Pyelonephritis in pregnancy: clinical and laboratorial aspects and perinatal results / Pielonefrite na gestação: aspectos clínicos e laboratoriais e resultados perinatais

Abstract Objective To identify the prevalence of pyelonephritis during pregnancy and to analyze the clinical and laboratorial aspects, perinatal results and complications. Methods A transversal study of 203 pregnant women who had pyelonephritis during pregnancy and whose labor took place between 2010 and 2016 at a hospital in the state of Santa Catarina, Brazil. The analysis was based on medical records as well as on the hospital's database. Clinical and laboratory conditions, antibiotics, bacterial resistance, perinatal outcomes and complications were all taken into account. The data was compared using the Mann-Whitney test and the Chi-square test. Results A prevalence of 1.97% with pyelonephritis was evidenced, with most patients having it during the second trimester of gestation. The bacteriamost commonly found in the urine cultures was Escherichia coli, in 76.6% of cases, followed by Klebsiella pneumoniae (8.7%). Ceftriaxone had the lowest bacterial resistance (only 3.5% of the cases). On the other hand, ampicillin and cephalothin presented higher bacterial resistance, 52% and 36.2%, respectively. The risk of very premature delivery was more than 50% higher in patients with pyelonephritis. Conclusion Ampicillin and first-generation cephalosporins are associated with a higher bacterial resistance while ceftriaxone proved to have a high efficacy for the treatment of pyelonephritis due to low bacterial resistance. Patients with pyelonephritis showed a higher risk for very premature delivery (< 32 weeks). In this casuistry, there were no others significant differences in the overall perinatal outcomes when compared with the routine service series.

Resumo Objetivo Identificar a prevalência da pielonefrite durante a gestação, analisar seus aspectos clínicos e laboratoriais, resultados perinatais e complicações. Métodos Estudo transversal que incluiu 203 gestantes com pielonefrite durante a gestação e cujos partos aconteceram entre 2010 e 2016 em um hospital no estado de Santa Catarina, no Brasil. A análise foi feita através de informações coletadas de prontuários e da base de dados do hospital. Foram levados em consideração aspectos received Resultados Foi evidenciada uma prevalência de 1,97%, sendo que a maioria das pacientes se encontrava no segundo trimestre de gestação. A bactériamais encontrada nas uroculturas foi a Escherichia coli, em 76,6% dos casos, seguido pela Klebsiella pneumoniae (8,7%). A ceftriaxona, usada como primeira escolha, demonstrou ser o antibiótico commenor resistência bacteriana (apenas 3,5% dos casos). A ampicilina e a cefalotina apresentaram maiores resistências bacterianas, 52% e 36,2%, respectivamente. O risco de parto prematuro extremo (<32 semanas) foimais que 50% maior em pacientes com pielonefrite. Conclusão A ampicilina e cefalosporinas de primeira geração estão associadas à maior resistência bacteriana enquanto a ceftriaxona provou ter uma alta eficácia para o tratamento da pielonefrite devido à baixa resistência bacteriana. Pacientes com pielonefrite têm maior risco para parto prematuro extremo (< 32 semanas). Nesta casuística, não houveram outras diferenças significativas nos resultados perinatais gerais quando comparados com a série de serviços de rotina.

Pharmacodynamic profiling of commonly prescribed antimicrobial drugs against Escherichia coli isolates from urinary tract

Since antimicrobial resistance among uropathogens against current first line agents has affected the management of severe urinary tract infection, we determined the likelihood that antibiotic regimens achieve bactericidal pharmacodynamic exposures using Monte Carlo simulation for five antimicrobials (ciprofloxacin, ceftriaxone, piperacillin/tazobactam, ertapenem, and meropenem) commonly prescribed as initial empirical treatment of inpatients with severe community acquired urinary tract infections. Minimum inhibitory concentration determination by Etest was performed for 205 Brazilian community urinary tract infection Escherichia coli strains from 2008 to 2012 and 74 E. coli bloodstream strains recovered from a surveillance study. Pharmacodynamic exposure was modeled via a 5000 subject Monte Carlo simulation. All isolates were susceptible to ertapenem and meropenem. Piperacillin/tazobactam, ceftriaxone and ciprofloxacin showed 100%, 97.5% and 83.3% susceptibility among outpatient isolates and 98.6%, 75.7% and 64.3% among inpatient isolates, respectively. Against outpatient isolates, all drugs except ciprofloxacin (82.7% in aggressive and 77.6% in conservative scenarios) achieved high cumulative fraction of response: car-bapenems and piperacillin/tazobactam cumulative fraction of responses were close to 100%, and ceftriaxone cumulative fraction of response was 97.5%. Similar results were observed against inpatients isolates for carbapenems (100%) and piperacillin/tazobactam (98.4%), whereas ceftriaxone achieved only 76.9% bactericidal cumulative fraction of response and ciprofloxacin 61.9% (aggressive scenario) and 56.7% (conservative scenario) respectively. Based on this model, standard doses of beta-lactams were predicted to deliver sufficient pharmacodynamic exposure for outpatients. However, ceftriaxone should be avoided for inpatients and ciprofloxacin empirical prescription should be avoided in both inpatients and outpatients with complicated urinary tract infection.

Resultados de dois esquemas de tratamento da pielonefrite durante a gravidez e correlação com o desfecho da gestação / Results of two treatment regimens for pyelonephritis during pregnancy and correlation with pregnancy outcome

OBJETIVO: Determinar o perfil epidemiológico das gestantes internadas por infecção do trato urinário, bem como verificar os agentes mais prevalentes e a resposta à antibioticoterapia. MÉTODOS: Estudo retrospectivo, que incluiu 106 gestantes internadas para tratamento de infecção do trato urinário no período entre janeiro de 2007 a dezembro de 2010. A avaliação constituiu-se de análise de prontuários dessas gestantes, observando-se informações sobre a internação e a gestação, bem como seu desfecho. Foi realizada a análise estatística por meio do programa Statistical Package for the Social Science, versão 15.0. Foram utilizados, para análise dos dados, o teste bilateral exato de Fisher e o teste t de Student, bem como métodos de estatística descritiva. RESULTADOS: Uroculturas positivas foram encontradas em 60,5% das gestantes internadas por infecção do trato urinário. O agente infeccioso mais frequente foi Escherichia coli e não houve diferença quanto à resistência, à recorrência ou a complicações entre os agentes etiológicos mais frequentes. Gestantes com infecção do trato urinário prévia tiveram maior risco de recorrência (OR=10,8; p<0,05). Os antibióticos mais frequentemente utilizados na internação foram ampicilina e cefazolina. Troca de esquema terapêutico por resistência bacteriana ocorreu em 11,9% das pacientes que usaram cefazolina e em 20% das que usaram ampicilina (OR=5,5; p<0,05). O índice de complicações gestacionais foi igual nos dois tratamentos. Não houve diferença entre as médias do número de dias de internação para os dois tratamentos. CONCLUSÃO: A ampicilina esteve associada a maior índice de resistência bacteriana que a cefazolina, necessitando de maior número de trocas do esquema terapêutico, sem resultar em diferença nos desfechos clínicos e tempo de internação.

PURPOSE: To determine the epidemiological profile of women admitted for urinary tract infection as well as to verify the most prevalent agents and response to antibiotic therapy. METHODS: A retrospective study of 106 pregnant women admitted to a university hospital for urinary tract infection treatment during the period between January 2007 to December 2010. The evaluation was based on analysis of the medical records of these pregnant women, with the observation of hospitalization and pregnancy data, as well as its outcome. Statistical analysis was performed using Statistical Package for the Social Science, version 15.0. The bilateral Fisher exact test and Student's t test were used for data analysis, as well as descriptive statistical methods. RESULTS: Positive urine cultures were observed in 60.5% of pregnant women admitted due to urinary tract infection. The most frequent infectious agent was Escherichia coli and no difference in resistance, recurrence or complications was observed between the most frequent etiologic agents. Pregnant women with previous UTI had a higher recurrence risk (OR=10.8; p<0.05). The antibiotics most commonly used during hospitalization were ampicillin and cefazolin. Change of therapeutic agent due to bacterial resistance occurred in 11.9% of patients who took cefazolin and in 20% of patients who took ampicillin (OR=5.5; p<0.05). The rate of gestational complications was the same for both treatments. There was no difference in mean number of days of hospitalization between the treatments. CONCLUSION: In the studied population ampicillin showed a higher rate of bacterial resistance than cefazolin, requiring a larger number of treatment regimen exchanges, without resulting in differences in clinical outcome or time of hospitalization.

[Comparison of genetic patterns of E. coli strains isolated from patients with cystitis and pyelonephritis, using Pulsed Field Gel Electrophoresis]

Urinary tract infection [UTI] is one of the most frequently acquired bacterial infections caused by a large genetically heterogeneous group of Escherichia coli which are called uropathogenic E. coli [UPEC]. Cystitis and pyelonephritis are two most common symptoms seen in patients with UTI. The genetic diversity of this organism has hampered the identification of UTI strains and it is unclear whether all UPEC isolates are capable of causing both cystitis and pyelonephritis. Therefore, Careful selection of appropriate genotyping methods is mandatory. The most popular method is Pulsed Field Gel Electrophoresis [PFGE] that is used in the present study to evaluate the genetic patterns of UPEC. In this cross-sectional study a total of 90 E. coli strains consisting of 48 isolates causing pyelonephritis and 42 isolates causing cystitis in children were analyzed by PFGE and their corresponding patterns were compared. Sixty six PFGE profiles were obtained from the genome of E. coli strains by this genotyping method. Most strains exhibited twelve and thirteen bands and the patterns with eight or nineteen bands had the lowest rate. Genome size of strains was between 1610-4170 kbp. According to these results, it can be suggested that in some cases the strains causing pyelonephritis or cystitis have common patterns and different clinical symptoms could be attributed to different gene factors

Virulence factors and genetic variability of uropathogenic Escherichia coli isolated from dogs and cats in Italy

In this study, the association between virulence genotypes and phylogenetic groups among Escherichia (E.) coli isolates obtained from pet dogs and cats with cystitis was detected, and fingerprinting methods were used to explore the relationship among strains. Forty uropathogenic E. coli (UPEC) isolated from dogs (n = 30) and cats (n = 10) in Italy were analysed by polymerase chain reaction (PCR) for the presence of virulence factors and their classification into phylogenetic groups. The same strains were characterized by repetitive extragenic palindromic (REP)- and enterobacterial repetitive intergenic consensus (ERIC)-PCR techniques. We found a high number of virulence factors such as fimbriae A, S fimbriae (sfa) and cytotoxic necrotizing factor 1 (cnf1) significantly associated with phylogenetic group B2. We demonstrated a high correlation between alpha-hemolysin A and pyelonephritis C, sfa, and cnf1 operons, confirming the presence of pathogenicity islands in these strains. In addition, UPEC belonging to group B2 harboured a greater number of virulence factors than strains from phylogenetic groups A, B1, and D. REP- and ERIC-PCR grouped the UPEC isolates into two major clusters, the former grouping E. coli strains belonging to phylogenetic group B2 and D, the latter grouping those belonging to groups A and B1. Given the significant genetic variability among the UPEC strains found in our study, it can be hypothesized that no specific genotype is responsible for cystitis in cats or dogs.

Pielonefritis aguda en el embarazo y susceptibilidad antimicrobiana de uropatógenos: comparación de dos décadas / Acute pyelonephritis in pregnancy and antimicrobial susceptibility of uropathogens: comparison of two decades

ANTECEDENTES: La infección de tracto urinario (ITU) es la patología infecciosa bacteriana más frecuente del embarazo. Los esfuerzos por lograr una detección precoz y tratamiento adecuado se basan en la toma sistemática de urocultivo al inicio del embarazo, estudiando los agentes causales y la sensibilidad de éstos a los antibióticos recomendados durante la gestación. OBJETIVO: Describir los cuadros clínicos y microbio-lógicos de los casos de ITU registrados en embarazadas atendidas en nuestra institución durante el año 2007 y compararlos con los reportes de 1988 y 2001. MÉTODOS: Se revisaron las historias clínicas de 112 embarazadas que cursaron ITU durante 2007, determinando la frecuencia de pielonefritis aguda (PNA), agente infeccioso y susceptibilidad a los antimicrobianos. Se compararon estos datos con los registrados en 2001 y 1988 mediante el cálculo de Odds Ratios. RESULTADOS: La proporción de PNA mostró una tendencia decreciente entre 1988, 2001 y 2007 (p<0,001). Escherichia coli fue el agente infeccioso más frecuente, sin embargo, su frecuencia disminuyó entre 2001 y 2007 (OR 0,32; IC95% 0,17-0,58). Se observó un aumento de ITU por Streptococcus agalactiae (SGB) (OR 3,98; 1,85-8,67) durante igual período. La sensibilidad antimicrobiana a ampicilina, gentamicina, nitrofurantoina y cotrimoxazol no presentó diferencias significativas entre 2001-2007. CONCLUSIÓN: Se documentó un cambio en el perfil clínico y microbiológico de las ITU en embarazadas, reduciéndose la proporción de PNA e ITU por Escherichia coli.

BACKGROUND: Urinary tract infection (UTI) is the most frequent bacterial infectious pathology during pregnancy. Efforts to accomplish an early detection and treatment are based on universal urine culture during pregnancy, study of etiologic agents and their susceptibility to antimicrobials prescripted during pregnancy. OBJECTIVE: To describe the clinical and microbiological characteristics of cases of UTI in pregnant women attended in our institution during 2007 and compare them with the reports of 1988 and 2001. METHODS: Clinical records of 112 pregnant women who presented UTI were reviewed, establishing the frequency of acute pyelonephritis (APN), infectious agent and antimicrobial susceptibility. Data were compared statistically with the records of 2001 and 1988 by calculating odds ratios. RESULTS: The proportion of APN showed a decreasing trend between 1988, 2001 and 2007 (p<0.001). Escherichia coli was the most frequent infectious agent, although its frequency reduced between 2001 and 2007 (OR 0.32; IC95% 0.17-0.58). On the other hand, the frequency of UTI caused by Streptococcus agalactiae (GBS) increased during the same period of time (OR 3.98; 1.85-8.67). Antimicrobial susceptibility to ampicillin, gentamicin, nitrofurantoin y cotrimoxazole did not present significant differences between 2001-2007. CONCLUSION: A change in the clinical and microbiological characteristics of UTI in pregnant women was documented. The proportion of APN and UTI caused by Escherichia coli were reduced.

Emphysematous renal tract disease due to Aspergillus fumigatus.

Emphysematous renal tract disease (ERTD) is a rare necrotizing infection of renal parenchyma and/or urinary tract caused by gas producing organisms. A case of acute emphysematous renal tract disease (ERTD) (emphysematous pyelonephritis along with emphysematous cystitis) caused by Aspergillus fumigatus in a non-diabetic patient, who did not apparently have any risk factor for fungal infection, is presented. Patient had refused for any surgical intervention. He was treated successfully with liposomal amphotericin B and 5-flucytosin and achieved complete recovery. Various causes of ERTD and available therapeutic options are discussed.

Infección cervico vaginal en la pielonefritis aguda del embarazo: relación con los resultados del tratamiento antibiótico y con la contractilidad uterina anormal / Cervix-vaginal infection in acute pyelonephritis in pregnancy: it relation with the results of antibiotic treatment and with abnormal uterine contractility

Antecedentes. La embarazada desarrolla fácilmente infecciones de la vía urinaria por cambios funcionales y por ubicación del meato uretral. En la pielonefritis aguda del embarazo no es muy conocida la participación de la infección del tracto genital inferior en los resultados del tratamiento antibiótico y en la presencia de contracción uterina del aborto y parto prematuro. Objetivos. Conocer la microbiología de la vía uterina y del tracto genital en la pielonefritis aguda del embarazo y su relación con los resultados del tratamiento y con la existencia de contracción uterina. Diseño del estudio. Embarazada entre 12 y 34 semanas de gestación con el diagnóstico de pielonefritis aguda se enrolaron. Se tomaron muestras de orina y cervicovaginales para cultivo. Recibieron randomizadamente cefuroxima o cefradina. Se observó la contracción uterina. En el seguimiento se pidieron cultivos de orina como controles. Resultados. 97 mujeres cumplieron con los criterios de inclusión. Escherichia coli se aisló del urocultivo en el 94,8 por ciento de los casos. La vaginosis bacteriana se presentó en el 32,0 por ciento y la infección cervicovaginal en el 57,7 por ciento de las pacientes. En la infección cervicovaginal E. coli se aisló en el 65,2 por ciento. El fracaso en la erradicación de la bacteria de la vía urinaria, se asoció con infección cervicovaginal (76,9 por ciento vs 52,9 por ciento, p< 0.05) y con leucocitos aumentados en la muestra cervical (76,9 por ciento vs 47,1 por ciento, p< 0,01). La contracción uterina se asoció significativamente con: infección cervicovaginal (p < 0,01), vaginosis bacteriana (p < 0,001) y con hallazgo en la muestra cervical de : leucocitos aumentados (p < 0,01), flora polimicrobiana (p < 0,001), aislamiento de E. coli (p < 0.001) y disminución de Lactobacillus sp (p < 0.01). Conclusiones: La infección del tracto genital inferior existente en la pielonefritis aguda del embarazo se relaciona con el fracaso de la terapia antimicrobiana en la erradicación de la bacteria de la vía urinaria y con contracción uterina presente

Haemolytic Escherichia coli in etiopathogenesis of pyelonephritis in rats--an experimental study.

Of the 26 urinary E. coli strains employed in the present study, 16 were haemolytic and 10 were non haemolytic in character. Of the 16 haemolytic strains injected through the exposed femoral vein of the rats, 12 showed the lesions of pyelitis, pyelonephritis and proliferation of glomerular tuft while 2 showed only the lesions of pyelitis and pyelonephritis. It was interesting to note that none of the nonhaemolytic strains produced any lesion in the animal. The data demonstrated a positive correlationship between haemolytic activity of E. coli and pyelonephritis in rats.

Patogénesis y manejo de la infección urinaria durante la gestación / Urinary tract infection during pregnancy etiologic agents and treatment

La infección urinaria es uno de los problemas más frecuentes en las pacientes embarazadas. En el momento actual se puede afirmar que existe una correlación entre la cacteriuria asintomática, el parto pretérmino y el bajo peso al nacimiento. La pielonefritis es la infección que ocasiona un mayor número de efectos adversos perinatales, como: retardo en el crecimiento intrauterino y prematurez en el producto, y disminución en la depuración de creatinina y anemia en la madre. Escherichia coli es el agente etiológico más común tanto en la población general como en las mujeres gestantes. El tratamiento antimicrobiano variará de acuerdo al tipo de infección urinaria con que curse la paciente y el momento del embarazo en que se presente. La detección temprana de la infección urinaria es la medida preventiva más significativa para evitar el desarrollo de pielonefritis y de sus repercusiones perinatales adversas.

Enfoque microbiológico de las pielonefritis / Approach of pyelonephritis microbiologic

Los factores condicionantes de los procesos infecciosos urinarios depende de las condiciones fenotípicas de la flora infectante, pasando por las predisposiciones personales de acuerdo al sexo hasta las alteraciones anatomofuncionales heredadas o adquiridas. La terapia en estos pacientes con alto riesgo debe estar orientada hacia la esterilización total de la orina y obviamente a la corrección clínico-quirúrgica del factor predisponente y condiciona las infecciones recidivantes . La terapia antimicrobiana debe ser establecida con base en un buen conocimiento farmacocinético del o los productos seleccionados

Pielonefritis enfisematosa / Emphysematous pyelonephritis

La pielonefritis enfisematosa es una infección del parénquima renal asociada con la producción de gas, el que se localiza en el parénquima renal y puede extenderse al espacio perirrenal. Se presenta el caso de una mujer de 61 años con pielonefritis enfisematosa diabética, con obstrucción ureteral, urocultivo y homocultivo positivos para Escherichia coli, comprobándose en la autopsia alteraciones histológicas que corroboran las características clínicas de enfisema renal y perirrenal, resultando este caso, de especial interés por la bilateralidad de las lesiones. Esta enfermedad es poco frecuente y afecta a pacientes con diabetes mellitus y obstrucción ureteral. La producción de gas se debe a la acción de bacterias anaeróbicas facultativas que fermentan la glucosa y producen ácido láctico y dióxido de carbono. El tratamiento se fundamenta en la reposición hidroelectrolítica, control del estado ácido base, corrección de la descomposición diabética y antibiótico-terapia. Se destacan las ventajas del tratamiento quirúrgico precoz, basado en la nefrectomía y/o en el drenaje del espacio perirrenal