Trimethoprim has recently been marketed as a single-entity product for the treatment of initial episodes of uncomplicated symptomatic urinary tract infections; it was previously available only in combination with sulfamethoxazole. Trimethoprim exerts antimicrobial activity by blocking the reduction of dihydrofolate to tetrahydrofolate, the active form of folic acid, by susceptible organisms. It has inhibitory activity for most gram-positive aerobic cocci and some gram-negative aerobic bacilli. Resistance to trimethoprim may be either intrinsic or acquired. Acquired resistance most commonly stems from a chromosomal mutation that results in the production of a dihydrofolate reductase enzyme which is less vulnerable to trimethoprim inhibition. Gastrointestinal intolerance and skin eruptions are the most common untoward reactions resulting from the administration of trimethoprim. Trimethoprim constitutes very effective therapy for women with acute symptomatic urinary tract infections caused by E. coli, and the compound compares favorably with alternative standard agents, such as ampicillin and cephalexin. The safety of trimethoprim in the pregnant woman has not been established. Since indiscriminate use of trimethoprim could foster the emergence of trimethoprim resistance, thereby negating the value of both trimethoprim and trimethoprim-sulfamethoxazole, trimethoprim should only be prescribed for well defined indications. Trimethoprim is currently being investigated as definitive therapy for a wide range of infections, including bacterial exacerbations of chronic bronchitis, bacterial pneumonia, and typhoid fever. Initial reports are encouraging.

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For the period 1979-1980, a prospective study was made of 13 elderly patients with catheter-related urosepsis, who required hospitalization. Several features appeared to distinguish these patients: (1) a traumatic catheter-related event invariably preceded the acute symptomatic process, (2) polymicrobic bacteriuria predominated, and (3) the urinary pathogens were often resistant to the antimicrobial agents commonly prescribed for communityassociated symptomatic urinary-tract infections. A diagnostic and therapeutic approach for these patients is outlined.The infected urinary tract has been identified as the most common source for bacteremia in elderly patients admitted to a community hospital.' For the elderly patient, acute symptomatic urosepsis often necessitates hospitalization and occasionally results in death. In the present prospective study we assessed the clinical, bacteriologic, immunologic, and the rape u t i c feature s of s y m p t o m at i c , catheterassociated urosepsis as experienced by 13 consecutive elderly patients who required hospital admission. Our intent was to focus on the features of the disease that appear to be unique to the elderly catheterized patient, and to outline a diagnostic and therapeutic approach for these patients. MATERIALS AND METHODSThis prospective study commenced in December 1979 and was concluded in November 1980. During this period, 4955 patients aged 65 or older were discharged from the medical and surgical services of the hospital.The study group consisted of 13 symptomatic, elderly white febrile patients with indwelling bladder-catheters who were admitted to the hospital because of community-acquired urosepsis. Fever, constitutional symptoms, and "significant" bacteriuria (more than 105 colony-forming units per ml of a recognized urinary pathogen) were required criteria for participation in the study. Patients were excluded if another infection, a neoplasm, or an inflammatory disorder existed that could provide an alternative explanation for the admission fever and symptoms.Vincent Hospital, a 650-bed community hospital and major teaching affiliate of the University of Massachusetts Medical School. The patients' private physicians arid the members of the medical house staff made all the diagnostic and therapeutic decisions.The patients were classified according to the severity of their associated medical illnesses? Identification of septic shock required the presence of fever, altered mental status, and a systolic blood pressure less than 90 mm Hg.3 Patients known to be hypertensive before hospitalization were considered to have sustained shock if their admission systolic blood pressures fell by more than 50 mm Hg.The study received the approval of the institutional review committee for human research of Saint Vincent Hospital. Statistical differences between groups were analyzed with Student's twotailed t-test.Quantitative analysis for bacteriuria was carried out by the calibrated loop technique. Biotyping of Escherichia coli was performed to differentiate bacteria...