Management of Complicated Urinary Tract Infections in the Era of Antimicrobial Resistance
Management of Complicated Urinary Tract Infections in the Era of Antimicrobial Resistance
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DOI：
10.3810/pgm.2010.11.2217
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发表时间：
2010-11-01
影响因子：
4.2
通讯作者：
Brooks, Annie
中科院分区：
文献类型：
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作者：
Bader, Mazen S.;Hawboldt, John;Brooks, Annie
复杂性尿路感染（cUTI）是住院的主要原因，并与显著的发病率和医疗保健费用相关。疑似UTI的患者应筛查是否存在并发因素，如泌尿生殖道的解剖和功能异常。在cUTIs的情况下，病原体的病因和易感性是不可预测的;因此，当怀疑感染时，除了培养和敏感性测试外，患者还应进行尿液分析。尽管并非所有复杂性肾盂肾炎病例都需要进行血培养，但在某些临床环境中仍适合进行血培养。随着抗生素耐药性的流行，以及缺乏精心设计的临床试验，cUTI的治疗对临床医生来说可能是一个挑战。虽然耐药微生物并不总是与致病因子有关，但所有cUTI患者都应评估易感风险因素。最佳抗菌药物的考虑应基于局部耐药模式、患者特异性因素（包括感染的解剖部位和疾病的严重程度）、药代动力学和药效学原理以及成本。对一线抗菌药物（包括氟喹诺酮类）的耐药性在大肠杆菌中越来越常见。氟喹诺酮类药物不应作为经验性治疗严重cUTI的一线选择，特别是当患者表现出携带耐药微生物的风险因素时，如既往或近期使用氟喹诺酮类药物。氟喹诺酮类、甲氧苄啶-磺胺甲恶唑和呋喃妥因仍然是轻度较低cUTI的适当经验选择。然而，对于存在耐药微生物风险因素的严重cUTI，经验性治疗应包括广谱抗生素，如碳青霉烯类或哌拉西林-他唑巴坦。一旦确定了微生物和敏感性，就应相应地进行治疗。呋喃妥因和磷霉素在cUTI中的效用有限，在确认病原体后，应保留作为较低cUTI的替代治疗选择。当认为一线选择不合适或患者治疗失败时，氨基糖苷类、替加环素和多粘菌素可用于治疗严重cUTI。cUTI的治疗持续时间尚未明确;然而，根据临床情况，治疗持续时间可为1 - 4周。
Complicated urinary tract infections (cUTIs) are a major cause of hospital admissions and are associated with significant morbidity and health care costs. Patients presenting with a suspected UTI should be screened for the presence of complicating factors, such as anatomic and functional abnormalities of the genitourinary tract. In the setting of cUTIs, the etiology and susceptibility of the causative organism is not predictable; therefore, when infection is suspected, patients should undergo a urinalysis in addition to culture and sensitivity testing. Although not warranted in all cases of complicated pyelonephritis, blood cultures are appropriate in some clinical settings. With the increased prevalence of antimicrobial resistance, and the lack of well-designed clinical trials, treatment of cUTIs can be challenging for clinicians. Although resistant organisms are not always implicated as the causative agent, all patients with cUTIs should be assessed for predisposing risk factors. Consideration of an optimal antimicrobial agent should be based on local resistance patterns, patient-specific factors, including anatomic site of infection and severity of disease, pharmacokinetic and pharmacodynamic principles, and cost. Resistance to first-line antimicrobial agents, including fluoroquinolones, has become increasingly common in Escherichia coli. Fluoroquinolones should not be used as a first-line option for empiric treatment of serious cUTIs, especially when patients exhibit risk factors for harboring a resistant organism, such as previous or recent use of fluoroquinolones. Fluoroquinolones, trimethoprim-sulfamethoxazole, and nitrofurantoin are still appropriate empiric options for mild lower cUTIs. However, empiric treatment for serious cUTIs, where risk factors for resistant organisms exist, should include broad-spectrum antibiotics such as carbapenems or piperacillin-tazobactam. Once organisms and susceptibilities are identified, treatment should be targeted accordingly. Nitrofurantoin and fosfomycin have limited utility in the setting of cUTIs and should be reserved as alternative treatment options for lower cUTIs following confirmation of the causative organism. Aminoglycosides, tigecycline, and polymyxins can be used for the treatment of serious cUTIs when first-line options are deemed to be inappropriate or patients fail therapy. The duration of treatment for cUTIs has not been well established; however, treatment durations can range from 1 to 4 weeks based on the clinical situation.