- Email: [email protected]
SP34-2 Recurrent urinary tract infections. Antibiotic resistance and non-antibiotic prophylaxis
S38
Keynote sessions and Symposia / International Journal of Antimicrobial Agents 42S2 (2013) S1–S40
SP34-2 Recurrent urinary tract infections. Antibiotic resistance and non-antibiotic prophylaxis M.A. Beerepoot *. Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam, The Netherlands E-mail address : [email protected] Emerging antibiotic resistance necessitates studying non-antibiotic alternatives in the prevention of urinary tract infections. This presentation focuses on non-antibiotic prophylaxis of urinary tract infections in adults, mainly women, with recurrent urinary tract infections. In addition, the development of antibiotic resistance in women using long-term low-dose antibiotic prophylaxis and the predictive value of asymptomatic bacteriuria in women with recurrent urinary tract infections will be discussed. First, the results of a systematic review and meta-analysis on the efficacy and tolerability of non-antibiotic prophylaxis compared to placebo or no treatment will be presented. Of the oral immunostimulant OM-89, the vaginal mucosal vaccine Urovac, (vaginal or oral) estrogens, acupuncture, cranberries and lactobacilli prophylaxis, OM-89 seems the most promising. Second, the results of the two double-blind randomized controlled trials of the NAPRUTI study (“Non-antibiotic versus Antibiotic Prophylaxis for Recurrent Urinary Tract Infections”) will be shown. In these two interlinked non-inferiority trials, the effect of 12 months of non-antibiotic prophylaxis (cranberry or lactobacilli capsules) was compared to long-term low-dose antibiotic prophylaxis with trimethoprim–sulfamethoxazole. Primary endpoints were the rate of UTI recurrence and the development of antibiotic resistance. Cranberry was found to be inferior to antibiotic prophylaxis. Lactobacilli prophylaxis was only slightly less effective than antibiotic prophylaxis. However, unlike trimethoprim–sulfamethoxazole, cranberries and lactobacilli did not increase antibiotic resistance. Determinants contributing to the development of antimicrobial resistance in Escherichia coli isolated from urinary and fecal samples will also be considered. Third, we discuss the predictive value of asymptomatic bacteriuria. Whether asymptomatic E. coli strains are predictive for the subsequent UTI-causing strain with regard to antimicrobial susceptibility and pulsed-field gel-electrophoresis pattern will be elucidated. Finally, the implications for future research and clinical practice will be discussed. SP34-3 Treatment and prevention for urinary tract infection in children S.S. Yang1,2 *. 1 Division of Urology, Department of Surgery, Buddhist Tzu Chi General Hospital, Taipei Branch, New Taipei, Taiwan , 2 Department of Urology, School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan E-mail address : [email protected], [email protected] Treatment of urinary tract infection (UTI) in children relies mainly on early recognition of non-specific infection signs, particularly in infants. Then empirical antibiotics based on local susceptibility can be given immediately. Definite antibiotics can be adapted by the subsequent culture. The recommended duration of antibiotics treatment is 10–14 days in parental or oral forms. With this active and prolonged antibiotic treatment, hopefully, new renal scar formation could be avoided. To avoid the serious consequence of UTI in children, vigorous diagnostic tests are used to detect the underlying pathophysiology. Lower urinary tract dysfunction (LUTD) is one of the most common causes in the development and UTIs. Through managing LUTD, hopefully, pediatric UTI can be reduced. Elevated or increased post-void residual urine (PVR) has been defined as PVR > 10% bladder capacity in adults and PVR > 10 ml in children. Our recent observation in healthy children found that PVR is related to age, gender and bladder capacity. Based on the lower value of two consecutive PVRs, elevated PVR can be defined as PVR > 10 ml or 6% of bladder capacity. Using 4-hour voiding observation, we defined the cut-off point for elevated PVR in nontoilet infants and children as 10 ml or 20% of bladder capacity. With
this new definition, hopefully, the relationship between PVR and UTI can be clearly delineated. Dysfunctional voiding, defined as increased sphincter activity during voiding, may result in increased PVR, vesicoureteral reflux (VUR). The dyscoordinated sphincter may squeeze bacteria from the urethra to the bladder. Hence, dysfunctional voiding increases the risk of UTI. Biofeedback relaxation of pelvic floor muscle may reverse dysfunctional voiding, reduce the recurrence of UTI, and improve the resolution of VUR. Vesicoureteral reflux is a risk factor for upper urinary tract damage. VUR can be a result of LUTD. Through managing LUTD, more than half of VUR will be subsided. Based on a recent report of American Pediatric Association, the role of VUR in the management of UTI is decreasing. Urethrovaginal reflux can cause persistent infection in the vagina, and re-UTI. Urethrovestibular reflux is a variant of urethrovaginal reflux. Recognizing and treating these two specific refluxes are valuable in the prevention of recurrent UTI. Bladder outlet obstruction (BOO) such as bladder neck dysfunction, posterior urethral valve, Cobb’s collar and anterior urethral valve may increase PVR and result in UTI. Adequate treatment of BOO is the corner stone in the treatment of LUTD and, possible, the prevention of UTI. In conclusion, urological factors should be investigated in children with recurrent UTI. Well management of the underlying urological factors is mandatory in the treatment and prevention of UTI. SP34-4 Prevention of surgical site infection in urology S. Arakawa *. Kobe, Japan E-mail address : [email protected] In the urological field, various operations such as clean, clean contaminated, contaminated ones are performed routinely. Generally the concept of surgical management around operations is changing. Among them, prompt perioperative antimicrobial prophylaxis (AMP) to prevent surgical site infections (SSI) is considered to be more and more important. Urology is one of the surgical divisions and handles many organs – kidney, ureter, bladder, adrenal, prostate, testis, and so on – operatively. According to CDC recommendations, within 24 hours administration of AMP after the operation is gold standard, however in Japanese guide composed by Japanese Association for Infectious Diseases and Japan Society of Chemotherapy AMP within 48 hours is proposed. There is evidence that 72 hours or more administration of perioperative AMP causes the emergence of multi drug resistant bacteria significantly often. Important task is whether one day administration of AMP shows no different or less rates of SSI than more longer AMP or not. Japanese Society for Surgical Infection is now studying double blind comparative trials of SSI incidence between one day AMP and multiple days AMP groups. If these studies prove no different or less rates of SSI in one day group, Japanese principle will change to be one day AMP. In the urological field also, in near future most operations especially clean and clean contaminated ones would need only one day AMP. This concept will contribute more proper distribution of medical budget and resolve of increasing expenditure of social services. Symposium 35. Complicated intra-abdominal infections with antibiotic resistance increasing SP35-1 Gram-positive bacteria (MRSA, VRE) in complicated intra-abdominal infections – do they play a role? C. Eckmann *. Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Germany E-mail address : [email protected] Complicated intra-abdominal infections (cIAI) are difficult to manage, often leading to substantial morbidity and mortality in affected patients. The treatment of cIAI consists in general of surgical and/or interventional source control, intensive care and administration of antibiotics. Failure to initiate appropriate antimicrobial therapy early
Keynote sessions and Symposia / International Journal of Antimicrobial Agents 42S2 (2013) S1–S40
SP34-2 Recurrent urinary tract infections. Antibiotic resistance and non-antibiotic prophylaxis M.A. Beerepoot *. Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam, The Netherlands E-mail address : [email protected] Emerging antibiotic resistance necessitates studying non-antibiotic alternatives in the prevention of urinary tract infections. This presentation focuses on non-antibiotic prophylaxis of urinary tract infections in adults, mainly women, with recurrent urinary tract infections. In addition, the development of antibiotic resistance in women using long-term low-dose antibiotic prophylaxis and the predictive value of asymptomatic bacteriuria in women with recurrent urinary tract infections will be discussed. First, the results of a systematic review and meta-analysis on the efficacy and tolerability of non-antibiotic prophylaxis compared to placebo or no treatment will be presented. Of the oral immunostimulant OM-89, the vaginal mucosal vaccine Urovac, (vaginal or oral) estrogens, acupuncture, cranberries and lactobacilli prophylaxis, OM-89 seems the most promising. Second, the results of the two double-blind randomized controlled trials of the NAPRUTI study (“Non-antibiotic versus Antibiotic Prophylaxis for Recurrent Urinary Tract Infections”) will be shown. In these two interlinked non-inferiority trials, the effect of 12 months of non-antibiotic prophylaxis (cranberry or lactobacilli capsules) was compared to long-term low-dose antibiotic prophylaxis with trimethoprim–sulfamethoxazole. Primary endpoints were the rate of UTI recurrence and the development of antibiotic resistance. Cranberry was found to be inferior to antibiotic prophylaxis. Lactobacilli prophylaxis was only slightly less effective than antibiotic prophylaxis. However, unlike trimethoprim–sulfamethoxazole, cranberries and lactobacilli did not increase antibiotic resistance. Determinants contributing to the development of antimicrobial resistance in Escherichia coli isolated from urinary and fecal samples will also be considered. Third, we discuss the predictive value of asymptomatic bacteriuria. Whether asymptomatic E. coli strains are predictive for the subsequent UTI-causing strain with regard to antimicrobial susceptibility and pulsed-field gel-electrophoresis pattern will be elucidated. Finally, the implications for future research and clinical practice will be discussed. SP34-3 Treatment and prevention for urinary tract infection in children S.S. Yang1,2 *. 1 Division of Urology, Department of Surgery, Buddhist Tzu Chi General Hospital, Taipei Branch, New Taipei, Taiwan , 2 Department of Urology, School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan E-mail address : [email protected], [email protected] Treatment of urinary tract infection (UTI) in children relies mainly on early recognition of non-specific infection signs, particularly in infants. Then empirical antibiotics based on local susceptibility can be given immediately. Definite antibiotics can be adapted by the subsequent culture. The recommended duration of antibiotics treatment is 10–14 days in parental or oral forms. With this active and prolonged antibiotic treatment, hopefully, new renal scar formation could be avoided. To avoid the serious consequence of UTI in children, vigorous diagnostic tests are used to detect the underlying pathophysiology. Lower urinary tract dysfunction (LUTD) is one of the most common causes in the development and UTIs. Through managing LUTD, hopefully, pediatric UTI can be reduced. Elevated or increased post-void residual urine (PVR) has been defined as PVR > 10% bladder capacity in adults and PVR > 10 ml in children. Our recent observation in healthy children found that PVR is related to age, gender and bladder capacity. Based on the lower value of two consecutive PVRs, elevated PVR can be defined as PVR > 10 ml or 6% of bladder capacity. Using 4-hour voiding observation, we defined the cut-off point for elevated PVR in nontoilet infants and children as 10 ml or 20% of bladder capacity. With
this new definition, hopefully, the relationship between PVR and UTI can be clearly delineated. Dysfunctional voiding, defined as increased sphincter activity during voiding, may result in increased PVR, vesicoureteral reflux (VUR). The dyscoordinated sphincter may squeeze bacteria from the urethra to the bladder. Hence, dysfunctional voiding increases the risk of UTI. Biofeedback relaxation of pelvic floor muscle may reverse dysfunctional voiding, reduce the recurrence of UTI, and improve the resolution of VUR. Vesicoureteral reflux is a risk factor for upper urinary tract damage. VUR can be a result of LUTD. Through managing LUTD, more than half of VUR will be subsided. Based on a recent report of American Pediatric Association, the role of VUR in the management of UTI is decreasing. Urethrovaginal reflux can cause persistent infection in the vagina, and re-UTI. Urethrovestibular reflux is a variant of urethrovaginal reflux. Recognizing and treating these two specific refluxes are valuable in the prevention of recurrent UTI. Bladder outlet obstruction (BOO) such as bladder neck dysfunction, posterior urethral valve, Cobb’s collar and anterior urethral valve may increase PVR and result in UTI. Adequate treatment of BOO is the corner stone in the treatment of LUTD and, possible, the prevention of UTI. In conclusion, urological factors should be investigated in children with recurrent UTI. Well management of the underlying urological factors is mandatory in the treatment and prevention of UTI. SP34-4 Prevention of surgical site infection in urology S. Arakawa *. Kobe, Japan E-mail address : [email protected] In the urological field, various operations such as clean, clean contaminated, contaminated ones are performed routinely. Generally the concept of surgical management around operations is changing. Among them, prompt perioperative antimicrobial prophylaxis (AMP) to prevent surgical site infections (SSI) is considered to be more and more important. Urology is one of the surgical divisions and handles many organs – kidney, ureter, bladder, adrenal, prostate, testis, and so on – operatively. According to CDC recommendations, within 24 hours administration of AMP after the operation is gold standard, however in Japanese guide composed by Japanese Association for Infectious Diseases and Japan Society of Chemotherapy AMP within 48 hours is proposed. There is evidence that 72 hours or more administration of perioperative AMP causes the emergence of multi drug resistant bacteria significantly often. Important task is whether one day administration of AMP shows no different or less rates of SSI than more longer AMP or not. Japanese Society for Surgical Infection is now studying double blind comparative trials of SSI incidence between one day AMP and multiple days AMP groups. If these studies prove no different or less rates of SSI in one day group, Japanese principle will change to be one day AMP. In the urological field also, in near future most operations especially clean and clean contaminated ones would need only one day AMP. This concept will contribute more proper distribution of medical budget and resolve of increasing expenditure of social services. Symposium 35. Complicated intra-abdominal infections with antibiotic resistance increasing SP35-1 Gram-positive bacteria (MRSA, VRE) in complicated intra-abdominal infections – do they play a role? C. Eckmann *. Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Germany E-mail address : [email protected] Complicated intra-abdominal infections (cIAI) are difficult to manage, often leading to substantial morbidity and mortality in affected patients. The treatment of cIAI consists in general of surgical and/or interventional source control, intensive care and administration of antibiotics. Failure to initiate appropriate antimicrobial therapy early