Israel Medical Association Journal

Background: In an era of increasing antimicrobial resistance, knowledge of local antimicrobial susceptibility patterns of common uropathogens is essential for prudent empiric therapy of community-acquired urinary tract infections.

Objectives: To define antimicrobial susceptibility of Gram-negative uropathogens in northern Israel over a 10 year period and to compare it with antibiotic-use patterns in the same community.

Methods: We tested the susceptibility of all Gram-negative urinary isolates from outpatients at HaEmek Medical Center over the years 1995, 1999, 2002 and 2005 to common antimicrobial agents. MIC₉₀ of Escherichia coli to some of these agents was determined and antibiotic consumption data over the years 2000–2005 (DDD/1000/day) were obtained.

Results: We observed a rise in susceptibility rates of E. coli to amoxicillin-clavulanate, trimethoprim-sulfamethoxazole and nitrofurantoin and of other Gram-negative isolates to amoxicillin-clavulanate, ceftriaxone and cephalothin. Susceptibility rates of all Gram-negative uropathogens to ciprofloxacin decreased significantly. MIC₉₀ of E. coli for all drugs tested remained stable. There was a significant decrease in the use nitrofurantoin and TMP-SMX[1] and a significant increase in the use of ampicillin, cephalothin and ceftriaxone.

Conclusions: Antibiotic resistance patterns mostly remained unchanged or improved slightly. There was, however, a constant decrease in susceptibility of all Gram-negative uropathogens to ciprofloxacin. Antibiotic use patterns could not explain the changes seen in antibiotic susceptibility patterns.

Background: Acute focal nephritis is an inflammatory process of the renal parenchyma affecting principally the cortex of the kidney. It is considered a midpoint in the spectrum of upper urinary tract infections, ranging from uncomplicated pyelonephritis to intrarenal abscesses, and until recently the hyperechoic sonographic appearance of this lesion was considered uncommon.  

Objectives: To determine the relative prevalence of hyperechoic and hypoechoic sonographic appearance of focal renal lesions in patients with the clinical diagnosis of acute pyelonephritis and to correlate the findings with those of the color Doppler examinations.

Methods: We reviewed the sonograms of 367 patients hospitalized with the clinical diagnosis of acute pyelonephritis. The sonograms were reviewed for acute renal inflammatory changes. When a focal lesion was detected, we noted the echogenicity, side, form, location and color Doppler characteristics.

Results: Abnormal sonographic findings related to the infection were found in 78 cases. In 52 patients a focal lesion was diagnosed. Forty-seven focal lesions appeared hyperechoic related to the adjacent parenchyma. These lesions were more frequently located at the upper pole and were wedge-shaped in most of the cases. The areas appeared hypo/avascular on the color Doppler examination.

Conclusions: Our data suggest that the most common appearance of acute focal nephritis is an area of increased echogenicity in the parenchyma of the affected kidney.
 

Background: Until recently trimethoprim-sulfamethoxazole was the drug recommended in the Leumit Health Fund for the empiric treatment of uncomplicated urinary tract infection in women. However, due to increased uropathogen resistance to this drug, the fund has designated nitrofurantoin as its new drug of choice.

Objectives: To evaluate the potential economic impact of implementing this new pharmaco-policy.

Methods: Using data derived from the electronic patient records of the Leumit Health Fund we identified all non-recurrent cases of women aged 18–49 with a diagnosis of acute cystitis or UTI[1] without risk factors for complicated UTI and empirically treated with antibiotics throughout 2003. The final sample comprised 5,489 physician-patient encounters. The proportion of cases treated with each individual drug was calculated, and the excess expenditure due to non-adherence to the new guideline from the perspective of the health fund was evaluated using 5 days of therapy with nitrofurantoin as the reference treatment.

Results: Ofloxacin was the most frequently prescribed drug (30.24%), followed by TMP-SMX[2] (22.43%), cephalexin (15.08%), and nitrofurantoin (12.59%). The observed net aggregate drug expenditure was 2.3 times greater than expected had all cases been treated with nitrofurantoin according to the guideline duration of 5 days. The cost of treatment in 53% of the cases exceeded the expected cost of the guideline therapy.

Conclusions: Successful implementation of the new drug policy will likely improve quality of care and reduce costs to the health fund.

Objectives: To assess patient satisfaction, subjective long-term continence and complications after AMS 800 artificial urinary sphincter implantation.

Methods: The medical records of 34 patients who underwent artificial urinary sphincter implantation for radical prostatectomy (n=23), simple prostatectomy (n=9) or neurogenic disease (n=2) between 1995 and 2003 were studied retrospectively. Median follow-up was 49 months (range 3–102 months). Records were analyzed for urinary sphincter survival and complications. Quality of life and continence assessment was done by mailing an impact questionnaire.

Results: In 4 of the 34 patients (11.7%) the device was removed due to infection. One of the four had surgical revision elsewhere, and the other three were not interested in re-implantation of the device. Two patients (5.9%) underwent revisions due to mechanical failure. One patient died and three patients were not located. Twenty-seven out of a possible 30 patients (88%) completed the questionnaire; 22 (85%) achieved social continence (0–2 pads daily), and one patient had subjective difficulty activating the device. Subjective improvement and patient satisfaction was rated as 4.22 and 4.11, respectively (scale 0 to 5).
Conclusions: Artificial urinary sphincter implantation is an efficacious option for sphincter-related incontinence. This study documents the positive impact of artificial urinary sphincter implantation on quality of life with acceptable complications; these results are comparable to other published studies.

Background: Multiple factors are involved in the pathogenesis of hypertension in the obese individual.

Objective: To evaluate the role of a decrease in sympathetically mediated thermogenesis and the effect of the correlation between the plasma leptin and daily urinary nitric oxide levels on obesity-related hypertension.

Methods: We evaluated three groups: 25 obese hypertensive patients (age 45.7±1.37 years, body mass index 34.2±1.35 kg/m², systolic/diastolic blood pressure 155±2.9/105±1.3, mean arterial pressure 122±1.50 mmHg); 21 obese normotensive patients (age 39.6±1.72, BMI[1] 31.3±0.76, SBP/DBP[2] 124±2.1/85.4±1.8, MAP[3] 98.2±1.80); and 17 lean normotensive subjects (age 38.1±2.16, BMI 22.1±0.28, SBP/DBP 117±1.7/76.8±1.5, MAP 90.1±1.50). We determined basal resting metabolic rates, plasma insulin (radioimmunoassay), norepinephrine (high performance liquid chromatography) in all subjects. Thereafter, 14 obese hypertensives underwent a weight reduction diet. At weeks 6 (n=14) and 14 (n=10) of the diet the above determinations were repeated. Plasma leptin (enzyme-linked immunosorbent assay) and UNOx[4] (spectrophotometry) were assayed in 17 obese hypertensives and 17 obese normotensives, and in 19 obese hypertensives versus 11 obese normotensives, respectively.

Results: Obese hypertensive patients had significantly higher basal RMR[5] and plasma NE[6] levels. Insulin levels were lower in the lean group, with no difference between the hypertensive and normotensive obese groups. At weeks 6 and 14, BMI was significantly lower, as were insulin and NE levels. RMR decreased to values of normotensive subjects. MAP normalized but remained significantly higher than that of obese normotensives. Leptin blood levels and the leptin/UNOx ratio were significantly higher in the obese hypertensive compared to the obese normotensive patients. Both these parameters were strongly correlated to BMI, MAP⁵, RMR, and plasma NE and insulin .Obese hypertensive patients excreted less urinary NO metabolites. A strong correlation was found between MAP and the leptin/UNOx ratio.  

Conclusions: A reduction of sympathetically mediated thermogenesis, as reflected by RMR, results in normalization of obesity-related hypertension. In contrast, insulin does not seem to play a major role in the pathogenesis of hypertension associated with obesity. Increased leptin levels in conjunction with decreased NO production in the presence of enhanced sympathetic activity may contribute to blood pressure elevation in the obese.

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[1] BMI = body mass index

[2] SBP/DBP = systolic blood pressure/diastolic blood pressure

[3] MAP = mean arterial pressure

[4] UNOx = urinary nitric oxide

[5] RMR – resting metabolic rate

[6] NE = norepinephrine

Background: Urinary incontinence in older women is common. Its characteristics and impact on quality of life is not well established since these women are usually reluctant to tell their healthcare providers about the problem.

Objective: To determine the characteristics of urinary incontinence in women and the manner in which it affects patients quality of life.

Methods: Twenty family physicians were requested to distribute a questionnaire to the first 25 consecutive women aged 30 to 75 years who visited their clinic for any reason. The questionnaire covered general health issues, symptoms of urinary incontinence, and quality of life.

Results: A total of 418 women, mean age 50.0 ± 11.8 years, completed the questionnaire (84% response rate). Of these, 148 (36%) reported having episodes of urinary incontinence. Urinary incontinence was found to be associated with older age, menopause, obesity and coexisting chronic disorders. Sixty percent of the women with urinary incon­tinence found it to be a disturbing symptom, and 44% reported that it had a detrimental effect on their quality of life. Only 32% of the affected women had sought medical advice, half of them from their family physician. Treatment was recommended to 66% of those who sought help, and in about two-thirds of these it brought some measure of relief.

Conclusions: Urinary incontinence is a common com­plaint among women attending primary care clinics, but it does not receive appropriate attention, Though it often adversely affects quality of life, only a small proportion of women seek medical advice. Family physicians should raise the issue as a part of the routine general health check-up.
 

Background: Lower urinary tract symptoms are highly prevalent in older men, have been shown to affect men’s quality of life, and may be associated with more serious outcomes.

Objectives: To determine the prevalence of LUTS among men aged 50 years or older registered at family practice centers in Israel and to assess the effect of these complaints on different aspects of their life.

Methods: In a random sample cohort of men aged 50 years and older, fluent in Hebrew, drawn from those registered in four family clinics in Israel, patients identified with LUTS were interviewed by phone using a structured questionnaire.

Results: The prevalence of LUTS in our study was 21%. Less than a third of these patients had low severity LUTS (28%), 59% were rated moderate, and 13% had severe symptoms. Age had a positive correlation with the severity of LUTS, and increasing severity of symptoms had a negative effect on the daily function and quality of life of patients.

Conclusions: Our community-based study shows that LUTS is a common finding among men above the age of 50 (21%) and has a significant negative effect on their quality of life and daily function. Knowledge of these data should make primary care physicians more aware of this common problem and thus improve the treatment and quality of life of these patients by better identification and prompt treatment.

Background: Abdominal tuberculosis usually presents with general symptoms and obscure abdominal complaints for which computerized tomography is often the first imaging study.

Objective: To evaluate the CT findings of abdominal tuberculosis.

Methods: The CT scans of 19 patients (10 men and 9 women aged 20-85 years) with proven abdominal tuberculosis were retrospectively reviewed to define the location and extent of the disease. The patients were referred for the study mainly with general systemic symptoms. Additional abdominal com­plaints were present in four, including acute abdomen in one. Two had symptoms deriving from the urinary tract. Nine patients had recently arrived from high prevalence countries five of them and two others were positive for human immunodeficiency virus. Three patients had a family history of tuberculosis one had previously been treated for tubercu­losis and four others had an underlying chronic disease. The diagnosis of tuberculosis was established by standard micro­biological and histological techniques.

Results: We divided the disease manifestations into intraperitoneal (n-13) and genitourinary involvement (n- 6). Peritoneal tuberculosis was fairly common, characterized by ascites, omental and mesenteric infiltration, and smooth thickening of the parietal peritoneum. One oncology patient had a false positive Tc-99m CEA isotope scanning, suggesting tumor recurrence. Genitourinary disease manifested mainly as hydronephrosis and calcifications. Three patients had pulmon­ary tuberculosis as well.

Conclusion: The CT findings of abdominal tuberculosis may mimic various diseases, mainly diffuse peritoneal malig­nancy. We emphasize the need to consider tuberculosis in the differential diagnosis in patients with obscure abdominal symptoms, especially with multi-organ involvement. A high degree of clinical suspicion and familiarity with the abdominal CT manifestations allow early diagnosis of this treatable disease.

Background: Many beside urine culture devices have been developed with the aim of reliability, simplicity and use in both the physician’s office and the clinical laboratory. 

Objective: To compare a novel beside urine culture device (DipStreak, Novamed Ltd. Israel) comprising a combination of MacConkey and Colombia CAN blood agar with conventional seeding on the same culture media. 

Methods: A total of 1000 urine specimens sent to our microbiology laboratory were simultaneously processed by both methods. Results were evaluated after 24 and 48 hours incubation at 370C. 

Results: Altogether, 171 (17.1%) and 124 (12.4%) specimens were defined as positive by the conventional method using cutoff values of 104 colony-forming units/ml and 105 CFU/ml respectively; 178 specimens (17.8%) were defined as contaminated. The sensitivity, specificity, positive and negative predictive values of DipStreak for urinary tract infection were 98.8%, 98.6%, 96% and 99.6% respectively, using a cutoff value of 104 CFU/ml, and 99.3%, 99.2%, 96% and 99.8 respectively, using cutoff value of 105 CFU/ml. Full agreement between both techniques was 95%. 

Conclusion: The agreement rate between DipStreak and conventional seeding was remarkably high. These results suggest that DipStreak in the agar combination tested in this study is a useful and precise tool for diagnosing urinary tract infection.

Background: Urinary tract infection is one of the most common bacterial infections. Since antibiotics are given empirically, it is necessary to assess the distribution and susceptibility of the microorganisms in each case.

Objectives: To evaluate the demographic characteristics of ambulatory patients with UTI, the distribution and susceptibility of uropathogens, and the risk factors associated with trimethoprim-sulfamethoxazole resistant bacteria in women.

Methods: During 12 days in August 1997 all the urine cultures sent to the Tel-Hanan Laboratory (Haifa) were evaluated. Demographic characteristics of the patients, their underlying diseases and the previous use of antibiotics were obtained.

Results: During the 12 day survey 6,495 cultures were sent for evaluation. Of the 1,075 (17%) that were positive 950 were included in the study; 83.7% were from females, of whom 57% were ≥50 years old. Escherichia coli was the most common pathogen, with 74.7% in the female and 55% in the male population; 86.2% of the E. coli were resistant to amoxicillin, 38.8% to cephalexin and 46.8% to TMP-SMX. Cefuroxime (4.2%), ofloxacin (4.8%), ciprofloxacin (4.8%) and nitrofurantoin (0.4%) showed the lowest rates of resistance. By a multivariant analysis, post-menopause and recurrent UTI were found to be independent factors related to TMP-SMX resistance in women.

Conclusion: In northern Israel, ampicillin, cephalexin and TMP-SMX cannot be used empirically in the treatment of community-acquired UTI. Post-menopause and recurrent UTI are independent factors associated with TMP-SMX resistant pathogens in women.

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UTI= urinary tract infection

TMP-SMX= trimethoprim-sulfamethoxazole