Objective: To determine the optimal management of catheter-acquired bacteriuria after short-term catheter use in women. Patients: Asymptomatic patients (119) with catheter-acquired bacteriuria were...

How Long Should Catheter-Acquired Urinary Tract Infection in Women Be Treated?

An objective measure of clinical performance

Isolates of gentamicin-resistant gram-negative bacilli from clinical specimens peaked at nine to 10 per month in 1973-1974. Instituting barrier-type precautions during 1974-1977 was associated with a sustained 87% reduction in resistant Enterobacteriaceae. The number of resistant Pseudomonadaceae fell temporarily by 28%, paralleling gentamicin usage. During an endemic 15-month period in 1976-1977 nonenzymatically mediated resistant Pseudomonas aeruginosa often emerged after aminoglycoside therapy in patients who had prior carriage of sensitive strains of the same serotype (P = 0.002); this resistance was associated with wound or sputum isolates (P = 0.003). Resistant Enterobacteriaceae more often demonstrated the converse, that is, spread of urinary tract isolates with enzymatically mediated resistance from patients not on aminoglycoside therapy. These findings suggest that control measures to minimize occurrence of resistant bacilli include barrier-type precautions for patients with resistant Enterobacteriaceae, evaluation of transfers and readmissions as a source of resistant organisms, and reduction of aminoglycoside use to decrease the selection of nonenzymatic resistance.

Endemic Aminoglycoside Resistance in Gram-Negative Bacilli: Epidemiology and Mechanisms

One hundred seventeen unselected women with symptoms of acute cystitis were randomized to groups for immediate therapy with one of the following four single-dose regimens: (1) 1 g of sulfisoxazole; (2) 2 g of sulfisoxazole; (3) a combination of trimethoprim, 160 mg, and sulfamethoxazole, 800 mg; and (4) a combination of trimethoprim, 320 mg, and sulfamethoxazole, 1,600 mg. Forty-one women were excluded, 13 did not return for follow-up, and 28 did not have significant bacteriuria in the pretherapy culture. Escherichia coli was isolated in 81% of infections. Antibacterial activity was significantly greater in urine collected during the 24 hours after therapy in those who received trimethoprim-sulfamethoxazole. However, overall cure varied from 85% to 95%, without any great differences between the regimens. The rate of cure of 69% in the 13 patients with presumptive evidence of renal infection (antibody-coated bacteria present) was significantly lower than the rate of cure of 95% in women without evidence of renal infection. Single-dose therapy with these regimens was safe and effective in adult women with symptoms of acute cystitis, regardless of the localization of the site of infection. ( JAMA 1982;247:1839-1842)

Therapy for acute cystitis in adult women. Randomized comparison of single-dose sulfisoxazole vs trimethoprim-sulfamethoxazole.

Thirteen women and two preadolescent girls who suffered recurrences after six months of prophylaxis with trimethoprim (TMP; 40 mg) and sulfamethoxazole (SMZ; 200 mg) taken thrice weekly at bedtime were enrolled in a 24-month study of prophylaxis with the same region. During 29.1 cumulative patient-years of prophylaxis, two infections due to Escherichia coli and one each due to Staphylococcus epidermidis and Streptococcus faecalis occurred (0.14 infection/patient-year). MICs for these isolates were less than or equal to 2 micrograms of TMP/ml and greater than 512 micrograms of SMZ/ml. During prophylaxis, 106 of 116 cultures from the periurethral area and 66 of 97 cultures from the anal and canal yielded no aerobic gram-negative bacilli. In three patients, the periurethral area was colonized with aerobic gram-negative bacilli with MICs of greater than or equal to 2 micrograms of TMP/ml. Thirteen patients were followed after the discontinuation of prophylaxis. Eight suffered recurrences, seven with organisms susceptible to TMP. After one year the remaining five had experienced no recurrences. It is concluded that long-term prophylaxis with 40 mg of TMP and 200 mg of SMZ thrice weekly is an effective, well-tolerated regimen that can maintain an infection-free state in women with histories of frequent urinary reinfections.

Long-Term Antimicrobial Prophylaxis for Recurrent Urinary Tract Infection in Women

Netilmicin, a new semisynthetic aminoglycoside antibiotic, was used to treat 41 infections in 38 patients. The outcome of four infections could not be evaluated: two patients received inadequate therapy and two did not have gram-negative infections. Clinical improvement occurred in 36 (97%) of the 37 gram-negative infections, and bacteriologic cure occurred in 30 (86%) of the 35 evaluable infections. Therapeutic serum concentrations of netilmicin were readily achieved by both intramuscular and intravenous routes. Reversible ototoxic effects occurred in 1 (3%) of 35 courses of therapy evaluated, reversible nephrotoxic effects occurred in 5 (14%) of 36 courses and mild reversible alterations in liver function occurred in 3 (19%) of 34 courses. Netilmicin appears to be effective and safe in the treatment of aerobic gram-negative infections.

Clinical efficacy and toxicity of netilmicin in the treatment of gram-negative infections

The efficacy and safety of amikacin were evaluated in 42 patients with infections presumed to be due to gram-negative rods. The dosage of 7.5 mg of amikacin/kg every 12 hr was administered intramuscularly to 32 patients and intravenously to seven patients; three patients with renal impairment were given a modified regimen. The duration of treatment was three to 51 days (mean, 9.6 days). Of 19 patients with acute pyelonephritis, five had positive blood culture results. Ten patients had chronic urinary infection, and isolates of Pseudomonas aeruginosa from four of these patients acquired resistance to amikacin during therapy. Of seven patients with gram-negative bacteremia from sources other than the urinary tract, four showed satisfactory and three had less than optimal responses to therapy with amikacin. Two patients with chronic osteomyelitis or soft tissue infection improved but subsequently relapsed. Two patients with acute febrile illness, in whom the etiologic agent was unidentified, recovered. Serial audiograms revealed no change in 26 of 27 patients; one had a significant deterioration in hearing. A transient rise in the level of serum creatinine was noted in three patients. Serial tests of liver function revealed no abnormalities.

Clinical Evaluation of Amikacin in Treatment of Infections Due to Gram-Negative Aerobic Bacilli

Tobramycin, an aminoglycoside antibiotic, was used to treat 52 infections due to gram-negative organisms in 51 patients. Complicated urinary tract infections, bacteremia and pyelonephritis accounted for 80% of the infections. The rate of immediate satisfactory response was 79%. During therapy with tobramycin, resistant organisms emerged in four patients--two Pseudomonas aeruginosa and two Escherichia coli strains. There were four superinfections with tobramycin-resistant Providencia sp. In four seriously ill patients the serum creatinine concentration increased 1 mg/dL or more; in three the increase was transient. No auditory toxicity was noted in the 19 patients in whom serial audiograms were made. In vitro testing of isolates from these patients showed that tobramycin and gentamicin had equal activity against Enterobacteriaceae. Tobramycin was two to four times more active against susceptible P. aeruginosa.

Clinical and laboratory study of tobramycin in the treatment of infections due to Gram-negative organisms.

Abstract This case–control study of 25 cases with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with vancomycin minimum inhibitory concentration (MIC) ≥ 2 µg/mL and 391 controls (MIC < 2 µg/mL) characterized the clinical characteristics, treatments, and outcomes associated with elevated vancomycin MIC. Elevated vancomycin MIC was associated with baseline hemodialysis, prior MRSA colonization, and metastatic infection.

/pdf/methicillin-resistant-staphylococcus-aureus-bacteremia-with-2z1dfjb4.pdf

Methicillin-resistant Staphylococcus aureus bacteremia with elevated vancomycin minimum inhibitory concentrations

Clinical andlaboratory study oftobramycin inthetreatment ofinfections duetogram*negative organisms

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