今日の臨床サポート

急性腎盂腎炎

著者: 濵砂良一 国家公務員共済組合連合会 新小倉病院 副院長 泌尿器科部長

監修: 中川昌之 公益財団法人 慈愛会 今村総合病院 泌尿器科顧問

著者校正/監修レビュー済:2022/11/09
参考ガイドライン:
  1. 日本感染症学会日本化学療法学会:JAID/JSC 感染症治療ガイドライン 2016 -尿路感染症・男性器感染症- (日本化学療法学会雑誌 64(1):1-30, 2016)
  1. 日本感染症学会日本化学療法学会:JAID/JSC 感染症治療ガイド 2019 XI 尿路感染症(JAID/JSC 感染症治療ガイド 2019, 202-220, ライフサイエンス出版株式会社 東京, 2018)
患者向け説明資料

概要・推奨   

  1. 急性単純性腎盂腎炎は細菌の逆行性感染による腎盂および腎実質の非特異的炎症であり、性的活動期の女性に好発する。
  1. 妊婦にも1~2%の頻度でみられ、妊娠時の合併症の中で重要なものの1つである。
  1. 複雑性腎盂腎炎とは、尿路に何らかの基礎疾患、または免疫が低下するような全身性の疾患を持つ患者に合併した腎盂腎炎で、一般に慢性に経過する。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
濵砂良一 : 特に申告事項無し[2022年]
監修:中川昌之 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 日本感染症学会/日本化学療法学会からのガイドライン、治療ガイド、および尿路感染症の原因菌の新しい薬剤感受性試験結果をもとに、新たな治療ガイドを作成した。
  1. 複雑性腎盂腎炎について追記を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 急性単純性腎盂腎炎
  1. 急性単純性腎盂腎炎とは、細菌の逆行(上行)性感染による腎盂および腎実質の非特異的炎症である。
  1. 尿路・全身性基礎疾患が認められない単純性尿路感染症であり、主として性的活動期の女性に好発する。原因菌は腎盂粘膜へ付着し、増殖する。
  1. 発熱、全身倦怠感などの全身症状と患側の腎部痛を主症状とする。
  1. 原因菌は大腸菌が主体(約70%)であり抗菌化学療法での治癒が期待できるが、再発する症例がみられる。
  1. 経口抗菌薬で外来治療可能な軽症例から、入院治療を要し注射薬での治療が必要な症例までが経験される。時に敗血症や播種性血管内凝固症候群(DIC)を伴うような重症例がみられる。
  1. 複雑性腎盂腎炎
  1. 複雑性腎盂腎炎とは、尿路に何らかの基礎疾患、または免疫が低下するような全身性の疾患を持つ患者に合併した腎盂腎炎で、一般に慢性に経過する。
  1. 尿路の基礎疾患は、尿路結石、尿路腫瘍、下部尿路の閉塞、神経障害、尿路の先天異常(特に小児)が挙げられる。
  1. 発熱、全身倦怠感などの全身症状と患側の腎部痛を主症状とするが、軽症または無症状である症例も多い。特に、尿路に閉塞を来した状態では重症化する場合が多く(閉塞性腎盂腎炎)、敗血症、DICを合併し重症となる。
  1. 慢性で経過しながら、急激に発熱、腰背部痛、全身倦怠感を訴える症例がある(慢性複雑性腎盂腎炎の急性増悪)。
  1. 原因菌は大腸菌が多いが(30-40%)、グラム陰性桿菌、グラム陽性球菌、真菌など多くの菌種が検出される。
  1. 抗菌薬治療が期待できるが、基礎疾患を治療しないと、再発、再燃を繰り返す症例が多い。
問診・診察のポイント  
  1. 急性単純性腎盂腎炎は性的活動期の女性に好発する。

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文献 

Giorgina Barbara Piccoli, Valentina Consiglio, Maria Chiara Deagostini, Melania Serra, Marilisa Biolcati, Francesca Ragni, Alberto Biglino, Agostino De Pascale, Mauro Felice Frascisco, Andrea Veltri, Francesco Porpiglia
The clinical and imaging presentation of acute "non complicated" pyelonephritis: a new profile for an ancient disease.
BMC Nephrol. 2011 Dec 15;12:68. doi: 10.1186/1471-2369-12-68. Epub 2011 Dec 15.
Abstract/Text BACKGROUND: Acute pyelonephritis (APN) is differently defined according to imaging or clinical criteria. In adults information on the relationship between imaging and clinical data is lacking.Our study was aimed at analysing the relationship between the clinical and imaging presentation of APN, defined according to imaging criteria (parenchymal involvement at MR or CT scan).
METHODS: All consecutive patients hospitalized for "non-complicated" APN were considered (June 2005-December 2009). Clinical, biochemical and imaging data at hospitalization were analyzed by univariate and logistic regression analysis.
RESULTS: There were 119 patients, all females, median age 32 years (15-72). At hospitalization, inflammatory markers were elevated (CRP median: 12.1 mg/dL, normal < 0.8). Incomplete presentations were frequent: fever was absent in 6.7%, pain in 17.8%, lower urinary tract symptoms in 52.9%. At CT or MR scan the lesions were bilateral in 12.6%, multiple in 79.8%; abscesses were present in 39.5%. Renal scars were found in 15.1%. Positive cultures were correlated with multiple foci (multivariate OR 4.2; CI 1.139-15.515). No other sign/symptom discriminated between small lesions, abscesses or multifocal involvement.
CONCLUSIONS: APN is a protean disease. In the absence of strict correlation with clinical or biochemical markers, imaging studies are required to assess the severity of kidney involvement.

PMID 22171968
B R McMurray, K D Wrenn, S W Wright
Usefulness of blood cultures in pyelonephritis.
Am J Emerg Med. 1997 Mar;15(2):137-40.
Abstract/Text To evaluate the usefulness of blood cultures in patients admitted with pyelonephritis, a retrospective chart review was-conducted of inpatients at a 594-bed urban, academic medical center from 1990 through 1992 with a primary discharge diagnosis of pyelonephritis. A total of 338 patients had this primary discharge diagnosis. One or more sets of blood cultures were obtained in 307 patients (91%). Fifty-six (18%) patients had a positive blood culture; 24 (32%) positive blood cultures grew coagulase-negative Staphylococcus species, in all but two instances considered a skin contaminant. Of the blood cultures drawn, only 1 (0.2%) grew a pathogenic organism not found in the urine culture, with no impact on clinical management. These results support the conclusion that blood cultures are rarely clinically useful and seldom vary from urine culture results. Potential annual cost savings of between $10 million and $20 million in the United States could result from eliminating routine blood cultures in the setting of uncomplicated acute pyelonephritis.

PMID 9115512
Ryoichi Hamasuna, Satoshi Takahashi, Hiroshi Nagae, Tatsuhiko Kubo, Shingo Yamamoto, Soichi Arakawa, Tetsuro Matsumoto
Obstructive pyelonephritis as a result of urolithiasis in Japan: diagnosis, treatment and prognosis.
Int J Urol. 2015 Mar;22(3):294-300. doi: 10.1111/iju.12666. Epub 2014 Nov 16.
Abstract/Text OBJECTIVES: To study the current scenario of diagnosis, treatment and mortality of obstructive pyelonephritis secondary to urolithiasis in Japan.
METHODS: The study was a retrospective and multicenter survey for hospitalized patients with obstructive pyelonephritis as a result of urolithiasis in educational facilities for specialists by the Japanese Urological Association. Patients' characteristics including physical or laboratory examinations, treatment and prognosis were recorded, and the risk factors for disease death were analyzed.
RESULTS: A total of 1363 patients from 208 hospitals were analyzed. The median age of patients was 68 years, and there were 2.2-fold more female patients than male patients. From 844 patients, 891 species of bacteria or fungi were isolated, and Gram-negative rods accounted for 76.5% of cases. The mortality of patients was 2.3%. The risk factors related to disease death by univariate analysis were identified as older age, solitary kidney, ambulance use to visit hospital, disturbance of consciousness, severe appetite loss, higher performance status, disseminated intravascular coagulation status or systemic inflammatory response syndrome, vasopressors and anti-disseminated intravascular coagulation therapies, increased pulse rates, lower hemoglobin, lower serum albumin, and high blood urea nitrogen values. The predictive risk factors for disease death of patients' status at hospitalization were age over 80 years, systemic inflammatory response syndrome, disseminated intravascular coagulation status, disturbance of consciousness and solitary kidney by multivariate analysis.
CONCLUSIONS: Obstructive pyelonephritis as a result of urolithiasis represents an emergent disease in the urological field with relatively high mortality. Patients with older age or poor conditions should be hospitalized, and intervention by a urology specialist is likely to be required.

© 2014 The Japanese Urological Association.
PMID 25400222
Yudai Ishikawa, Hiroshi Fukushima, Hajime Tanaka, Soichiro Yoshida, Minato Yokoyama, Yoh Matsuoka, Yasuyuki Sakai, Yukihiro Otsuka, Ryoji Takazawa, Masataka Yano, Tetsuro Tsukamoto, Tetsuo Okuno, Akira Noro, Katsushi Nagahama, Shigeyoshi Kamata, Yasuhisa Fujii
Prognostic Accuracy of the qSOFA Score for In-Hospital Mortality in Elderly Patients with Obstructive Acute Pyelonephritis: A Multi-Institutional Study.
Diagnostics (Basel). 2021 Dec 5;11(12). doi: 10.3390/diagnostics11122277. Epub 2021 Dec 5.
Abstract/Text Prognostic accuracy of the quick sequential organ failure assessment (qSOFA) score for mortality may be limited in elderly patients. Using our multi-institutional database, we classified obstructive acute pyelonephritis (OAPN) patients into young and elderly groups, and evaluated predictive performance of the qSOFA score for in-hospital mortality. qSOFA score ≥ 2 was an independent predictor for in-hospital mortality, as was higher age, and Charlson comorbidity index (CCI) ≥ 2. In young patients, the area under the curve (AUC) of the qSOFA score for in-hospital mortality was 0.85, whereas it was 0.61 in elderly patients. The sensitivity and specificity of qSOFA score ≥ 2 for in-hospital mortality was 80% and 80% in young patients, and 50% and 68% in elderly patients, respectively. For elderly patients, we developed the CCI-incorporated qSOFA score, which showed higher prognostic accuracy compared with the qSOFA score (AUC, 0.66 vs. 0.61, p < 0.001). Therefore, the prognostic accuracy of the qSOFA score for in-hospital mortality was high in young OAPN patients, but modest in elderly patients. Although it can work as a screening tool to determine therapeutic management in young patients, for elderly patients, the presence of comorbidities should be considered at the initial assessment.

PMID 34943514
M A Behr, R Drummond, M D Libman, J S Delaney, J S Dylewski
Fever duration in hospitalized acute pyelonephritis patients.
Am J Med. 1996 Sep;101(3):277-80. doi: 10.1016/S0002-9343(96)00173-8.
Abstract/Text PURPOSE: To study persistence of fever in treated pyelonephritis with respect to guidelines recommending investigation and modification of therapy after 2 to 3 days of fever.
PATIENTS AND METHODS: A retrospective chart review was made of 70 patients hospitalized for febrile pyelonephritis at a community hospital in Canada.
RESULTS: Median duration of fever was 34 hours; persistence of fever at 48 and 72 hours was 26% and 13%, respectively. No patients had complications such as intrarenal or perirenal abscess. Prolonged fever was independently associated with increasing baseline creatinine (P = 0.0001), younger age (P = 0.027), and increasing total leukocyte count (P = 0.026). Results of ultrasonography and intravenous urograms were not predictors of fever duration.
CONCLUSION: Fever in treated pyelonephritis can take 4 days to resolve, and routine urologic investigation after 2 to 3 days of fever may be unwarranted.

PMID 8873489
M C Soulen, E K Fishman, S M Goldman, O M Gatewood
Bacterial renal infection: role of CT.
Radiology. 1989 Jun;171(3):703-7. doi: 10.1148/radiology.171.3.2655002.
Abstract/Text The imaging studies done on 62 patients hospitalized for acute renal infections were retrospectively reviewed. Thirty-six (58%) had one or more abscesses, 17 (27%) had focal or diffuse acute bacterial nephritis, five (8%) had pyonephrosis, and four (6%) had pyelonephritis. All had prolonged fever (greater than or equal to 72 hours) and leukocytosis. Among 25 patients examined with both ultrasound (US) and computed tomography (CT), US failed to depict three of five (60%) cases of acute bacterial nephritis and seven of 15 (47%) intrarenal and extrarenal abscesses. One renal abscess was misdiagnosed as a tumor at CT. US is not an adequate screening test for detecting lesions that may require invasive therapy. CT is more sensitive for the detection of acute renal inflammatory disease and for defining the extent of disease for planning of radiologic or surgical intervention.

PMID 2655002
Betsy Foxman, Kelly L Klemstine, Patricia D Brown
Acute pyelonephritis in US hospitals in 1997: hospitalization and in-hospital mortality.
Ann Epidemiol. 2003 Feb;13(2):144-50.
Abstract/Text PURPOSE: To describe the 1997 incidence of hospitalization for acute pyelonephritis in the US and the risk factors for in-hospital mortality associated with acute pyelonephritis.
METHODS: Cases were defined as those with ICD9-CM codes corresponding to acute pyelonephritis in the 1997 Health Care Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). Frequencies and calculations were weighted to produce either national or state estimates. Hospitalization rates were calculated using 1997 US Census Bureau population projections for the denominator.
RESULTS: Females were almost five times as likely as males to be hospitalized for acute pyelonephritis (11.7/10,000 vs. 2.4/10,000), but males had higher mortality rates (16.5/1000 vs. 7.3/1000); 30% greater after adjustment. Hospitalization and in-hospital mortality rates increased with age, but not with diabetes. Mortality rates increased with number of procedures, diagnoses and having a major diagnostic category other than disorders of the kidney and urinary tract. Persons living in zip codes with lower median incomes were also at higher risk of mortality. There was little variation in mortality by hospital size, ownership, location or teaching status.
CONCLUSION: In hospital mortality for pyelonephritis was associated with patient rather than hospital characteristics suggesting uniform application of standard care across hospitals and populations.

PMID 12559674
Uday Mann, Kunal Jain, Rachel Wong, Zack Li, Amanda Eng, Ruben Blachman-Braun, Premal Patel
Predictors of mortality for patients admitted to the intensive care unit with obstructing septic stones.
Can Urol Assoc J. 2021 Nov;15(11):E593-E597. doi: 10.5489/cuaj.7118.
Abstract/Text INTRODUCTION: Patients diagnosed with septic stone are at significant risk of morbidity and mortality should source control through drainage be delayed, and they are often admitted to intensive care units (ICU) for hemodynamic support. The purpose of this study was to determine patient factors that may predict mortality in patients admitted to ICU with septic stone, particularly whether rural patients at a greater distance from a tertiary care center were at greater risk of mortality given the inherent delay in intervention.
METHODS: The Manitoba Intensive Care Unit prospective registry began in 1999 and includes all patients admitted to ICU across Manitoba. Baseline characteristics, such as age, gender, vital signs, creatinine, Charlson comorbidity index (CCI), mortality outcomes, and location of residency were obtained for those admitted to ICU for septic stone. Association between death and clinical/demographic variables was performed with adjusted multivariable logistical regression analysis.
RESULTS: A total of 342 patients admitted to the ICU were analyzed, with a mean age of 63.5±15.5 years. Baseline characteristics were similar between groups (p>0.05). On multivariable adjusted logistical regression, the presence of acute kidney injury (AKI) (p<0.001) and intubation (p<0.001) were associated with mortality. There was no difference in mortality attributable to location of residency, vital signs, or CCI.
CONCLUSIONS: Among patients admitted to the ICU for septic stones in Manitoba, we demonstrate an association between AKI and intubation with mortality. Other factors, such as whether patients were from a rural region and baseline patient characteristics, were not predictive of mortality.

PMID 33999808
Tetsuro Matsumoto, Ryoichi Hamasuna, Kiyohito Ishikawa, Satoshi Takahashi, Mitsuru Yasuda, Hiroshi Hayami, Kazushi Tanaka, Hiroshi Kiyota, Tetsuro Muratani, Koichi Monden, Soichi Arakawa, Shingo Yamamoto
Nationwide survey of antibacterial activity against clinical isolates from urinary tract infections in Japan (2008).
Int J Antimicrob Agents. 2011 Mar;37(3):210-8. doi: 10.1016/j.ijantimicag.2010.10.032. Epub 2011 Jan 16.
Abstract/Text In this study, the causative bacteria and their sensitivity to various antimicrobial agents as well as risk factors for quinolone-resistant Escherichia coli were investigated in patients with acute uncomplicated cystitis or complicated cystitis by isolation and culture of bacteria from urine samples. In total, 1312 strains were isolated from 1009 patients with acute uncomplicated cystitis, including E. coli (63.3%), Enterococcus faecalis (12.8%) and Streptococcus agalactiae (4.6%). In addition, 994 strains were isolated from 725 patients with complicated cystitis, including E. coli (36.4%), E. faecalis (19.2%), Klebsiella pneumoniae (5.0%), S. agalactiae (4.7%) and Pseudomonas aeruginosa (4.5%). At least 90% of E. coli isolates from acute uncomplicated cystitis showed sensitivity to fluoroquinolones and cephems, whilst 70.4-88.4% of E. coli isolates from complicated cystitis were sensitive to fluoroquinolones and 85.4-89.5% were sensitive to cephems. Factors associated with quinolone-resistant E. coli included two or more episodes of cystitis within 1 year, failure of quinolone therapy, underlying urinary tract disease, prior quinolone treatment within 1 month and age ≥ 75 years. It is important to confirm the sensitivity of causative bacteria for optimal antimicrobial therapy, and empirical antimicrobial agents should be selected by considering patient characteristics and other factors.

Copyright © 2011. Published by Elsevier B.V.
PMID 21242062
Kanao Kobayashi, Shingo Yamamoto, Satoshi Takahashi, Kiyohito Ishikawa, Mitsuru Yasuda, Koichiro Wada, Ryoichi Hamasuna, Hiroshi Hayami, Shinichi Minamitani, Tetsuya Matsumoto, Hiroshi Kiyota, Kazuhiro Tateda, Junko Sato, Hideaki Hanaki, Naoya Masumori, Yoshiki Hiyama, Hiroki Yamada, Shin Egawa, Takahiro Kimura, Hiroyuki Nishiyama, Jun Miyazaki, Kazumasa Matsumoto, Yukio Homma, Jun Kamei, Kiyohide Fujimoto, Kazumasa Torimoto, Kazushi Tanaka, Yoshikazu Togo, Shinya Uehara, Akio Matsubara, Koichi Shoji, Hirokazu Goto, Hisao Komeda, Toru Ito, Katsuhisa Mori, Koji Mita, Masao Kato, Yoshinori Fujimoto, Takako Masue, Hisato Inatomi, Yoshito Takahashi, Satoshi Ishihara, Kazuo Nishimura, Kenji Mitsumori, Noriyuki Ito, Sojun Kanamaru, Daisuke Yamada, Maeda Hiroshi, Masuo Yamashita, Masaya Tsugawa, Tadasu Takenaka, Koichi Takahashi, Yasuhiko Oka, Tomihiko Yasufuku, Shuji Watanabe, Yoshitomo Chihara, Kazuhiro Okumura, Hiroaki Kawanishi, Masanori Matsukawa, Masanobu Shigeta, Shuntaro Koda
The third national Japanese antimicrobial susceptibility pattern surveillance program: Bacterial isolates from complicated urinary tract infection patients.
J Infect Chemother. 2020 May;26(5):418-428. doi: 10.1016/j.jiac.2020.01.004. Epub 2020 Feb 17.
Abstract/Text The antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using national surveillance data. The data consisted of 881 bacterial strains from eight clinically relevant species. The data were collected for the third national surveillance project from January 2015 to March 2016 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was undertaken with the cooperation of 41 medical institutions throughout Japan. Fluoroquinolone required a MIC90 of 2-64 mg/L to inhibit the 325 Escherichia coli strains tested and the proportion of levofloxacin resistant E. coli strains increased to 38.5% from 29.6% in 2011 and 28.6% in 2008. The proportion of levofloxacin resistant strains of Pseudomonas aeruginosa and Enterococcus faecalis decreased from previous reports and the proportion of multidrug-resistant P. aeruginosa and carbapenem-resistant Enterobacteriaceae remained low. Among methicillin-resistant Staphylococcus aureus (MRSA) strains, strains with reduced susceptibility to vancomycin (minimum inhibitory concentration, 2 μg/mL) increased to 14.7% from 5.5%. Bacterial strains that produced extended-spectrum β-lactamase included E. coli (79 of 325 strains, 24.3%), Klebsiella pneumoniae (9 of 177 strains, 7.7%), and Proteus mirabilis (6 of 55 strains, 10.9%). The proportion of extended-spectrum β-lactamase producing E. coli and K. pneumoniae strains increased from previous surveillance reports.

Copyright © 2020 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
PMID 32081647
Tracy Marien, Alon Y Mass, Ojas Shah
Antimicrobial resistance patterns in cases of obstructive pyelonephritis secondary to stones.
Urology. 2015 Jan;85(1):64-8. doi: 10.1016/j.urology.2014.10.007.
Abstract/Text OBJECTIVE: To characterize the local antimicrobial resistance pattern in patients with obstructing ureteral stones and fever, compare this with our local antibiograms, and guide recommendations for empiric antibiotic regimens.
METHODS: A retrospective chart review was performed of patients who underwent ureteroscopic intervention for the management of ureteral stones at a neighboring private hospital and a public hospital to identify those patients who had undergone prior decompression for obstructing ureteral stones and fever between 2004 and 2011. Urine culture results were captured to identify uropathogens and sensitivity patterns to antibiotics. These were compared with respective hospital antibiograms.
RESULTS: Sixty-five patients were identified, of which 35 had positive urine culture results. More than 25% of the voided urine and upper urinary tract urine cultures differed. Antimicrobial resistance patterns were higher for patients at the public hospital than the hospital antibiogram. The opposite was true at the private hospital. The public hospital demonstrated an overall higher resistance pattern than the private hospital.
CONCLUSION: Antimicrobial resistance makes the selection of empiric antibiotic treatment challenging in patients with obstructive pyelonephritis secondary to ureteral stones. Because of discordance between voided urine cultures and those captured at the time of decompression, it is imperative to obtain both voided urine and urine from the kidney to ensure adequate antibiotic coverage. Local population-specific antimicrobial guidelines that are frequently updated are essential to ensure adequate coverage and treatment of obstructive pyelonephritis, and condition-specific antibiograms would be recommended in the future.

Copyright © 2015 Elsevier Inc. All rights reserved.
PMID 25530365
Koji Yoshimura, Noriaki Utsunomiya, Kentaro Ichioka, Nobufumi Ueda, Yoshiyuki Matsui, Akito Terai
Emergency drainage for urosepsis associated with upper urinary tract calculi.
J Urol. 2005 Feb;173(2):458-62. doi: 10.1097/01.ju.0000150512.40102.bb.
Abstract/Text PURPOSE: We examined the characteristics of patients with urosepsis associated with upper urinary tract calculi requiring emergency drainage.
MATERIALS AND METHODS: From January 1994 to December 2003, 424 patients were admitted to our urological department a total of 473 times for treatment of upper urinary tract calculi, of whom 53 required a total of 59 emergency drainage procedures for urosepsis. We summarized the characteristics of these patients and events, and determined risk factors for emergency drainage using logistic regression analysis.
RESULTS: In 14 events (24%) intensive management, such as the use of vasopressors and anticoagulants, was performed. Transient thrombocytopenia less than 100,000/mm occurred in 18 events (31%). Hyperbilirubinemia occurred in 8 of 38 events (16%) without prior antibiotic therapy. One patient (2%) died of urosepsis. Patients with calculi who underwent emergency drainage required a longer hospital stay than those without emergency drainage (25.2 vs 14.8 days, p <0.001). Of the variables analyzed poor performance status (Karnofsky performance status 70% or less, OR 2.9, p = 0.003), age 75 years or older (OR 2.1, p = 0.038) and female sex (OR 1.8, p = 0.046) were risk factors on multivariate analysis.
CONCLUSIONS: Our findings suggest that the frequency of emergency drainage in elderly patients with poor performance status has increased in recent years, at least in our rural area of Japan. Preventing calculous formation and urinary tract infection in individuals with poor performance status will be of considerable importance in the future.

PMID 15643207
Noa Eliakim-Raz, Dafna Yahav, Mical Paul, Leonard Leibovici
Duration of antibiotic treatment for acute pyelonephritis and septic urinary tract infection-- 7 days or less versus longer treatment: systematic review and meta-analysis of randomized controlled trials.
J Antimicrob Chemother. 2013 Oct;68(10):2183-91. doi: 10.1093/jac/dkt177. Epub 2013 May 21.
Abstract/Text BACKGROUND: Acute pyelonephritis is a frequent cause of morbidity, with a wide variation in duration of therapy. We performed a systematic review of all randomized controlled trials (RCTs) comparing ≤7 days treatment with a longer course.
METHODS: Electronic databases were searched to identify RCTs that assessed adults treated for pyelonephritis, comparing a 7 day or shorter versus longer therapy. Primary outcome was clinical failure at the end of the long treatment arm (EOT). Secondary outcomes included clinical failure at the end of follow-up (EOF), microbiological failure, all-cause mortality, the development of resistance and adverse events.
RESULTS: Clinical failure at EOT did not significantly differ between the two treatment arms [relative risk (RR) 0.63, 95% CI 0.33-1.18, I(2) = 41%]. Results did not differ when including studies comparing only fluoroquinolones, reducing the heterogeneity (RR 0.76, 95% CI 0.49-1.17, I(2) = 0%). We found no difference between the short and long treatment arms regarding clinical failure at EOF, even in a small subgroup of bacteraemic patients. No difference was found between the arms regarding microbiological failure at EOF, except in a subgroup of studies with a high percentage of patients with urogenital abnormalities, where microbiological failure at EOF was significantly higher in the short treatment arm (RR 1.78, 95% CI 1.02-3.10, I(2) = 21%). Adverse events were similar between the arms.
CONCLUSIONS: Seven days of treatment for acute pyelonephritis is equivalent to longer treatment in terms of clinical failure and microbiological failure, including in bacteraemic patients. In patients with urogenital abnormalities, the evidence, although weak, suggests that longer treatment is required.

PMID 23696620
Hiroshi Hayami, Satoshi Takahashi, Kiyohito Ishikawa, Mitsuru Yasuda, Shingo Yamamoto, Koichiro Wada, Kanao Kobayashi, Ryoichi Hamasuna, Shinichi Minamitani, Tetsuya Matsumoto, Hiroshi Kiyota, Kazuhiro Tateda, Junko Sato, Hideaki Hanaki, Naoya Masumori, Hiroyuki Nishiyama, Jun Miyazaki, Kiyohide Fujimoto, Kazushi Tanaka, Shinya Uehara, Akio Matsubara, Kenji Ito, Kenji Hayashi, Yuichiro Kurimura, Shin Ito, Toshimi Takeuchi, Harunori Narita, Masanobu Izumitani, Hirofumi Nishimura, Motoshi Kawahara, Makoto Hara, Takahide Hosobe, Kenji Takashima, Hirofumi Chokyu, Masaru Matsumura, Hideari Ihara, Satoshi Uno, Koichi Monden, Toru Sumii, Shuichi Kawai, Satoru Kariya, Takashi Sato, Masaru Yoshioka, Hitoshi Kadena, Shinji Matsushita, Shohei Nishi, Yukinari Hosokawa, Takeshi Shirane, Mutsumasa Yoh, Syuji Watanabe, Shinichi Makinose, Tetsuji Uemura, Hirokazu Goto
Second nationwide surveillance of bacterial pathogens in patients with acute uncomplicated cystitis conducted by Japanese Surveillance Committee from 2015 to 2016: antimicrobial susceptibility of Escherichia coli, Klebsiella pneumoniae, and Staphylococcus saprophyticus.
J Infect Chemother. 2019 Jun;25(6):413-422. doi: 10.1016/j.jiac.2019.02.021. Epub 2019 Mar 21.
Abstract/Text The Japanese Surveillance Committee conducted a second nationwide surveillance of antimicrobial susceptibility patterns of uropathogens responsible for acute uncomplicated cystitis (AUC) in premenopausal patients aged 16-40 years old at 31 hospitals throughout Japan from March 2015 to February 2016. In this study, the susceptibility of causative bacteria (Escherichia coli, Klebsiella pneumoniae, Staphylococcus saprophyticus) for various antimicrobial agents was investigated by isolation and culturing of organisms obtained from urine samples. In total, 324 strains were isolated from 361 patients, including E. coli (n = 220, 67.9%), S. saprophyticus (n = 36, 11.1%), and K. pneumoniae (n = 7, 2.2%). The minimum inhibitory concentrations (MICs) of 20 antibacterial agents for these strains were determined according to the Clinical and Laboratory Standards Institute (CLSI) manual. At least 93% of the E. coli isolates showed susceptibility to fluoroquinolones and cephalosporins, whereas 100% of the S. saprophyticus isolates showed susceptibility to fluoroquinolones and aminoglycosides. The proportions of fluoroquinolone-resistant and extended-spectrum β-lactamase (ESBL)-producing E. coli strains were 6.4% (13/220) and 4.1% (9/220), respectively. The antimicrobial susceptibility of K. pneumoniae was retained during the surveillance period, while no multidrug-resistant strains were identified. In summary, antimicrobial susceptibility results of our second nationwide surveillance did not differ significantly from those of the first surveillance. Especially the numbers of fluoroquinolone-resistant and ESBL-producing E. coli strains were not increased in premenopausal patients with AUC in Japan.

Copyright © 2019 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
PMID 30905628
Koichiro Wada, Teruhiko Yokoyama, Satoshi Uno, Motoo Araki, Takuya Sadahira, Yuki Maruyama, Herik Acosta, Hirochika Nakajima, Yoshiki Hiyama, Yasuharu Kunishima, Yoshikazu Togo, Takuhisa Nukaya, Hiroki Yamada, Katsumi Shigemura, Shin Ito, Masanobu Tanimura, Kanao Kobayashi, Hiroyuki Kitano, Jun Teishima, Mitsuru Yasuda, Shinya Uehara, Ryoichi Hamasuna, Toyohiko Watanabe, Tohru Nakagawa, Hiroshi Hayami, Jun Miyazaki, Satoshi Takahashi, Naoya Masumori, Kiyohito Ishikawa, Hiroshi Kiyota, Masato Fujisawa, Soichi Arakawa, Yasutomo Nasu, Shingo Yamamoto
Nationwide surveillance of bacterial pathogens isolated from patients with acute uncomplicated cystitis in 2018: Conducted by the Japanese Research Group for Urinary Tract Infections (JRGU).
J Infect Chemother. 2021 Aug;27(8):1169-1180. doi: 10.1016/j.jiac.2021.03.012. Epub 2021 May 27.
Abstract/Text INTRODUCTION: The aim of this study was to monitor the development of drug-resistant bacteria isolated from acute uncomplicated cystitis (AUC) and to evaluate methodology of the survey conducted by collecting only clinical data.
METHODS: We enrolled female patients at least 16 years of age diagnosed with AUC in 2018. Patient information including age, menopausal status, and results of bacteriological examination were collected and analyzed regardless of bacterial identification, antimicrobial susceptibility testing or extended-spectrum β-lactamase (ESBL) detection method.
RESULTS: A total of 847 eligible cases were collected. Escherichia coli (E. coli) was the most frequently isolated bacterial species at about 70%, with proportions of fluoroquinolone-resistant E. coli (QREC) and ESBL-producing E. coli isolates at 15.6% and 9.5% of all E. coli isolates, respectively. The proportion of Staphylococcus saprophyticus (S. saprophyticus) was significantly higher in premenopausal women. Regarding the drug susceptibility of E. coli, isolates from Eastern Japan had significantly higher susceptibility to cefazolin, cefotiam and cefpodoxime and lower susceptibility to levofloxacin in postmenopausal women. ESBL-producing E. coli isolates had a high susceptibility to tazobactam-piperacillin, cefmetazole, carbapenems, aminoglycosides, and fosfomycin. In S. saprophyticus, the susceptibility to β-lactams including carbapenems was 40-60%.
CONCLUSIONS: The proportions of QREC and ESBL-producing E. coli were increasing trends and lower susceptibility to LVFX in postmenopausal women was observed. Such surveillance, consisting of the collecting only clinical data, could be conducted easily and inexpensively. It is expected to be continuously performed as an alternative survey to conventional one collecting bacterial strains.

Copyright © 2021 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
PMID 33863634

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