent febrile or symptomatic urinary tract infections resistant pathogens were increased. This study provides the underpinning for guidelines that advocate for low-dose antibiotic prophylaxis for the first year of life; however, this remains an area of considerable controversy.

Prevalence and Bacteriology of Symptomatic Urinary Tract Infection among Pregnant women at Mbarara Regional Referral Hospital, South-western Uganda

Background: Urinary tract infections (UTIs) in pregnant women contribute about 25% of all infections and are among the most frequent clinical bacterial infections. Pregnancy changes in women that include anatomical, physiological and hormonal make them susceptible to develop UTI. Left untreated, UTI in pregnancy is associated with grave complications to the mother and fetus. These complications can be decreased by prompt and proper diagnosis and appropriate treatment that also reduces the emergency of drug resistance. Antimicrobial resistance is a major health problem in the treatment of UTI. We determined the prevalence, bacteriology and antimicrobial susceptibility of symptomatic urinary tract infection among pregnant women at Mbarara Regional Referral Hospital.Methods: We conducted a cross-sectional study from November 2019 to February 2020 involving 400 pregnant women with symptomatic UTI. Patient information was obtained using a structured questionnaire. We collected clean-catch midstream urine specimens for culture and performed antimicrobial susceptibility testing following Clinical and Laboratory Standards Institute standards. Data was entered into RED-cap Version 8.2 software and then exported to Stata Version 14.1 for analysis.Results: The proportion of culture-positive UTI was 140/400 (35%). Gram-negative bacteria were more prevalent (73%): Klebsiella pneumoniae 52(37.41%), Escherichia coli 40(28.78%), Pseudomonas aeruginosa and Proteus mirabilis 7(5.04% each), Citrobacter freundii 1(1%). Staphylococcus aureus 33(23.57%) was the only gram-positive isolate. All the isolates were resistant to ampicillin, amoxicillin, amoxicillin/clavulanic acid and ceftazidime/clavulanic acid (95.7%, 95.0%, 72.9% and 50.7% respectively). Prevalence of extended-spectrum beta-lactamases producing Enterobacteriaceae was 29.0% while that of methicillin-resistant Staphylococcus aureus was 33.3%. Multi-drug resistance (resistance in >2 drugs) was seen in 100% of the isolated bacteria. Majority of the bacterial isolates were sensitive to ciprofloxacin, ceftriaxone, nitrofurantoin, cefotaxime and gentamicin at 82.9%, 81.4%, 79.3%, 78.6%, 66.4% and 65.7% respectivelyConclusions: Klebsiella pneumoniae was the most prevalent isolate followed by E. coli. These two organisms were highly resistant to the commonly used antibiotics. Our study recorded a higher prevalence of culture-positive UTI in pregnancy than all the studies in Uganda. Empirical treatment of UTI should be minimized as sensitivity varies for each organism, for each drug and over time.

P1736FIRST PROSPECTIVE CLINICAL STUDY OF A SINGLE-USE STERILE CYSTOSCOPE DESIGNED FOR DOUBLE J (DJ) STENT REMOVAL IN AN ITALIAN TRANSPLANT CENTER

Background and Aims A DJ is routinely placed during kidney transplantation then post-operatively removed, usually within the first month after transplantation. The removal is mainly performed in urology unit, through reusable rigid scope in an operating theatre with anesthesiologist assistance. Such removal procedure requires a complex environment with reprocessing, periodic maintenance and repairs of scopes, leading to delays and postponed stent removals. Hematuria, pain or dysuria due to the local trauma, and urinary infection are the most common complications of the DJ removal procedure. To overcome these issues, we introduced in April 2018 in our unit the single use sterile cystoscope ready to use with integrated grasper designed for DJ removals. Method We hereby report our experience with single-use flexible cystoscope (Isiris® – Coloplast). We prospectively collected data of any DJ stent removal operation from April 2018 to December 2019 (92 procedures). Urine culture at the removal day and usually 1 week after, at the first outpatient control was performed. All complications (related or not to the procedure) were recorded. All removals were performed in our unit by the nephrologist. 87 patients were treated, from which 82 as outpatients, and 5 as in-patients. Results 86 out of 87 patients stent removals were effectively done with Isiris®. In a single case, we could not remove the stent with the single-use instrument and resorted to traditional rigid cystoscopy under general anaesthesia. This happened with the sixth patient of our series and we think that this failure happened in the learning curve phase. In 4 cases stent removal wasn’t possible at first attempt due to likely interference of the internal stitches of the anastomosis: our policy is NOT to force stent removal if any resistance is felt to light pulling. Indeed, in all 4 cases a second procedure performed one month later was completely successful with smooth withdrawal of the device. In one case, a removal procedure was not possible because of urethral stricture and stent removal was postponed after its treatment. Taking into account these five patients the success rate of using Isiris® is 98.9% during this period. No patient was admitted for complications related to the removal procedure, namely for symptomatic urinary tract infection requiring antibiotics. Two patients were admitted for obstructive nephropathy (namely ureteral stenosis) which became evident after stent removal. 16 patients had an asymptomatic positive urine culture for a multi-resistant microbe before the stent removal and maintained positivity after the procedure. 11 patients were negative on the day of the stent removal and resulted positive in the control done at the first control. Again, none developed symptoms, and none required treatment. 9 patients were positive before stent removal and were negative on the first control. The rest of the patients were negative both at baseline and thereafter. Conclusion Due to the simplicity of the procedure by the single use solution (with 98.9% removal success, no operating theatre, no anaesthesiologist) and the fact that it is entirely managed by the transplantation clinic staff, the timing of the stent removal always respected physician’s indication, with no procedure delayed for organizational reasons. Knowing the infection risk associated with longest ureteral stent dwell durations, and the vulnerability of these immunosuppressed patients, it is important to remove the DJ as safely as possible and in defined time. In our study, no patient had to be admitted for urinary tract infection after the procedure nor developed symptomatic urinary tract infection to be treated with antibiotics.

Asymptomatic Bacteriuria and Pyuria in Premenopausal Women

Background Asymptomatic bacteriuria and pyuria in healthy women often trigger inappropriate antimicrobial treatment, but there is a paucity of data on their prevalence and persistence. Methods To evaluate the prevalence and persistence of asymptomatic bacteriuria and pyuria in women at high risk of recurrent urinary tract infection, we conducted an observational cohort study in 104 healthy premenopausal women with a history of recurrent urinary tract infection with daily assessments of bacteriuria, pyuria, and urinary symptoms over a 3-month period. Results The mean age of participants was 22 years, and 74% were white. Asymptomatic bacteriuria events (urine cultures with colony count ≥105 CFU/mL of a uropathogen on days with no symptomatic urinary tract infection diagnosed) occurred in 45 (45%) women on 159 (2.5%) of 6283 days. Asymptomatic bacteriuria events were most commonly caused by Escherichia coli, which was present on 1.4% of days, with a median duration of 1 day (range, 1–10). Pyuria occurred in 70 (78%) of 90 evaluable participants on at least 1 day and 25% of all days on which no symptomatic urinary tract infection was diagnosed. The positive predictive value of pyuria for E. coli asymptomatic bacteriuria was 4%. Conclusions In this population of healthy women at high risk of recurrent urinary tract infection, asymptomatic bacteriuria is uncommon and, when present, rarely lasts more than 2 days. Pyuria, on the other hand, is common but infrequently associated with bacteriuria or symptoms. These data strongly support recommendations not to screen for or treat asymptomatic bacteriuria or pyuria in healthy, nonpregnant women.