InfectionsSurveillance Study in Europe and Brazil on Clinical Aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): Implications for Empiric Therapy
Introduction
Urinary tract infections (UTIs) are among the most frequent infections seen in women [1]. UTI is classified as uncomplicated if it occurs in patients with a structurally and functionally normal urinary tract. In otherwise healthy women, acute uncomplicated cystitis occurs frequently and is associated with high morbidity. Approximately 25–35% of women between 20 and 40 yr have experienced uncomplicated UTI [2]. Uncomplicated cystitis may occasionally occur in young adult males [3], [4]. Diabetic [5], pregnant [6], and postmenopausal women [7] are at higher risk to develop UTI as compared to otherwise healthy premenopausal women.
In acute uncomplicated UTI, Escherichia coli (E. coli) is the most frequent pathogen (75–95%), followed by Staphylococcus saprophyticus (5–10% of cases). Occasionally other Enterobacteriaceae, such as Proteus mirabilis and Klebsiella species, are isolated. Among other gram-positive bacteria, enterococci are rarely found [8].
Uncomplicated cystitis is generally treated empirically, when only clinical aspects are available. Moreover microbiologic investigations are not performed in routine practice. But for recommendation of first-line treatment epidemiology and local pathogens’ susceptibility to antibiotics have to be known, which depend on proper patient's selection (diagnosis) and on time and geographic areas. Systematic studies are necessary to reassess the epidemiology and susceptibility pattern in correlation to clinical aspects and immediately available laboratory tests, like urinalysis.
Section snippets
Patients, materials, and methods
The protocol of the ARESC study was first approved by a central ethical committee (Bayerische Landesärztekammer, Munich, Germany, No. 03172) and then by the respective local ethical committees. The study complies with the Declaration of Helsinki (Edinburgh, Scotland 2000), good clinical practice (GCP), and the applicable regulatory requirements. Written consent was obtained from all patients. The study was a prospective, multicentre, multinational observational epidemiologic survey.
Results
This survey started in September 2003 and ended in June 2006. Sixty-eight centres in nine European countries and in Brazil were involved.
A total of 4384/4400 female patients with uncomplicated lower UTI (cystitis) were screened/planned. One hundred and twenty patients (2.8%) were not eligible for protocol violations, mainly because of complicating factors, or no written consent, so that the clinical data of 4264 (urine samples only from 4244) eligible patients were analysed—from Austria 97/100,
Discussion
This survey has assessed the clinical aspects, epidemiology, and susceptibility pattern for standard antimicrobials used in the treatment of uncomplicated lower UTI (cystitis) in nine European countries and in Brazil. The enrolled female patients represent the general population with this infection concerning age, menopausal status, and presence of common risk factors such as diabetes mellitus, pregnancy, and recurrent UTI.
Of the patients presenting with typical symptoms of cystitis, about one
Conclusion
Despite wide cross-country variability of bacterial susceptibility/resistance rates to the other antimicrobials tested, fosfomycin, mecillinam, and nitrofurantoin have preserved their in vitro activity in all countries investigated. They may represent effective options for the empiric therapy of patients with uncomplicated lower UTI (cystitis).
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- 1
On behalf of the ARESC Study Group.