Management of urinary tract infections: historical perspective and current strategies: Part 2--Modern management.
OBJECTIVE
An understanding of the microbial origin of infectious diseases and the introduction of antimicrobial therapy stimulated more advances in the management of urinary tract infections (UTIs) in the 20th century than had occurred in the previous 5 centuries.


METHODS
Numerous resources were used to collect the information described in this review. Medical texts from the 19th and 20th century contain information regarding the traditional contemporary treatment of UTI during those eras. Early volumes of the Journal of Urology from the beginning of the 20th century describe the first attempts at chemotherapy for UTI. MEDLINE searches were used to collect appropriate information after 1969. Modern medical journals and modern medical texts were used to collect information on antimicrobial therapy since the late 1960s through today.


RESULTS
Numerous advances in the diagnosis and management of UTI were made during the 20th century. Advances in microbiological and chemical assays have facilitated the development of historical uroscopy into modern day urinalysis and culture techniques, which are the cornerstone of UTI diagnosis. Imaging technologies, including x-ray, ultrasound, nuclear imaging, magnetic resonance and computerized tomography, have been particularly helpful in the diagnosis of complicated or recurrent UTIs. Major innovations in nonpharmacological therapy include noninvasive shock wave lithotripsy and percutaneous drainage of kidney abscesses. The most profound advance in UTI management during the 20th century was the discovery of antimicrobial agents. Nitrofurantoin was the first truly effective and safe antimicrobial therapy for UTI but its spectrum of activity is limited. Broad use of amoxicillin (and other beta-lactams) after its introduction in the 1970s led to the development of resistance to this antimicrobial, prompting a gradual change to trimethoprim/sulfamethoxazole (TMP/SMX) as first line therapy for UTI. However, wide use of TMP/SMX also resulted in the progressive emergence of resistance, limiting the clinical usefulness of this therapy in the modern management of UTI. Fluoroquinolones offer an attractive alternative to TMP/SMX, and American and European guidelines recommend their empirical use in areas where TMP/SMX resistance is 10% or higher.


CONCLUSIONS
The development of antimicrobial therapy was the defining moment of 20th century medicine and one of the key innovations in medical history. While the initial promise of antimicrobials has been validated in clinical practice, overuse of certain agents has led to the emergence of resistance, illustrating the importance of using evidence based strategies to select therapy.
Nickel
J Curtis
JC
Department of Urology, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada K7L 2V7. jcn@post.queensu.ca
D000892:Anti-Infective Agents, Urinary / Q000627:therapeutic use; D024841:Fluoroquinolones / Q000627:therapeutic use; D006801:Humans; D009582:Nitrofurantoin / Q000627:therapeutic use; D016896:Treatment Outcome; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use; D016482:Urinalysis; D014552:Urinary Tract Infections / Q000175:diagnosis / Q000188:drug therapy*; D047090:beta-Lactams / Q000627:therapeutic use
D000892:Anti-Infective Agents, Urinary; D024841:Fluoroquinolones; D047090:beta-Lactams; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D009582:Nitrofurantoin