Enterococcal UTIs May Be Overtreated

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SAN DIEGO—Significant numbers of men with enterococcal UTIs are being overtreated and undertreated, according to findings reported here at the Infectious Diseases Society of America annual meeting.

 

Researchers at the Edward Hines, Jr. Veterans Affairs Hospital in Chicago retrospectively evaluated all episodes of Enterococcus isolated from urine cultures performed at the institution from the beginning of 2001 through the end of 2003. Of the 660 positive Enterococcus urine cultures screened, 326 episodes in 192 patients met study inclusion criteria.

 

Most patients were elderly (mean age 70 years), Caucasian (71%), male (95%), and had indwelling catheters (71%). The investigators found that 27% of the episodes involved symptomatic UTIs, 14% involved asymptomatic bacteriuria, 27% had colonization, and 31% were undetermined. Pyelonephritis was rare, occurring in only 5% of patients.

 

Overall, one in six isolates had vancomycin-resistant enterococci (VRE), but 62% of VRE isolates were found among inpatients. A total of 83% of isolates were E. faecalis. The clinical cure rate was 22% for VRE infections compared with 36% for non-VRE infections; it was 35% for E. faecalis infections compared with 11% for E. faecium infections. The microbiological cure rate was 13% for VRE compared with 12% for non-VRE, and 13% for E. faecalis compared with 11% for E. faecium.

 

Ninety percent of the UTIs were treated with antibiotics, resulting in a clinical cure rate of 68%. This increased to 82% when Enterococcus was the only pathogen isolated. Ten percent of symptomatic UTIs were not treated with antibiotics. One in five patients who did not have a true UTI (i.e., had positive cultures but no symptoms) received antibiotics.

 

Among VRE UTIs, the clinical cure rate was highest with combination therapy of quinolone/doxycycline (82%) and the lowest for nitrofurantoin (25%). “We found that a small but significant number of true infections that needed therapy were not treated, and this is something that we think we need to work on,” noted Badie Al Nemr, MD, the lead investigator of the study. “At the same time, there were some episodes that did not require treatment but were still treated inappropriately by our standards.”

 

An associate professor of medicine at Northeastern Ohio College of Medicine in Canton, Dr. Al Nemr conducted the study while serving at the Hines VA hospital.

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