BACKGROUND

1. Evaluation of the Appropriateness of Antibiotic Use for Treating Hospitalized Uncomplicated Acute Pyelonephritis 院內非複雜性腎盂腎炎之抗生素使用合理性評估 San-Ein Tuo 1, Wen-Tao Huang 1, Xiu Zhen Zhan 2, Zhong Wei Cai 2, Yi Chen Chen 2, Yen-Ying Lee 1 庹聖茵1 ,黃文濤1 ,詹秀珍2 ,蔡仲為2 ,陳怡辰2 ,黎燕縈1 Dept. of Pharmacy, Taipei Medical University-Wan Fang Hospital 1, College of Pharmacy, Taipei Medical University2 台北醫學大學‧市立萬芳醫院藥劑部1,台北醫學大學藥學院2 Diagnosis of uncomplicated APN or UTI (with symptoms of APN) (n=187) Exclusion (n=58) Drug allergy (10) Diabetes(19) Cancer (5) Immunosuppressive disease (4) Acute renal failure (5) Pregnancy (3) Recurrence (12) BACKGROUND Table 2. Urine Culture and Susceptibility Results Analyzed (n=129) Urinary Tract Infection (UTI) is a common disease for women. However, the resistance rates of antibiotics commonly used for uncomplicated UTI have been increasing in recent years. Therefore, to determine an appropriate empiric antibiotic for treating hospitalized uncomplicated UTI, such as acute pyelonephritis, is an important issue. OBJECTIVE To evaluate the appropriateness of antibiotic choice for treating hospitalized female patients with acute pyelonephritis (APN) by collecting empiric antibiotics, duration, and urine culture and susceptibility tests. METHOD *NA= Not Available Table 3. Empiric Therapy and Susceptibility Rates This was a retrospective observational study. Patients who were diagnosed of uncomplicated APN or UTI and hospitalized at Wanfang medical center in the period of 1 January 2007 to 31 December 2008 were included in the study. • Inclusion Criteria • A diagnosis of uncomplicated APN or UTI (with symptoms of APN) • Symptoms of flank pain/tenderness or fever≧37.5℃ or chills. • ≧15 y/o female • ≧103CFU/mL and/or urine WBC>5/mm3 • No episodes of UTI within the last six months • Exclusion Criteria • Diabetes • Cancer • Acute renal failure • Any immunosuppressive disease • Pregnancy or breast-feeding • Known allergy or contraindication to β-lactams or TMP-SMX or fluoroquinolones • Primary outcomes: • Frequency of correct initial empiric antibiotic treatments of inpatients with uncomplicated APN According to urine culture & susceptibility results • Summary of urine culture and susceptibility results of inpatients with uncomplicated APN Secondary outcomes: • Failure of initial empiric treatments of uncomplicated APN at our hospital • Treatment failure rate • Recurrent rate (within 6 weeks) • Duration of antibiotic treatment Table 4. Treatment Failure Rate and Recurrent Rate Table 5. Treatment Duration RESULTS Figure 1. Reasons forPatient Exclusion • Reasons for patient exclusion showed in figure 1. • Characteristics of the 129 patients showed in table 1. • Microbial organisms profile and urine culture and susceptibility results of the 129 patientswere summarized in figure 2 and table 2. E. coli was the most common pathogen. • The combination of cefazolin plus gentamicin was the most common empiric choice for antibiotics in the 129 patients reviewed. The empiric antibiotics and the frequency of correct initial empiric antibiotic treatments showed in Table 3. • Failure of initial empiric treatments and recurrent rates showed in Table 4. • The mean treatment duration was about 14 days. The duration of antibiotic treatment showed in Table 5 . DISCUSSIONS • The most common pathogen was E. coli, but TMP/SMZ was susceptible to only 47% of the time. Therefore, empiric use of TMP/SMZ to treat hospitalized uncomplicated acute pyelonephritis is not appropriate in our institution. • The most common empiric antibiotics treated in uncomplicated APN at WFH is Cefazolin plus Gentamicin: 89% • To evaluate the appropriateness of the empiric treatment of cefazolin and gentamicin by the susceptibility results: • Cefazolin is susceptible to most pathogens in patients with uncomplicated APN (89%, 77/87) and is capable as a single empiric treatment. • Concomitant treatment with gentamicin provides only a little benefit to the patients with Cefazolin resistance(3.4%, 3/87). Table 1. Characteristics of Patients Included 3.4% LIMITATIONS • Retrospective study • Lack of objective data of bacteria eradication in the urine. • Determination of treatment failure in vivo only depended on clinical responses. • The sample size of the study was too small. • This study included only inpatients (with symptoms of APN). Therefore, it would not be possible to extrapolated the results to the whole uncomplicated UTI patient population. Figure 2. Microbial Organisms Profile of The 129 Patients CONCLUSION • Cefazolin is appropriate as a single empiric treatment for inpatients with uncomplicated APN at our hospital. • Gentamicin, for the risks of side effects and ineffectiveness compared to cefazolin, combination with cefazolin is not recommended. REFERENCES Pharmacotherapy 6th ed - J. DiPiro, et al (McGraw-Hill, 2005) Foxman B., Barlow R., D'Arcy H., et al: Urinary tract infection: self-reported incidence and associated costs.  Ann Epidemiol 10. 509-515.2000 Scholes D., Hooton T.M., Roberts P.L., et al:  Risk factors for recurrent urinary tract infection in young women.  J Infect Dis 182. 1177-1182.2000 follow-up of 179 women.  Clin Infect Dis 22. 91-99.1996; Czaja CA; Scholes D; Hooton TM; Stamm WE: Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007 Aug 1;45(3):273-80. 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