Recurrent Urinary Tract Infections

Rekurirajuće uroinfekcije jesu one koje se javljaju u najmanje dva ili više navrata tijekom šest mjeseci ili u najmanje tri ili više navrata u tijeku godine dana, a etiološki su dokazane. Većina tih epizoda su cistitisi. Rekurirajuće uroinfekcije ozbiljan su javnozdravstveni problem zbog učestalosti javljanja te pobola i troškova koje izazivaju. Rekurirajuće uroinfekcije najčešće su među mlađim ženama te u postmenopauzi. Predisponirajući čimbenici za razvoj ovih infekcija dijele se na genske, biološke i čimbenike ponašanja. Odabir metode prevencije rekurirajućih infekcija ovisi o tipu infekcije. Osim antimikrobne profilakse danas su u upotrebi i brojni alternativni profilaktički pripravci, a postoji i mogućnost prevencije ovih infekcija imunostimulirajućim sredstvima. Liječenje rekurirajućih infekcija jednako je liječenju sporadičnih epizoda uz uzimanje u obzir podatka o osjetljivosti izolata iz prethodne epizode. Rekurirajuće infekcije mokraćnog sustava i nadalje su velik javnozdravstveni problem i područje intenzivnih istraživanja koja će bolje rasvijetliti patogenezu te omogućiti bolje zamjene antimikrobnoj profilaksi ovih infekcija.Recurrent urinary tract infections (UTIs) are infections that occur at least twice every six months or three or more times per year. They are etiologically proven and mostly present as cystitis. Recurrent UTIs are an important public health problem due to their high incidence, morbidity rate and costs. These infections are most frequent among young and postmenopausal women. Predisposing factors include genetic, biological and behavioral factors. The choice of prophylactic method depends on a type of an infection. Apart from the antimicrobial prophylaxis, there are numerous alternative prophylactic remedies and there is also a possibility of preventing recurrence by immunostimulation. Therapy of recurrent UTIs is the same as that of sporadic episodes except that the sensitivity of previous isolates should be taken into consideration. Recurrent UTIs still present a substantial public health problem and an area of intensive research to further elucidate their pathogenesis and improve prevention

Antibiotic sensitivity of enterobacteriaceae

Enterobakterije su važni uzročnici infekcija mokraćnog sustava (IMS), infekcija probavnog sustava te infekcija povezanih sa zdravstvenom skrbi. Pri odabiru empirijske antimikrobne terapije treba voditi računa o intrinzičnoj otpornosti nekih bakterijskih vrsta na određene grupe antibiotika, ali još veći problem predstavljaju brojni, stalno mijenjajući, mehanizmi stečene otpornosti na antibiotike. Beta-laktamski antibiotici su najčešće upotrebljavani antibiotici u kliničkoj praksi, a trimetoprim-sulfametoksazol (ko-trimoksazol) i kinoloni su dragocjeni u liječenju IMS i infekcija probavnog sustava, jer uspješno eradiciraju patogene iz ovih sustava. Na sve nabrojene grupe antibiotika javljaju se, međutim, mnogi mehanizmi otpornosti, koji često djeluju udruženo u istom bakterijskom soju. U Hrvatskoj otpornost E. coli iznosi 3% na III. generaciju cefalosporina, 24% na ko-trimoksazol te 11% na ciprofloksacin. K. pneumoniae je češće uzročnik infekcija povezanih sa zdravstvenom skrbi i pokazuje viši stupanj otpornosti na antibiotike; 29% na III. generaciju cefalosporina te 36% na ko-trimoksazol i ciprofloksacin. U Hrvatskoj otpornost enterobakterija na karbapeneme je još uvijek sporadična.Enterobacteriaceae are important pathogens in urinary tract infections (UTI), gastrointestinal and healthcare associated infections. When deciding on empirical antibiotic therapy intrinsic resistance mechanisms present in certain bacterial species should be considered but even more worrisome problem is the presence of numerous, always changing, mechanisms of acquired resistance. Beta-lactam antibiotics are the most frequently used antibiotics in clinical practice and trimethoprim-sulfamethoxazole (co-trimoxazole) and the quinolones are precious drugs in the treatment of UTI and gastrointestinal infections due to their ability to eradicate pathogens from these sites. Numerous resistance mechanisms have emerged to all these groups of antibiotics and often different mechanisms are present in the same strain. In Croatia, E. coli isolates resistance rates are 3% for the 3rd generation cephalosporins, 24% for co-trimoxazole and 11% for ciprofloxacin. K. pneumoniae more often causes healthcare associated infections and has higher rates of resistance; 29% for 3rd generation cephalosporins and 36% for co-trimoxazole and ciprofloxacin. In Croatia carbapenem resistance in enterobacteriaceae is still sporadic

Antibiotic Resistance of Causative Agents of Urogenital Infections

Odabir antibiotika za empirijsko liječenje urogenitalnih infekcija (UGI) nekada je bio jednostavan, no zbog velike i često iracionalne uporabe antibiotika danas se razvila značajna rezistencija među velikim brojem uropatogena. U Hrvatskoj je danas 50% E. coli i 30% P. mirabilis rezistentno na ampicilin, a udio sojeva E. coli, koji produciraju beta-laktamaze proširenog spektra (engl. “extended spectrum beta-lactamase”, ESBL) kreće se oko 2%. Ko-trimoksazol, zbog odlične eradikacije uzročnika iz urogenitalnog područja, dragocjen je lijek u liječenju infekcija mokraćnog sustava (IMS), no nažalost, diljem svijeta, pa i u Hrvatskoj, rezistencija E. coli na ko-trimoksazol iznosi više od 20% te je njegova uloga u empirijskoj terapiji IMS dovedena u pitanje. U Europi se bilježi stalni porast rezistencije E. coli na kinolone, što je uočljivo i u Hrvatskoj, gdje je rezistencija E. coli na kinolone dostigla 10%. Na mikoplazme, ureaplazme i klamidije dobru djelotvornost pokazuju tetraciklini, makrolidi i neki kinoloni. Rezistencija je u ovih patogena opisana, no još nije poprimila klinički značajne razmjere. Rezistencija gonokoka na penicilin i tetraciklin je visoka u nekim regijama svijeta, a u porastu je i rezistencija na kinolone. Prethodna uporaba antibiotika, prethodna hospitalizacija, uporaba kortikosteroida, dijabetes, kronična neurološka ili urološka bolest, boravak u domovima za stare i nemoćne, putovanje u regije s visokom incidencijom rezistentnih sojeva daljnji su rizični čimbenici za stjecanje infekcije multiplorezistentnim sojevima. Kako se većina UGI započinje liječiti empirijski, nužno je dobro poznavati sve rizične čimbenike te prevalenciju uzročnika i njihovu osjetljivost u lokalnoj sredini, ali i u drugim regijama svijeta. Sustavne informacije o stopama rezistencije mogu se dobiti preko European Antimicrobial Resistance Surveillance System (EARSS), a za Hrvatsku dodatno i preko Odbora za praćenje rezistencije bakterija na antibiotike, pri Akademiji medicinskih znanosti Hrvatske, koji prikuplja podatke iz 30 centara u Hrvatskoj.The choice of an antibiotic to treat urogenital infections (UGI) used to be easy. However, antibiotic resistance of uropathogens has become an increasing problem because of antibiotic overuse. In Croatia, 50% of E. coli and 30% of P. mirabilis isolates are resistant to ampicillin, and the rate of extended spectrum beta-lactamase (“ESBL”) producing E. coli is approx. 2%. Due to an excellent rate of bacterial eradication from the urogenital tract, co-trimoxazole is a valuable therapeutic option in the treatment of urinary tract infections (UTI). However, the resistance rate of E. coli to this drug has exceeded 20% in many parts of the world, including Croatia, thus putting the co-trimoxazole role in the empiric therapy of UTI into question. In Europe, the resistance of E. coli to quinolones has been constantly increasing, and resistance rates in Croatia have reached 10%. Tetracyclines, macrolides and some quinolones have good activity against mycoplasma, ureaplasma and chlamydia. Resistance in these pathogens has been described, but has not yet reached clinical signifi cance. Resistance to penicillin and tetracycline in gonococci is high in some parts of the world, and resistance to quinolones is increasing. Recent use of antibiotics, recent hospitalization, use of corticosteroids, diabetes, chronic neurologic or urologic disease, residence in a home for elderly and disabled, and recent travel to the areas with known high resistance rates are all considered as predisposing factors for acquiring infection with a multiresistant organism. As the onset of treatment of most urogenital infections is empirical, risk factors along with prevalence and antibiotic sensitivity patterns of uropathogens, both on national and international level, should be well known. The most reliable and up-to-date antibiotic resistance data could be obtained from the European Antimicrobial Resistance Surveillance System (EARSS). For Croatia, they could be also obtained from the Croatian Committee for Antibiotic Resistance Surveillance of the Croatian Academy of Medical Sciences that collects data from 30 centers in Croatia

Uropathogens and their susceptibility to antibiotics

Porast otpornosti bakterija na antibiotike ugrožava učinkovitost empirijske antibiotske terapije pri liječenju infekcija mokraćnog sustava (IMS). Cilj istraživanja ovog rada je ispitati učestalost pojedinih uzročnika IMS ovisno o vrsti IMS te ispitati otpornost na antibiotike najčešćih uzročnika IMS. Utjecaj vrste IMS na učestalost i osjetljivost uzročnika ispitivan je na bolnički i ambulantno liječenim bolesnicima Klinike za infektivne bolesti "Dr. Fran Mihaljević", Zagreb. Escherichia coli je najčešći uzročnik svih kategorija IMS. Najmanji udio ima među izolatima ambulantno liječenih bolesnika s kompliciranim i rekurirajućim IMS, u kojih značajani udio imaju enterokoki. Statistički značajna razlika (p < 0,05) u osjetljivosti E. coli između pojedinih kategorija IMS dokazana je za ko-trimoksazol (p = 0,007) i cefaleksin (p = 0,042), a za ciprofloksacin i norfloksacin su dobivene granične vrijednosti statističke značajnosti (p = 0,063).Increase of antibiotic resistance jeopardizes the effectiveness of empirical antibiotic therapy of urinary tract infections (UTI). The aim of this study was to estimate the frequency of UTI causative agents in relation to the UTI category and to investigate the resistance rates in the most frequent uropathogens. The influence of the UTI category on the frequency and sensitivity pattern of uropathogens was investigated among inpatients and outpatients of the University Hospital for Infectious Diseases, Zagreb. Escherichia coli was the most frequent causative agent in every UTI category. The lowest rate of E. coli was recorded among outpatients treated for complicated and recurrent UTI. These patients had significantly higher rate of enterococci. Statistically significant difference (p < 0.05) in E. coli resistance rates among different UTI categories was found for co-trimoxazole (p = 0.007) and cephalexin (p = 0.042), while differences for ciprofloxacin and norfloxacin demonstrated borderline values (p = 0.063)

Antimicrobial Treatment and Prophylaxis of Urinary Tract Infections in Adults

U članku su prikazane najnovije smjernice za antimikrobno liječenje i profi laksu infekcija mokraćnog sustava odraslih usklađene s višegodišnjim kliničkim iskustvom, rezultatima praćenja rezistencije najčešćih uzročnika na antimikrobna sredstva, vodećim svjetskim smjernicama, najnovijom stručno- znanstvenom literaturom te primjedbama kolega liječnika, polaznika brojnih tečajeva trajne edukacije održanih o toj temi unatrag 4 godine.This article describes the latest guidelines for antimicrobial treatment and prophylaxis of urinary tract infections in adults. These guidelines are based on long clinical experience, antimicrobial resistance monitoring results for the most common causative agents, leading global guidelines, recent scientifi c and professional literature, and observations of other physicians who attended numerous courses in this fi eld over the last four years

Organisational structure and activities of the Reference Centre for Urinary Tract Infections of the Ministry of Health and Social Welfare from 2005 to 2010

Referentni centar Ministarstva zdravstva i socijalne skrbi RH za infekcije mokraćnog sustava djeluje u Klinici za infektivne bolesti "Dr. Fran Mihaljević" u Zagrebu od siječnja 2005. godine. Referentni centar ispunjava sva zadana, zakonom propisana mjerila, te kao centar stručnosti i izvrsnosti, obavlja najsloženije oblike zdravstvene zaštite iz infekcija mokraćnog sustava (IMS) bolesnika. Mjerila stručnosti se odnose na postignute znanstvene i stručne rezultate u praćenju, proučavanju i unaprjeđenju prevencije, dijagnostike i terapije, a u skladu sa svjetskim standardima. Centar ima visoko - stručne kadrove i suvremene prostorne uvjete. Aktivnosti centra odvijaju se u sklopu bolničko-stacionarne i specijalističko - konzilijarne službe, uz potporu gotovo svih kliničkih laboratorija i zavoda Klinike. Veći dio bolesnika obrađivan je i liječen u Zavodu za urogenitalne infekcije, Klinike za infektivne bolesti "Dr. Fran Mihaljević" i u Ambulanti za urogenitalne infekcije. Na Klinici se za liječenje bolesnika s IMS primjenjuju najnoviji dijagnostički i terapijski postupci. Preporuke dijagnostike i liječenja IMS-a u suradnji sa stručnim društvima HLZ-a i srodnim Referentnim centrima MZSS RH donešene su 2004., 2006. i 2009. godine (9,10,11).The Reference Centre for Urinary Tract Infections of the Croatian Ministry of Health and Social Welfare has been active at the University Hospital for Infectious Diseases "Dr Fran Mihaljevic" in Zagreb since January 2005. The Reference Centre fulfills all mandatory, statutory requirements, and as the centre of professionalism and expertise provides the most complex tasks of patient health care in the field of urinary tract infections. The criteria of expertise refer to achieved scientific and professional results in monitoring, analysis and improvement of prevention, diagnostics and therapy of urinary tract infections in accordance with international standards. The reference centre has highly qualified and modern infrastructural conditions. The activities of the centre are performed at the inpatient, hospital and outpatient specialist departments, in collaboration with all clinical laboratories and departments of the hospital. The majority of the patients are treated at the Department for Urogenital Infections and the Outpatient Clinic for Urogenital Infections of the University Hospital for Infectious Diseases "Dr Fran Mihaljevic", Zagreb. Latest diagnostic and therapeutic procedures for the treatment of patients with urinary tract infections are in use at the hospital. Recommendations for diagnostics and treatment of urinary tract infections in collaboration with professional societies of the Croatian Medical Association and related reference centers have been published in 2004, 2006 and 2009. (9,10,11)

Mild clinical picture of human granulocytic anaplasmosis

A. phagocytophilum je uzročnik humane granulocitne anaplazmoze (HGA). U najvećem dijelu Europe, uključujući i Hrvatsku, glavni vektor za A. phagocytophilim je Ixodes ricinus, a rezervoar su šumski sisavci. Najčešće HGA prolazi asimptomatski, eventualno uz kratkotrajni febrilitet. Ukoliko se bolest razvije, može poprimiti različite oblike, od lakih do izrazito teških. Simptomi su uglavnom nespecifični: febrilitet, mialgije, artralgije, zimice, mučnina, povraćanje i glavobolja. Osip se javlja rijetko. U jednog dijela bolesnika se mogu javiti neurološki simptomi. Može se prezentirati i kao vrućica nepoznata porijekla u trajanju i do dva mjeseca. U radu je prikazan blagi oblik HGA u šezdestšestogodišnje bolesnice u koje pored febriliteta, općeg algičkog sindroma s izraženom jakom glavoboljom i početnom smušenošću nema drugih vodećih simptoma bolesti. U laboratorijskim nalazima kod dolaska registrirana je blago povišena vrijednost CRP-a, blaža jetrena lezija, leukopenija, trombocitopenija, povišena vrijednost LDH i diselektrolitemija. Dijagnoza je postavljena serološki nakon što je bolesnica otpuštena iz bolnice. Tijekom hospitalizacije, bolesnica je liječena simptomatski. U centralnoj i sjeverozapadnoj Hrvatskoj je moguće očekivati pojavu infekcija A. phagocytophilum i posljedično razvoj HGA te na ovu bolest treba misliti u diferencijalnoj dijagnostici bolesti koje se prenose krpeljima.A. phagocytophilum is the causative agent of human granulocytic anaplasmosis (HGA). In most of Europe, including Croatia, the main vector for the A.phagocytophilim is Ixodes ricinus, and reservoirs are forest mammals. HGA is usually asymptomatic, possibly with short-term fever. If the disease develops, it can take different forms, ranging from mild to severe. Symptoms are usually nonspecific: fever, myalgia, arthralgia, chills, nausea, vomiting and headache. The rash occurs rarely. Some of the patients may experience neurological symptoms. It may present as fever of unknown origin lasting up to two months. Here we present a mild form of HGA in a 66-year old female patient. Besides fever, algic syndrome with severe headache and expressed initial disorientation, no other leading symptoms were recorded. The laboratory findings registered on admission were: slightly elevated CRP levels, a mild liver lesion, leucopenia, thrombocytopenia, elevated LDH value and electrolyte disorders. The diagnosis was based on serology after the patient was discharged from the hospital. During hospitalization, the patient was treated symptomatically. In central and northwestern Croatia, we can expect the occurrence of A. phagocytophilum infection and subsequent development of the HGA, and the disease should be considered in the differential diagnosis of diseases transmitted by ticks

Research on the efficacy of prophylactic use of Acidosalus® probiotic in women with recurrent cystitis

Cilj ovog prospektivnog ispitivanja bio je ispitati djelotvornost profilaktičke primjene probiotika Acidosalusa® u žena s rekurentnim cistitisom. Acidosalus® je jedinstvena kombinacija Lactobacillus acidophilus, Lactobacillus rhamnosus i bifidobakterija u visokim terapijskim koncentracijama živih bakterija spremnih za razmnožavanje. Sadrži nadalje vitamine B skupine, folnu kiselinu, lako topive laktate, kalij, željezo, fosfor, te ima mogućnost stvaranja antimikrobnih supstanci - mliječne i octene kiseline, diacetila, laktocidina, acidofilucina, acidocina i acidofilina. Ispitivanje je provedeno u Ambulanti za urogenitalne infekcije Klinike za infektivne bolesti „Dr. Fran Mihaljević“ u Zagrebu u razdoblju od 01.01.2006. do 31.12.2009. godine. Ispitivano je 117 bolesnica u dobi od 18 do 65 godina s dijagnozom rekurentnog cistitisa - s više od dvije epizode cistitisa u posljednjih 6, odnosno više od 3 epizode u posljednjih 12 mjeseci. Uvjeti za uključivanje su bili: prisutnost simptoma infekcije donjeg urotrakta (dizurija, polakizurija, urgencija), identičan mikrobiološki nalaz obriska rodnice i urinokulture, leukociturija, te ultrazvukom isključena abnormalnost mokraćnog sustava. Sve su bolesnice kroz 7 dana liječene adekvatnom antimikrobnom terapijom, a zatim su nasumce podijeljene u dvije skupine. U jednih je odmah po prestanku antimikrobne terapije primijenjena profilaksa s probiotikom Acidosalus® te su kroz najmanje tri mjeseca kontinuirano uzimale peroralno Acidosalus® uz istovremenu vaginalnu primjenu Acidosalus® vaginaleta kroz najmanje 7 dana. Planirana primjena profilakse bila je 3 mjeseca. Na kontroli 1-2 tjedna nakon završene sedmodnevne antimikrobne terapije, sve su bolesnice bile klinički i bakteriološki izliječene. Do kontrole 3 mjeseca nakon završene sedmodnevne antimikrobne terapije u skupini od ukupno 56 žena koje su primale profilaksu probiotikom rekurentne epizode cistitisa imalo je njih 3 (5,4%), a u skupini od ukupno 61 žene koje nisu primale profilaksu broj rekurentnih epizoda bio je 11 (18,3%). Tri mjeseca nakon završene 7-dnevne antimikrobne terapije uropatogene bakterije su dokazane češće u rodnici žena koje nisu primale profilaksu probiotikom (u 44 od ukupno praćenih 50 bolesnica - 88%) nego u žena koje su primale profilaksu probiotikom (u 18 od ukupno 53 bolesnica - 34%). Rezultati ove studije pokazuju da je profilaktička primjena mješovite kulture probiotika sadržane u medicinskom proizvodu Acidosalus® u žena s rekurentnim uroinfekcijama djelotvorna i sigurna. Ističemo važnost istovremene oralne i vaginalne primjene, čime se uspostavlja obnavljanje i poboljšanje funkcije autohtone mikroflore crijeva i rodnice, smanjuje rezervoar uropatogenih bakterija u crijevu i jača imunitet općenito.The aim of this prospective research was to investigate the efficacy of prophylactic use of probiotic Acidosalus® in women with recurrent cystitis. Acidosalus® is a unique combination of Lactobacillus acidophilus, Lactobacillus rhamnosus and bifidobacteria in high therapeutic concentrations of live bacteria ready for multiplication. It consists of group B vitamins, folic acid, highly soluble lactates, potassium, iron, phosphorus, and has the possibility to produce antimicrobial substances - lactic and acetic acid, diacetyl, lactocidine, acidophilucin, acidocin and acidophylin. The research was conducted at the Outpatient Department for Urogenital Infections of the University Hospital for Infectious Diseases „Dr. Fran Mihaljević“ in Zagreb in the period between 01.01.2006. until 31.12.2009. We investigated 117 patients aged between 18 and 65 years with diagnosed recurrent cystitis – more than two episodes of cystitis in the past 6, i.e. more than three episodes in the past 12 months. The inclusion criteria were as follows: presence of symptoms of lower urinary tract infection (dysuria, polakisuria, urgency), identical microbiological finding of cervical swab and urinary culture, leukocyturia, ultrasound excluded urinary tract abnormality. All patients received adequate antimicrobial therapy for 7 days and then were randomly divided into two groups. One group received Acidosalus® probiotic as a prophylaxis immediately after the end of antimicrobial therapy – and at least three months continuously received Acidosalus® orally with simultaneous vaginal administration of Acidosalus® vaginalettes for at least 7 days. Planned duration of prophylaxis was three months. Follow up visit performed 1-2 weeks after completion of seven day course of antimicrobial therapy showed that all patients were clinically and bacteriologically cured. Until the follow up visit three months after completed 7-day antimicrobial therapy, recurrent episodes of cystitis were recorded in 3 (5,4%) out of a total of 56 women who received probiotic prophylaxis and in 11 (18,3%) out of a total of 61 women who did not receive probiotic prophylaxis. Three months after completed 7-day course of antimicrobial therapy, uropathogen bacteria were more often detected in vagina of women who did not receive probiotic prophylaxis (in 44 out of a total of 50 monitored patients - 88%) than in women who did not receive probiotic prophylaxis (in 18 out of a total of 53 patients - 34%). The results of this study have shown that prophylactic use of mixed probiotic culture present in medicinal product Acidosalus® in women with recurrent urinary tract infections is efficient and safe. We would like to stress the importance of simultaneous oral and vaginal application, by which we achieve regeneration and improved function of autochthonous intestinal and vaginal microflora, reduce a reservoir of uropathogen bacteria in intestines and boost immunity in general

Tricuspid Valve Endocarditis Due to Methicillin-Resistant <i>Staphylococcus aureus</i> in a Previously Healthy Young Patient without a Drug Abuse History: A Case Report and a Review of the Literature

Right-sided infective endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) is strongly associated with intravenous drug abuse, congenital heart disease, or previous medical treatment and is rare in healthy patients without a history of drug abuse. Here, we present a case of an 18-year-old male with no drug abuse history and no medical burden who was diagnosed with MRSA tricuspid valve endocarditis. Due to initial symptoms which indicated community-acquired pneumonia and radiological finding of interstitial lesions, empiric therapy with ceftriaxone and azithromycin was started. After the detection of Gram-positive cocci in clusters in several blood culture sets, endocarditis was suspected, and flucloxacillin was added to the initial therapy. As soon as methicillin resistance was detected, the treatment was switched to vancomycin. Transesophageal echocardiography established the diagnosis of right-sided infective endocarditis. A toxicological analysis of hair was carried out, and no presence of narcotic drugs was found. After six weeks of therapy, the patient was fully recovered. Exceptionally, tricuspid valve endocarditis can be diagnosed in previously healthy people who are not drug addicts. As the clinical presentation commonly resembles a respiratory infection, a misdiagnosis is possible. Although MRSA rarely causes community-acquired infections in Europe, clinicians should be aware of this possibility