[Immunotherapy and long-term chemoprophylaxis in prevention of recurrent urinary infections in women]. / Imunoterapia a dlhodobá chemoprofylaxia v prevencii recidivujaticich uroinfekcii u zien.

In clinical practice, management of urinary infections is a frequent task. Long-term prophylactic administration of small-dose chemotherapy had been shown to prevent recurrent urinary infections. Recently, an interest increases in applying immunotherapy in this indication. The authors compare immunomodulators Urovaxom and Luivac as part ofa combined immunotherapy and chemoprophylaxis regimens with small doses of fluorochinolones over 12 months in women with recurrent urinary infections. This treatment statistically significantly decreases occurrence of relapses and has been relatively well-tolerated. Unlike previous studies, we managed to isolate resistant strains producing the so-called extended-spectrum beta-lactamases (ESBL) and this may provide a signal for revision of some therapeutic approaches. In line with international recommendations, we prefer immunotherapy as comparably effective but safer treatment modality than the long-term chemoprophylaxis with fluorochinolones.

[Pharmacoeconomic profile of antibiotics used in the treatment of lower respiratory tract infections in geriatric patients]. / Farmakoekonomický profil antibiotík pouzitých v liecbe infekcií dolných dýchacích ciest u geriatrických pacientov.

The paper aims to evaluate the pharmacoeconomic profile of antibiotics (ATB) used in the treatment of lower respiratory tract (LRT) infections and thus contribute to rationalization of therapeutic procedures. Of 2870 patients hospitalized at the Geriatric Clinic of the Medical Faculty of Comenius University from 1 January 1999 to 31 December 2001, 189 patients with acute infections of the LRT were included in the retrospective study. For pharmacoeconomic evaluation, cost effectiveness analysis was employed, the principal parameter of which, cost effectiveness coefficient, was the ratio of the price of ATB treatment in Slovak crowns (SK) and the criterion of effectiveness (E), the number of asymptomatic days in a month. The authors separately evaluated ATBs administered perorally (p.o.); intravenously (i.v.), and sequentially, and they also compared i.v. and the corresponding sequentially administered ATBs. Statistical comparison revealed significant differences in the prices and cost effectiveness coefficients of individual alternatives of ATB treatment. Employed ATBs did not significantly differ in the criteria of effectiveness. According to the cost effectiveness coefficient (SK/asymptomatic day), fluoroquinolones were less expensive (median price/E: pefloxacin: p.o. 19.3; i.v. 29.1; sequentially administered 26.0, and ciprofloxacin: p.o., 14.7, i.v., 54.1, sequentially administered, 31.7). Sequential administration of ATBs (ampicillin-sulbactam, cefuroxime, amoxicillin-klavulanate, ciprofloxacin) was significantly cheaper in comparison with i.v. administration. With therapeutic equivalence, the total pharmacoeconomic profile of ATB treatment depended on the price parameter. In the selection of ATB it is also necessary to consider the price of the drug.

Cost-effectiveness analysis of switching from intravenous to oral administration of antibiotics in elderly patients.

OBJECTIVE: The aim of the introduced work was to evaluate pharmacoeconomic advantages of timely switching from intravenous to oral administration of antibiotics (ATB). METHODS: The evaluated group was selected out of 2870 patients, who were hospitalised at the Clinic of Geriatric Medicine of the Faculty of Medicine of Comenius University in Bratislava from January 1st 1999 to December 31st 2001. In our retrospective study we analysed 96 patients with community-acquired pneumonia successfully treated by ATB. In 43 of them ATB were given intravenously and in 53 the therapy was switched, i.e. the intravenous administration was used at the beginning and oral administration when the condition improved. We applied a cost-effectiveness analysis to the pharmacoeconomic evaluation. The cost-effectiveness coefficient was calculated as the ratio of ATB price (Slovak Crowns) to the effectiveness criterion (number of asymptomatic days in month). RESULTS: According to the cost-effectiveness coefficient, the switch therapy was significantly less expensive in all evaluated ATB (except for pefloxacin) in comparison with intravenous administration: ampicillin-sulbactam 93.9 vs 168.1; cefuroxime 90.0 vs 123.3; amoxicillin-clavulanate 74.0 vs 116.3; ciprofloxacin 31.7 vs 54.1. CONCLUSIONS: A timely switching from intravenous to oral administration of ATB in a suitable patient is an effective way to save financial resources. (Tab. 5, Ref: 21.)

Epidemiological analysis of the spread of pathogens from a urological ward using genotypic, phenotypic and clinical parameters.

Surveillance studies using molecular typing methods help clinicians assess the rate of potential spread of pathogens. The rate of cross transmission of uropathogens among patients on a urological ward was investigated. Urine samples were collected from 144 patients with urinary catheters and a significant bacteriuria. In a subgroup of 54 of these patients, cultures from a rectal swab were also made. Typing by PFGE, RAPD or bacteriocins showed that 41% of uropathogens were related and represented by 38 typing patterns. Endogenous infection was present in 30% and exogenous infection in 38% of isolates. Altogether, there was a high rate of clonal relationship amongst uropathogens in our urological ward and we conclude that hygienic means and measures are far from being optimal.

Risks of antibiotic treatment.

Adverse effects of antibiotics can cause a failure of antibiotic treatment. The authors give a survey of antibiotic toxicity manifestations, according to the target organ systems, with emphasis on identification of at-risk patients and on possible prevention of particular adverse effects. Although antibiotics belong to relatively safe pharmaceuticals, many of them can be a cause of a serious damage to the human organism. Beta-lactam antibiotics are considered the least dangerous. A considerable number of adverse effects, especially the dose-dependent ones, are preventable on condition that the risk factors, as the patient's age, functional capacity of eliminating organs (kidney, liver), associated diseases and simultaneous administration of drugs, are considered. In conclusion, the clinically significant drug interactions of antibiotics are pointed out, being of increasing importance especially in patients with multiple diseases and polypragmatic manner of treatment. (Tab. 2, Ref. 48.)

Treatment of lower urinary tract infection in pregnancy.

Urinary tract infection (UTI) is a common complication of pregnancy. Approximately 20--40% of women with asymptomatic bacteriuria will develop pyelonephritis during pregnancy. All pregnant women, therefore, should have their urine cultured at their first visit to the clinic. In a clinical study comparing single-dose treatment with 3 g fosfomycin trometamol versus a 3-day course of 400 mg ceftibuten orally, the inclusion criteria were acute symptomatic lower UTI (acute cystitis), significant bacteriuria (> or =10(3) CFU/ml), pyuria and confirmed pregnancy. Excluded were patients with asymptomatic bacteriuria or acute pyelonephritis. Predisposing factors comprised a history of recurrent UTI, diabetes mellitus, analgesic nephropathy, hyperuricaemia or Fanconi's syndrome. Escherichia coli was the most frequently isolated pathogen in both groups. Therapeutic success (clinical cure and bacteriological eradication of uropathogens) was achieved in 95.2% of the patients treated with fosfomycin-trometamol versus 90.0% of those treated with ceftibuten (P, non-significant). The treatment of acute cystitis in pregnant women using a single-dose of fosfomycin trometamol was equally effective as the 3-day course of oral ceftibuten. Both regimens were well tolerated with only minor adverse effects. Long-term chemoprophylaxis should be suggested in patients with recurrent UTI or following acute pyelonephritis during pregnancy.

Newer quinolones in the long term prophylaxis of recurrent urinary tract infections (UTI).

Up to 10% of premenopausal women experience recurrent symptomatic urinary tract infection (UTI), mainly due to reinfection from the faecal flora. The recently introduced fluoroquinolones possess a wide spectrum of activity against most uropathogens and achieve high urinary concentrations for extended time periods. Our initial study, conducted between 1993 and 1995, was designed to compare the efficacy and safety of oral pefloxacin 800mg once weekly with oral ciprofloxacin 125mg once daily, over a 12-month prophylactic course in women with recurrent UTI. A 12-month reinfection-free period was achieved in 83.3% of pefloxacin patients and in 78.9% of ciprofloxacin patients. The present study, which commenced in 1996, was designed to compare pefloxacin 400mg with oral fleroxacin 400mg once weekly. Prophylaxis was maintained for 12 months. There are no statistically significant differences between the 2 regimens in terms of efficacy and safety. The most frequently isolated pathogens causing breakthrough reinfections were Escherichia coli and Enterococcus spp. Adverse effects observed were mostly neuropsychic (insomnia) and gastrointestinal. In both studies, there was no evidence of emergence of quinolone-resistant organisms in the urine or rectal flora, even after 12 months of chemoprophylaxis.

Fungal urinary tract infections in patients at risk.

Fungal urinary tract infection (UTI) represents a high-risk event in severely ill patients. Its increasing incidence in recent years is associated with extensive and prolonged use of broad-spectrum antimicrobial agents, corticosteroids, immunosuppressive and cytotoxic drugs. Other important risk factors comprise higher age, diabetes mellitus, chronic renal failure, hemodialysis, renal transplantation, structural or functional abnormalities of urinary tract with indwelling urinary catheter or nephrostomy. Fifty hospitalized symptomatic patients with funguria of > 10(5) CFU/ml and leucocyturia were analysed for etiology, risk factors and outcome. Candida albicans was isolated in 36 patients, non-albicans Candida species (Candida tropicalis, Candida krusei) and non-Candida yeasts (Blastoschizomyces capitatus) in 14 patients, respectively. All patients were treated with systemic antifungals. In total, 42 patients of 50 (84%) were cured (32/36 with C. albicans and 10/14 with non-C. albicans associated funguria). Systemic antifungal therapy should be considered in high-risk patients with fungal UTI.

Ciprofloxacin once versus twice daily in the treatment of complicated urinary tract infections. German Ciprofloxacin UTI Study Group.

Ciprofloxacin is considered to be the standard treatment for patients with complicated urinary tract infections (UTI). This multicentre, randomized clinical study was designed to compare a once-daily regimen with 500 mg to the usual twice-daily regimen with 250 mg orally for 7-20 days. A total of 215 patients with significant bacteriuria (> or = 10(5) c.f.u./ml for females and > or = 10(4) c.f.u./ml for males) were included in the study. Eradication of bacteriuria was shown in 84.0% of patients treated with 500 mg q.i.d. and in 90.9% of patients treated with 250 mg b.i.d. Clinical cure or improvement was achieved in 97.3% of those treated with 500 mg q.i.d. versus 95.5% of those treated with 250 mg b.i.d. More superinfections occurred in patients treated with 500 mg q.i.d., mostly caused by gram-positive cocci. The statistical analysis concerning the elimination of bacteriuria using the 95% confidence interval showed a difference of up to 18.4% between the two treatment groups in favour of the 250-mg b.i.d. regimen. Ciprofloxacin was well tolerated with only mild to moderate side-effects (mostly gastrointestinal) in 8% of the patients. When using ciprofloxacin in patients with complicated UTI, its administration in two divided doses can be further recommended as a standard regimen.

[Postoperative analgesia with epidural administration of a combination of tramadol and clonidine]. / Pooperacná analgézia kombináciou tramadolu a klonidínu epidurálnou cestou.

Postoperative analgesia inhibits the stress cascade with negative effects on whole organism. Therefore the spectrum of drugs used for soothing postoperative pain quickly widens. The epidural route appears as being logical, since due to the direct effect in the transmission and processing of pain it suffices with a lower dosage. The authors refer to a group of 30 patients postoperatively treated by a combination of tramadol and Clonidine administrated by means of an epidural catheter. 26 patients evaluated the induced analgesia as excellent or sufficient. (Tab. 3, Ref. 4).

[Single-dose therapy of infections of the lower urinary tract]. / Jednorazová liecba infekcií dolných mocových ciest.

The authors analyze two clinical studies in the frame of single-dose treatment of uncomplicated infection of the lower urinary tract. The first study deals with comparison of the effect of netilmicin, ciprofloxacine and aztreonam. The second study deals with pefloxacine and cefuroxim-axetil. As the results implied, both long-term and short-term effectiveness of therapy comparable with other verified regimes was accomplished in female patients who were not pregnant and irrespective of their age. It is necessary to respect the contraindications of therapy. Chemotherapeutics which are appropriate for single-dose therapy of uncomplicated infections of the lower urinary duct include quinolones (pefloxacine, ciprofloxacine), phosphomycin-trometamol, co-trimoxozole a netilmicin. The majority of oral beta-lactam antibiotics cannot be recommended for a single-dose therapy of uroinfections. The authors summarize the advantages of a single-dose therapy of uroinfections and analyze the criteria of significant bacteriuria.

[Single dose administration of netilmicin in the treatment of urinary tract infections]. / Jednorazové podanie netilmicínu v liecbe infekcií mocových ciest.

The authors submit the results of treatment of non-complicated urinary tract infections by a single dose of netilmicin. They treated 23 patients to whom they administered a single dose of 200 mg netilmicin by the i.m. route. A positive short-term effect was recorded in 82.8%. Cases of failure of this treatment indicate the necessity of careful indication of a single dose of netilmicin only to patients with non-complicated infections of the urinary pathways.