開業醫師(GP)常見的下泌尿道感染

[李誠民]

Cystitis Treatment in Women, Circa 2011: New Role for an Old Drug
Henry J. Schultz and Randall S. Edson
Mayo Clin Proc. June 2011 86(6):477-479; doi:10.4065/mcp.2011.0184

---Mayo Clinic Proceedings, coupled with 2011 practice guidelines from the Infectious Diseases Society of America (IDSA) and European Society for Microbiology and Infectious Diseases,3 provides important and welcome changes in recommendations for cost-effective management of uncomplicated lower urinary tract infection (UTI) in women.

after sexual intercourse. Bladder invasion by bacteria may or may not lead to a symptomatic UTI, depending on the complex interplay of host genetic, behavioral, and biological factors.4 Women with symptomatic cystitis present with abrupt onset of dysuria, urinary frequency, and urinary urgency

Historical factors that increase the likelihood of UTI include the following: hematuria, suprapubic pain, malodorous or turbid urine, incontinence, prior UTIs, recent sexual intercourse, spermicidal contraception, and recent antibiotic administration

3 days of treatment with twice-daily trimethoprim-sulfamethoxazole (TMP-SMZ) or trimethoprim (TMP) alone has been the accepted first-line therapy for acute uncomplicated cystitis....--TMP-SMZ has increased substantially, uropathogens have shown increasing drug resistance.

Sulfonamide administration can also be associated with a variety of serious adverse reactions, including the Stevens-Johnson syndrome.
many clinicians now prescribe a 3-day course of a fluoroquinolone (FQ) as first-line empirical therapy for uncomplicated cystitis, rather than reserving FQs for treatment failures, resistant organisms, or patients with medication allergies.

increased TMP-SMZ resistance and the need to limit the use of FQs, investigators have reevaluated the role of nitrofurantoin—a nearly forgotten drug—in the treatment of uncomplicated UTIs
a 5-day course of twice-daily nitrofurantoin macrocrystals was equivalent or superior to a standard 3-day course of TMP-SMZ.

nitrofurantoin has poor activity against Proteus, Serratia, and Pseudomonas species and should not be used to treat UTIs due to these organisms. Nitrofurantoin is inexpensive, safe in early pregnancy, and rarely causes C difficile colitis. Although long-term use is associated with pulmonary fibrosis, the only common adverse effects with short-term use are nausea and headache. Hemolytic anemia can be seen in patients with glucose-6-phosphate dehydrogenase deficiency. Rare serious adverse effects include drug-induced hepatitis, hypersensitivity pneumonitis, and peripheral neuropathy (especially in patients with renal insufficiency).

present the results of a sophisticated decision analysis comparing the cost-effectiveness of nitrofurantoin, TMP-SMZ, and FQs in the treatment of uncomplicated UTIs. Decision analyses help clinicians answer questions about multiple treatment alternatives that would otherwise be difficult to resolve in a clinical trial

Consider nitrofurantoin (nitrofurantoin monohydrate/macrocrystals, 100 mg twice daily for 5 days) as first-line therapy for women with signs and symptoms of acute uncomplicated cystitis. Avoid nitrofurantoin use in patients with symptoms of upper tract disease (fever, chills, nausea, vomiting, or flank pain).

--TMP-SMZ remains a viable alternative (if local resistance is low), especially if the patient has not received recent TMP-SMZ therapy or has an infecting strain known to be susceptible.

--Reserve FQ therapy for treatment failures or for patients with suspected upper tract disease.

--Avoid using amoxicillin or ampicillin as empirical therapy because of high rates of antimicrobial resistance and poor efficacy.

--Alternative β-lactam therapies (eg, amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime) for 3 to 7 days are appropriate when other agents cannot be used.

--Fosfomycin trometamol (administered as a single 3-g dose).

Conclusion::
an old drug rediscovered to be an effective, safe, well-tolerated, and inexpensive first-line therapeutic option for cystitis. Nitrofurantoin has maintained its antimicrobial activity against most uropathogens that cause uncomplicated cystitis, and it is unlikely to induce antibiotic resistance. Clinicians accustomed to using TMP-SMZ for uncomplicated cystitis should consider switching to nitrofurantoin because of increasing TMP-SMZ resistance and treatment failures. Clinicians using FQs in this setting should consider switching to nitrofurantoin in order to reserve FQ use for more serious infections and to further curtail the development of resistant microorganisms.

[vsdog]

重點是inexpensive吧~

FQ; Fosfomycin ~expensive