Diagnosis and management of urinary tract infection in older adults

Changes of urine isolates of Escherichia coli and Klebsiella pneumoniae biofilm affect monocytes' response

The Gram negative rods as Escherichia coli and Klebsiella pneumoniae belong to the most common etiology agents of urinary tract infections. The aim of our study was to assess the diversity of biofilm formed in different urinary tract diseases and their impact on monocytes’ adherence and activation. The bacteria were obtained from patients with different kidney problems. Some of the patients were after renal transplantation, some of them were not. Changes in the size and granularity of monocytes, as well as their adherence to biofilm, were assessed using FACSVerse flow cytometer after 1 h co-incubation of monocytes and bacterial biofilm in 37 °C. The obtained results were validated against monocytes incubated without bacteria. The isolates from patients with chronic kidney disease formed the most adherent biofilm regardless the presence or absence of inflammatory reaction. Adherence of monocytes also increased during therapy with immunosuppressive agents, but monocytes’ response was different when cyclosporine or tacrolimus were used. Additionally the presence of inflammatory reaction in patients with kidney disease modified the monocytes response when the immunosuppressive drugs were used. Considering the obtained results, we conclude that the changes of monocytes’ morphology in response to biofilm formed by Gram negative rods could become a tool to detect urinary tract infection, especially in those groups of patients, where the knowledge of ongoing inflammation is important and the standard tools fail to detect it.

Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI.

OBJECTIVE

The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI.

METHODS

A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis.

RESULTS

Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without.

CONCLUSIONS

Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI.

Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis

Objective

To determine the associations of delirium with urinary tract infection (UTI) and asymptomatic bacteriuria (AB) in individuals aged 65 and older.

Methods

The protocol for this systematic review and meta‐analysis was published on PROSPERO (CRD42020164341). Electronic databases were searched for relevant studies, professional associations and experts in the field were additionally contacted. Studies with control groups reporting associations between delirium and UTI as well as delirium and AB in older adults were included. The random effects model meta‐analysis was conducted using odds ratios (ORs) with 95% confidence intervals (CIs) as effect size measures. The Newcastle‐Ottawa scale was used to rate the studies' quality. Heterogeneity was assessed using the Q and I² tests. The effects of potential moderators were investigated by both subgroup and meta‐regression analyses. The risk of publication bias was evaluated using the funnel plot and Egger's test.

Results

Twenty nine relevant studies (16,618 participants) examining the association between delirium and UTI in older adults were identified. The association between delirium and UTI was found to be significant (OR 2.67; 95% CI 2.12–3.36; p < 0.001) and persisted regardless of potential confounders. The association between delirium and AB in older adults in the only eligible study found (192 participants) was insignificant (OR 1.62; 95% CI 0.57–4.65; p = 0.37). All included studies were of moderate quality.

Conclusion

The results of this study support the association between delirium and UTI in older adults. Insufficient evidence was found to conclude on an association between delirium and AB in this age group. These findings are limited due to the moderate quality of the included studies and a lack of available research on the association between delirium and AB. Future studies should use the highest quality approaches for defining both delirium and UTI and consider AB in their investigations.

The Sensitivity and Specificity of White Blood Cells and Nitrite in Dipstick Urinalysis in Association With Urine Culture in Detecting Infection in Adults From October 2016 to October 2019 at King Abdulaziz Medical City

Background

Urinary tract infection (UTI) is one of the most common clinical presentations that exhaust the patients and confuse physicians. Some of the risk factors that contribute to UTIs are age, female gender, and diabetes. Urinalysis is used to detect abnormalities in the urine, such as the presence of leukocytes, blood, and nitrite. However, urinalysis accuracy depends on the patient and the analyzer. On the other hand, urine culture is considered gold standard for diagnosing UTI. For that, the aim of this study is to determine the sensitivity of white blood cells (WBC) and nitrite in dipstick urinalysis in detecting UTI.

Methods

A cross-sectional study was conducted at King Abdulaziz Medical City on adult patients aged 19-65 years who underwent dipstick urinalysis and culture at the same visit from October 2016 to October 2019. The data were collected from the medical records from all the departments by using a data collection sheet through Best Care system. The sample was selected conveniently, and it was determined to be 359 patients with a confidence interval of 95%. Data were analyzed using IBM SPSS version 20 (IBM Corp., Armonk, NY, USA). Chi-square test was used to analyze the association between the outcome and the results of the dipstick urinalysis and urine culture. P-value lower than 0.05 was considered significant.

Results

Three hundred and fifty-nine patients were included into the study with a majority of females (81.1%) with a mean age of 47.5 years. Two hundred and fifty-two patients were culture positive, WBC sensitivity and specificity were 62.7% and 100%, and nitrite sensitivity and specificity were 20.6% and 93.5%, respectively. Ninety-nine diabetic patients were culture positive; for diabetic patients, WBC sensitivity and specificity were 65.7% and 100% and nitrite sensitivity and specificity were 18.2% and 97.6%, respectively, while for non-diabetic patients, WBC sensitivity and specificity were 60.85% and 100% and nitrite sensitivity and specificity were 22.2% and 90.8%, respectively.

Conclusion

Our study showed that results of WBC are more sensitive and specific than those of nitrite in comparison to the gold standard (urine culture). Diabetics and non-diabetics have slightly different results. According to our results it is difficult to depend on the dipstick urinalysis without culture. More studies are recommended in this field.

A 5-Year Retrospective Analysis of Raoultella planticola Bacteriuria

Introduction

Raoultella planticola is an aerobic gram-negative rod predominantly found in soil and aquatic environments. The typical reservoirs of Raoultella spp. include the gastrointestinal tract and the upper respiratory tract. It usually causes pneumonia, biliary tract infections, and bacteremia. Urinary tract infection (UTI) secondary to R. planticola is an uncommon entity. Less than 10 cases of R. planticola-associated UTIs in adults have been published in the literature to date.

Objective

This is a single institution retrospective study undertaken to identify the epidemiology, patient characteristics, clinical spectrum, predisposing risk factors and the outcome of patients with UTI caused by R. planticola.

Results

A total of 37 R. planticola isolates were identified in urine samples over a 5-year study period. The mean age of the patient population was 77 years. The most common comorbidity was diabetes mellitus, which was present in 16 patients. Only 3 patients had a history of steroid use, an immunosuppressive condition, or were on chemotherapy. The most common presenting complaint was altered mental status followed by fever. Resistance to ampicillin was found in 35 isolates which seems to be an intrinsic characteristic of Raoultella spp. and 2 isolates were multidrug-resistant, but still susceptible to ciprofloxacin. The average length of stay was 3 days, and the average duration of antibiotic administration was 8 days. Ciprofloxacin was the most frequently prescribed antibiotic (9 patients). The severity of infection ranged from simple cystitis in 15 patients to urosepsis in 2 patients and septic shock in 2 patients. There were no mortalities in our cohort.

Conclusion

Our study revealed that patients with R. planticola UTI had higher proportion of diabetes mellitus, renal failure compared to the general population. Our study also confirms the intrinsic resistance to ampicillin of Raoultella spp., which has been documented previously in the literature.

The influence of mental status on reported local urinary tract symptoms in patients with bacteraemic urinary tract infections

AIM

In elderly patients with a urinary tract infection, the influence of mental status on the frequency of local urinary tract symptoms is uncertain. We aim to compare the frequency of reported local urinary tract symptoms between mentally intact and cognitively impaired older people with a bacteraemic urinary tract infection.

METHODS

We retrospectively selected consecutive patients aged 65 years or older hospitalised in internal medicine departments in a regional hospital from 1 January 2015 to 31 December 2016 if they had identical bacteria isolated from blood and urine cultures. Mentally intact patients were those who were alert on admission and throughout their hospitalisation and without a prior or new diagnosis of dementia.

RESULTS

Of 222 patients with a bacteraemic urinary tract infection, 125 (56.3%) did not have local urinary tract symptoms, 68.8% (86/125, 95% CI-60.7%-76.9%) cognitively impaired, compared with 40.2% (39/97, 95% CI-30.4%-50.7%) in those mentally intact (P < .001).

CONCLUSIONS

The absence of local urinary tract symptoms in elderly patients with a bacteraemic urinary tract infection is less frequent but common in those mentally intact, and should not preclude the need for a urine culture or antibiotic therapy.

Cement Augmentation of Vertebral Compression Fractures May Be Safely Considered in the Very Elderly

Objective

The objective of the current study was to perform a retrospective review of a national database to assess the safety of cement augmentation for vertebral compression fractures in geriatric populations in varying age categories.

Methods

The 2005–2016 National Surgical Quality Improvement Program databases were queried to identify patients undergoing kyphoplasty or vertebroplasty in the following age categories: 60–69, 70–79, 80–89, and 90+ years old. Demographic variables, comorbidity status, procedure type, provider specialty, inpatient/outpatient status, number of procedure levels, and periprocedure complications were compared between age categories using chi-square analysis. Multivariate logistic regressions controlling for patient and procedural variables were then performed to assess the relative periprocedure risks of adverse outcomes of patients in the different age categories relative to those who were 60–69 years old.

Results

For the 60–69, 70–79, 80–89, and 90+ years old cohorts, 486, 822, 937, and 215 patients were identified, respectively. After controlling for patient and procedural variables, 30-day any adverse events, serious adverse events, reoperation, readmission, and mortality were not different for the respective age categories. Cases in the 80- to 89-year-old cohort were at increased risk of minor adverse events compared to cases in the 60- to 69-year-old cohort.

Conclusion

As the population ages, cement augmentation is being considered as a treatment for vertebral compression fractures in increasingly older patients. These results suggest that even the very elderly may be appropriately considered for these procedures (level of evidence: 3).

Antimicrobial Resistance Patterns of Urinary Escherichia coli Among Outpatients in Washington State, 2013-2017: Associations with Age and Sex

BACKGROUND

Management of acute, uncomplicated cystitis in outpatients benefits from knowledge of drug resistance patterns in the population. However, antibiograms are often not available for the outpatient setting, and the role of host factors such as sex and age in assessing the likelihood of resistance are not well understood. We investigated whether antibiotic resistance patterns of outpatient urinary Escherichia coli (EC) isolates vary by age group and sex in a large database of antibiotic susceptibility test (AST) results from Washington State.

METHODS

We retrospectively analyzed AST data for outpatient urinary EC isolates in Washington State tested at a clinical reference laboratory from 2013 - 2017. In logistic regression models stratified by sex, we tested the associations of antibiotic resistance with patient age.

RESULTS

We found females >50 years had greater odds than females younger than 19 for resistance to amoxicillin-clavulanate (odds ratio [OR], 1.43; 95% CI, 1.22-1.69), ciprofloxacin (OR, 3.04; 95% CI, 2.48-3.74), ceftriaxone (OR, 2.58; 95% CI, 1.77-3.92), and gentamicin (OR, 1.62; 95% CI, 1.27-2.08) (all p<0.001). Compared to males younger than 19, males >50 years had greater odds of resistance to ciprofloxacin (OR, 2.59; 95% CI, 1.18-5.69) and lower odds of resistance to amoxicillin-clavulanate (OR, 0.56; 95% CI, 0.34-0.96) (all p<0.05).

CONCLUSION

These findings demonstrate that age and sex are associated with variability in antibiotic resistance patterns in the outpatient setting. Availability of outpatient antibiotic resistance data based on sex and age may be useful to inform empiric prescribing for outpatient UTIs and to support antibiotic stewardship efforts.

Infections in Older Adults

Infections in elderly patients can prove diagnostically challenging. Age-related factors affecting the immune system in older individuals contribute to nonspecific presentations. Other age-related factors and chronic conditions have symptoms that may or may not point to an infectious diagnosis. Delay in administration of antimicrobials can lead to poor outcomes; however, unnecessary administration of antimicrobials can lead to increased morbidity and contribute to the emergence of multidrug-resistant organisms. Careful clinical assessment and consideration of patient history and risk factors is crucial. When necessary, antimicrobials should be chosen that are appropriate for the diagnosis and deescalated as soon as possible.

Effectiveness and Safety of SGLT2 Inhibitors in Clinical Routine Treatment of Patients with Diabetes Mellitus Type 2

The aim of this study was to investigate the effectiveness of SGLT2 inhibitors with regard to metabolic parameters and patient safety under routine ambulatory conditions. Retrospective longitudinal study of 95 patients with type 2 diabetes (diabetes duration 13.3 y; HbA1c 8.9%; eGFR 80.1 mL/min) receiving SGLT-2-inhibitors. Metabolic control and adverse event profile were evaluated. The mean follow-up time was 1.2 ± 0.8 years. The following changes were observed: HbA1c -1.0% ± 1.9 (p < 0.001), eGFR -7.0 mL/min ± 13.3 (p < 0.001), albuminuria -23.9 mg/g creatinine ± 144.5 (p = 0.118), bodyweight -3.0 kg ± 5.8 (p < 0.001), systolic blood pressure -6 mmHg ± 22 (p = 0.01), diastolic blood pressure -2 mmHg ± 14 (p = 0.243). 53 participants continuously applied the therapy. Twenty-eight participants discontinued SGLT-2-inhibitors due to various reasons: 20 participants because of genital- or urinary tract infections. One for dysuria, seven due to reduced eGFR below 45 mL/min. This study showed a considerable reduction of HbA1c and a modest reduction of eGFR, bodyweight and systolic blood pressure under clinical routine conditions. Genital infections occurred markedly more often than in randomized controlled trials. To apply SGLT-2-inhibitors more safely in clinical routine individual risks for genital and urinary tract infections should be considered and re-evaluated during therapy.

Mobile origami immunosensors for the rapid detection of urinary tract infections

Urinary tract infections (UTI) have a high prevalence and can yield poor patient outcomes if they progress to urosepsis. Here we introduce mobile origami biosensors that detect UTIs caused by E. coli at the bedside in less than 7 minutes. The origami biosensors are made of a single piece of paper that contains antibody-decorated nanoparticles. When the urine sample contains E. coli, the biosensors generate colored spots on the paper strip. These are then quantified with a mobile app that calculates the pixel intensity in real time. The tests are highly specific and do not cross-react with other common uropathogens. Furthermore, the biosensors only yielded one false negative result when queried with a panel containing 57 urine samples from patients, which demonstrates that they have excellent sensitivity and specificity. This, along with the rapid assay time and smartphone-based detection, makes them useful for aiding in the diagnosis of UTIs at the point of care.

Treatment of uncomplicated UTI in males: a systematic review of the literature

BACKGROUND

Urinary tract infections (UTIs) affect around 20% of the male population in their lifetime. The incidence of UTIs in men in the community is 0.9-2.4 cases per 1000 aged <55 years and 7.7 per 1000 aged ≥85 years.

AIM

To evaluate the outcomes of randomised controlled trials (RCTs) comparing the effectiveness of different antimicrobial treatments and durations for uncomplicated UTIs in adult males in outpatient settings.

METHOD

A systematic literature review of RCTs of adult male patients with an uncomplicated UTI treated with oral antimicrobials in any outpatient setting. The outcomes were symptom resolution within 2 weeks of starting treatment, duration until symptom resolution, clinical cure, bacteriological cure, and frequency of adverse events.

RESULTS

From the 1052 abstracts screened, three provided sufficient information on outcomes. One study compared trimethoprim-sulfamethoxazole for 14 days (21 males) with 42 days (21 males). Fluoroquinolones were compared in the two other RCTs: lomefloxacin (10 males) with norfloxacin (11 males), and ciprofloxacin for 7 days (19 males) and 14 days (19 males). Combining the results from the three RCTs shows that for 75% males with a UTI (76/101) bacteriological cure was reported at the end of the study. Of the 59 patients receiving a fluoroquinolone, 57 (97%) reported bacteriological and clinical cure within 2 weeks after treatment.

CONCLUSION

The evidence available is insufficient to make any recommendations in relation to type and duration of antimicrobial treatment for male UTIs. Sufficiently powered RCTs are needed to identify best treatment type and duration for male UTIs in primary care.

Sensitivity of C-reactive protein and procalcitonin measured by Point-of-Care tests to diagnose urinary tract infections in nursing home residents: a cross-sectional study

Background

Diagnosing urinary tract infections (UTIs) in nursing home residents is complex, as specific urinary symptoms are often absent and asymptomatic bacteriuria (ASB) is prevalent. The aim of this study was to assess the sensitivity of blood C-reactive protein (CRP) and procalcitonin (PCT), measured by point-of-care tests (PoCTs), to diagnose UTIs in this setting.

Methods

Elderly residents (≥65 years old) with a suspected UTI were recruited from psychogeriatric, somatic, or rehabilitation wards across 13 participating nursing homes. CRP and PCT were tested simultaneously in the same study participants. To assess the tests’ sensitivities, a stringent definition of “true” UTI was used that included the presence of symptoms, urinary leucocytes, a positive urine culture, and symptom resolution during antibiotic treatment covering isolated uropathogen(s). The original sample size was 440 suspected UTI episodes, in order to detect a clinically relevant sensitivity of at least 65% when calculated using the matched analysis approach to compare both PoCTs.

Results

After enrollment of 302 episodes (68.6% of the planned sample size), an unplanned and funder-mandated interim analysis was done, resulting in premature discontinuation of the study for futility. For 247 of 266 eligible episodes, all mandatory items required for the true UTI definition (92.9%) were available. In total, 49 episodes fulfilled our stringent UTI definition (19.8%). The sensitivities of CRP (cut-off, 6.5 mg/L) and PCT (cut-off, 0.025 ng/mL) were 52.3% (95% confidence interval [CI], 36.7–67.5%) and 37.0% (95% CI, 23.2–52.5%), respectively.

Conclusions

Our results indicate that CRP and PCT are not suitable tests for distinguishing UTI and ASB in nursing home residents.

Clinical Trials Registration

Netherlands Trial Registry NL6293.

Evaluation of urinary inflammatory index in rapid screening of urinary tract infection

The objective of this study was to assess the diagnosis value of urinary inflammatory index (UII) and systemic immune-inflammation index (SII) for UTI. Nine inflammatory indexes including neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, SII and six UIIs were calculated for Receiver operating characteristic curve analysis to select which one is suitable for the screening of UTIs or distinguishing the types of bacteria. UII3, which calculated from leucocyte esterase (LE), nitrite, white blood cells and bacteria, was preferentially used as an indicator for the diagnosis of UTI when the threshold was set at 0.53. UII2 was more suitable for the distinction between groups when the cutoff is set to 0.94. Appropriate urinary inflammation index calculated by rapid urinalysis of urine dipstick and urine sediment can help us to predict urinary tract infection and bacterial type, and reduce the workload and costs of urine culture.

"A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: a qualitative study

BACKGROUND

Diagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent non-specific symptomatology and asymptomatic bacteriuria. The objective of this study was to explore health care professionals' perceptions of the proposed use of inflammatory marker Point-Of-Care Testing (POCT) in this respect.

METHODS

We conducted a qualitative inquiry (2018-2019) alongside the multicenter PROGRESS study (NL6293), which assessed the sensitivity of C-reactive protein and procalcitonin POCT in UTI. We used semi-structured face-to-face interviews. The participants were physicians (n = 12) and nurses (n = 6) from 13 nursing homes in the Netherlands. Most respondents were not familiar with inflammatory marker POCT, while some used POCT for respiratory tract infections. Both the interview guide and the analysis of the interview transcripts were based on the Consolidated Framework for Implementation Research.

RESULTS

All respondents acknowledged that sufficiently sensitive POCT could decrease diagnostic uncertainty to some extent in residents presenting with non-specific symptoms. They primarily thought that negative test results would rule out UTI and justify withholding antibiotic treatment. Secondly, they described how positive test results could rule in UTI and justify antimicrobial treatment. However, most respondents also expected new diagnostic uncertainties to arise. Firstly, in case of negative test results, they were not sure how to deal with residents' persisting non-specific symptoms. Secondly, in case of positive test results, they feared overlooking infections other than UTI. These new uncertainties could lead to inappropriate antibiotics use. Therefore, POCT was thought to create a false sense of confidence.

CONCLUSIONS

Our study suggests that inflammatory marker POCT will only improve UTI management in nursing homes to some extent. To realize the expected added value, any implementation of POCT requires thorough guidance to ensure appropriate use. Developing UTI markers with high negative and positive predictive values may offer greater potential to improve UTI management in nursing homes.

A diagnostic algorithm for detection of urinary tract infections in hospitalized patients with bacteriuria: The "Triple F" approach supported by Procalcitonin and paired blood and urine cultures

For acute medicine physicians, distinguishing between asymptomatic bacteriuria (ABU) and clinically relevant urinary tract infections (UTI) is challenging, resulting in overtreatment of ABU and under-recognition of urinary-source bacteraemia without genitourinary symptoms (USB). We conducted a retrospective analysis of ED encounters in a university hospital between October 2013 and September 2018 who met the following inclusion criteria: Suspected UTI with simultaneous collection of paired urinary cultures and blood cultures (PUB) and determination of Procalcitonin (PCT). We sought to develop a simple algorithm based on clinical signs and PCT for the management of suspected UTI. Individual patient presentations were retrospectively evaluated by a clinical "triple F" algorithm (F1 ="fever", F2 ="failure", F3 ="focus") supported by PCT and PUB. We identified 183 ED patients meeting the inclusion criteria. We introduced the term UTI with systemic involvement (SUTI) with three degrees of diagnostic certainty: bacteremic UTI (24.0%; 44/183), probable SUTI (14.2%; 26/183) and possible SUTI (27.9%; 51/183). In bacteremic UTI, half of patients (54.5%; 24/44) presented without genitourinary symptoms. Discordant bacteraemia was diagnosed in 16 patients (24.6% of all bacteremic patients). An alternative focus was identified in 67 patients, five patients presented with S. aureus bacteremia. 62 patients were diagnosed with possible UTI (n = 20) or ABU (n = 42). Using the proposed "triple F" algorithm, dichotomised PCT of < 0.25 pg/ml had a negative predictive value of 88.7% and 96.2% for bacteraemia und accordant bacteraemia respectively. The application of the algorithm to our cohort could have resulted in 33.3% reduction of BCs. Using the diagnostic categories "possible" or "probable" SUTI as a trigger for initiation of antimicrobial treatment would have reduced or streamlined antimicrobial use in 30.6% and 58.5% of cases, respectively. In conclusion, the "3F" algorithm supported by PCT and PUB is a promising diagnostic and antimicrobial stewardship tool.

Effect of Fosfomycin on Cyclosporine Nephrotoxicity

Fosfomycin (Fos) has emerged as a potential treatment against multidrug-resistant organisms, however, there has been little work done on its influence on calcineurin inhibitor nephrotoxicity (CIN). This study was designed to evaluate the effect of Fos in combination with cyclosporine (CsA) on CIN. Two sets of experiments were undertaken. In the first, Wistar rats received different doses of Fos: 0, 62.5, 125, 250, and 500 mg/kg. In the second, rats were divided into four groups: control, CsA 15 mg/kg s.c., CsA + fosfomycin 62.5 mg/kg (CsA + LF), and CsA + Fos 500 mg/kg (CsA + HF). CsA was administrated daily for 14 days, whereas Fos administration started on the ninth day followed by two more doses, delivered 48 h apart. The administration of different Fos doses did not alter renal function. In contrast, CsA induced arteriolopathy, hypoperfusion, a reduction in the glomerular filtration rate, and downregulation of eNOS, angiotensinogen, and AT1R mRNA levels. Lower doses of Fos did not modify CIN. Instead, the CsA + HF group exhibited greater hypoperfusion, arteriolopathy, and oxidative stress, and increased mRNA levels of pro-inflammatory cytokines. This study shows that Fos administered by itself at different doses did not cause renal injury, but when it was given repeatedly at high dosages (500 mg/kg) in combination with CsA, it increased CIN through the promotion of greater oxidative stress and renal inflammation.

Prostate Artery Embolization - Adverse Events and Peri-Procedural Management

As prostate artery embolization (PAE) for treatment of lower urinary tract symptoms attributed to benign prostatic hyperplasia becomes more commonly performed, operator knowledge of the adverse events is essential to inform patient selection, patient preparation, and postprocedural management. The aim of this article is to discuss the incidence, presentation, and management of adverse effects after PAE.

Different antibiotic regimes in men diagnosed with lower urinary tract infection - a retrospective register-based study

OBJECTIVE

To compare the proportion of therapy failure, recurrence and complications within 30 days after consultation between men diagnosed with lower urinary tract infection (UTI) treated with narrow-spectrum antibiotics (nitrofurantoin or pivmecillinam) and broad-spectrum antibiotics (fluoroquinolones or trimethoprim or trimethoprim/sulfamethoxazole).

DESIGN

A retrospective cohort study based on data derived from electronic medical records between January 2012 and December 2015.

SETTING

Primary health care and hospital care in five different counties in Sweden. Patients: A total of 16,555 men aged between 18 and 79 years diagnosed with lower UTI.

MAIN OUTCOME MEASURES

Treatment with narrow-spectrum antibiotics was compared with broad-spectrum antibiotics regarding therapy failure, recurrence and complications within 30 days.

RESULTS

The median age of included men was 65 IQR (51-72) years. Narrow-spectrum antibiotics were prescribed in 8457 (40%) and broad-spectrum antibiotics in 12,667 (60%) cases, respectively. Therapy failure was registered in 192 (0.9%), recurrence in 1277 (6%) and complications in 121 (0.6%) cases. Therapy failure and recurrence were more common in patients treated with narrow-spectrum antibiotics and trimethoprim (p < 0.001), but no such difference could be detected regarding complications.

CONCLUSION

There was no difference in incidence of complications within 30 days between men treated with narrow- or broad-spectrum antibiotics. Patients prescribed broad-spectrum antibiotics had lower odds of reconsultation because of therapy failure and recurrence. From current data, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men with lower UTI. KEY POINTS Complications such as pyelonephritis and sepsis are uncommon in men diagnosed with lower urinary tract infection treated with antibiotics. There was no difference in incidence of complications among men diagnosed with lower urinary tract infection treated with narrow- or broad-spectrum antibiotics. In spite of higher incidence of therapy failure and recurrence, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men diagnosed with lower UTI.

Bacterial Resistance to Cephalosporin Treatment in Elderly Stable Patients Hospitalized With a Urinary Tract Infection

BACKGROUND

It is unclear if parenteral cephalosporin treatment is appropriate in stable elderly patients hospitalized with a urinary tract infection (UTI) in settings with a high prevalence of bacterial resistant organisms.

METHODS

We selected 934 consecutive stable patients aged ≥65 years with a UTI, 94.4% (n = 882) treated with a parenteral cephalosporin. Patients were divided into those with and without bacterial resistance to initial antibiotic therapy (BRIAT). Outcome measures were response to antibiotic therapy at 72 hours, prolonged hospitalization (>5 days) and mortality.

RESULTS

There were 316 patients (33.8%) with BRIAT. At 72 hours, 33.9% (107/316) did not respond to initial treatment. The odds of a prolonged hospitalization was 2.1 (95% confidence interval-1.6-2.9), but no patient with BRIAT died from urosepsis (0%, 95% confidence interval-0-1.2%).

CONCLUSIONS

In elderly stable patients hospitalized with a UTI, treatment with a parenteral cephalosporin might be appropriate despite a high prevalence of resistant organisms.

Vesicoureteral Reflux in Adults with Urinary Tract Infections: Is There a Role for Treatment?

PURPOSE OF REVIEW

Urinary tract infections (UTI) place a significant burden on individual patients and the healthcare system as a whole. Vesicoureteral reflux (VUR) is a risk factor for UTIs and is the focus of much research in the pediatric field due to the opportunity for early intervention and prevention of long-term sequelae. However, VUR in the adult population is not well studied and can present different treatment challenges. The goal of this review article is to discuss the role VUR plays in UTIs in the adult population with a specific focus on complications and treatment.

RECENT FINDINGS

The true prevalence of VUR in the adult population remains unknown, and urologists need to maintain an index of suspicion for VUR when evaluating adult patients with recurrent pyelonephritis or complicated UTIs. A number of case series and smaller retrospective studies have documented successful endoscopic treatment of adult VUR patients with recurrent pyelonephritis. Ureteral reimplantation remains an option for adult patients who are refractory to endoscopic treatment of VUR. The current treatments and recommendations for VUR in adults have been extrapolated from the pediatric population due to the scarcity of research. VUR is uncommon in the adult population and requires a high index of suspicion by the clinician. Accurate diagnosis and treatment of VUR can relieve patients from recurrent infections, repetitive antibiotic use, and the risk of hospitalization.

Urinalysis Using a Diaper-Based Testing Device

Urinary tract infections (UTI), one of the most common bacterial infections, annually affect 150 million people worldwide. Infants and the elderly are likely to have missed or delayed diagnosis of UTI due to difficulty clearly describing their symptoms. A rapid screening method for UTI is a critical and urgent need for these populations. The aim of our study is to develop a diaper-based testing device to assay urine biomarkers including pH, leukocyte, and nitrite level. This all-in-one device assists in urine collection and testing using a colorimetric approach to provide easily read visual results on the outside surface of a test strip-integrated diaper. In this study, we tested samples from 46 patients using testing strips and examined the results from 7 patients recruited to validate the strip-integrated diaper. In conclusion, this new diaper-based testing device is easy to use, rapid, and inexpensive, all of which imbue it with tremendous potential for development into a commercially viable UTI screening system.

Accuracy of blood-tests and synovial fluid-tests in the diagnosis of periprosthetic joint infections

INTRODUCTION

Periprosthetic joint infection (PJI) is one of the most complex complications following total joint arthroplasty. Despite significant progress in recent years, the use of blood and synovial biomarkers to diagnose PJI remains a challenge.

AREAS COVERED

A combination of serological, synovial, microbiological, histological, and radiological investigations is suggested by consensus and international guidelines. Novel biomarkers and molecular methods have shown promise in recent years. The purpose of this review is to provide an update about the biomarkers used to diagnose PJI and highlight their sensitivity and specificity. In addition, guidance on the diagnostic steps and clinical workflow will be included.

EXPERT OPINION

The diagnostic algorithm developed and validated by the international consensus meeting group is still the most valuable resource to approach PJI diagnosis. The current combination of blood and synovial biomarkers yield acceptable results and good performance. However, there is a need for new biomarkers and further research to understand the limitations of current tests better, as well as explore new options such as alpha-defensin, D-dimer, interleukin-6, and leukocyte esterase.

Distribution of Pathogenicity Island Markers and H-Antigen Types of Escherichia coli O25b/ST131 Isolates from Patients with Urinary Tract Infection in Iran

Escherichia coli serogroup O25b-sequence type 131 (E. coli O25b/ST131) is known as a multidrug-resistant organism with high virulence potential and has received attention internationally. We aim to investigate the prevalence of O25b/ST131 and the distribution of bla_CTX-M-15, pathogenicity island (PAI) markers, phylogenetic groups, and H-antigen typing in the E. coli O25b/ST131 isolated from patients with urinary tract infection (UTI) in Tehran, the capital of Iran. Seventy (26.9%) E. coli isolates were identified as O25b/ST131. There was also a significant difference in the prevalence of virulence genes, including papA, sfa, sat, cnf1, iutA, kpMII, traT, and usp, in the O25b/ST131 isolates rather than non-O25b/ST131 ones (p ≤ 0.05). Furthermore, 78% of the O25b/ST131 isolates carried four to seven PAIs, while 71% of non-O25b/ST131 isolates carried two to four PAI markers (p ≤ 0.05). Our study showed that in addition to H4, other H-antigens may play a role in the O25b/ST131 virulence potential. Besides, a significant association was found between the history of previous UTIs and infection among the O25b/ST131 clone isolates. Pulsed-field gel electrophoresis revealed circulating of O25b:H4-ST131/PST43 clone in both hospital and community. Approximately one in every three uropathogenic E. coli isolates was the O25b/ST131 clone, representing a significant public health threat. Practical investigation on O25b/ST131 can be helpful in better understanding of ST131 evolution and controlling UTI in hospitals.

An Intact Cell Bioluminescence-Based Assay for the Simple and Rapid Diagnosis of Urinary Tract Infection

Urinary tract infection (UTI) is one of the most common infections, accounting for a substantial portion of outpatient hospital and clinic visits. Standard diagnosis of UTI by culture and sensitivity can take at least 48 h, and improper diagnosis can lead to an increase in antibiotic resistance following therapy. To address these shortcomings, rapid bioluminescence assays were developed and evaluated for the detection of UTI using intact, viable cells of Photobacterium mandapamensis USTCMS 1132 or previously lyophilized cells of Photobacterium leiognathi ATCC 33981™. Two platform technologies-tube bioluminescence extinction technology urine (TuBETUr) and cellphone-based UTI bioluminescence extinction technology (CUBET)-were developed and standardized using artificial urine to detect four commonly isolated UTI pathogens-namely, Escherichia coli, Proteus mirabilis, Staphylococcus aureus, and Candida albicans. Besides detection, these assays could also provide information regarding pathogen concentration/level, helping guide treatment decisions. These technologies were able to detect microbes associated with UTI at less than 105 CFU/mL, which is usually the lower cut-off limit for a positive UTI diagnosis. Among the 29 positive UTI samples yielding 105-106 CFU/mL pathogen concentrations, a total of 29 urine specimens were correctly detected by TuBETUr as UTI-positive based on an 1119 s detection window. Similarly, the rapid CUBET method was able to discriminate UTIs from normal samples with high confidence (p ≤ 0.0001), using single-pot conditions and cell phone-based monitoring. These technologies could potentially address the need for point-of-care UTI detection while reducing the possibility of antibiotic resistance associated with misdiagnosed cases of urinary tract infections, especially in low-resource environments.

Urinary tract infections in the elderly: a review of disease characteristics and current treatment options

Urinary tract infections (UTIs) are common in the elderly, and cover a range of conditions from asymptomatic bacteriuria to urosepsis. Risk factors for developing symptomatic UTIs include immunosenescence, exposure to nosocomial pathogens, multiple comorbidities, and a history of UTIs. European guidelines on urological infections recommend antimicrobial treatment only for symptomatic UTIs. Non-antimicrobial options to treat and prevent UTIs include among others cranberry products, OM-89 Escherichia coli bacterial lysate vaccine, and estrogen therapy in postmenopausal women, although evidence for their efficacy is weak. Another non-antimicrobial option to control and prevent UTIs is a medical device (Utipro Plus^®) containing xyloglucan, gelatin, propolis, and extracts of Hibiscus sabdariffa. The device acts in the intestine as a mechanical barrier to protect against invasion by uropathogenic E. coli strains. A randomized controlled trial of Utipro Plus^® in patients with uncomplicated UTIs provided good-quality evidence of its efficacy compared with placebo. In an observational study of Utipro Plus^® in patients with recurrent UTIs, more than 80% women reported a return to their pre-UTI clinical status and about 30% transitioned from symptomatic UTIs to asymptomatic bacteriuria. New treatment strategies that offer a safe and effective non-antimicrobial means of managing UTIs could have an important role in the elderly.

A Clinical Perspective on the Antimicrobial Resistance Spectrum of Uropathogens in a Romanian Male Population

Considering urinary tract infections (UTIs), a significant public health problem with negligible recent research, especially on the male eastern European population, we aimed to determine the antimicrobial resistance rates of uropathogens for the most commonly used antibiotics in urological practice in our country. We conducted a multicenter retrospective study in two different teaching hospitals in Romania, analyzing urine samples from 7719 patients to determine the frequency of incriminating pathogens and their resistance to different antibiotics, in a comparative approach. We determined Escherichia coli (35.98%) to be the most common pathogen with the highest sensitivity to amikacin (S = 91.72%), meropenem (S = 97.17%) and fosfomycin (S = 86.60%) and important resistance to amoxicillin-clavulanic ac. (R = 28.03%) and levofloxacin (R = 37.69%), followed by Klebsiella spp. (22.98%) with the highest sensitivity to amikacin (S = 78.04%) and meropenem (S = 81.35%) and important resistance to amoxicillin-clavulanic ac. (R = 65.58%) and levofloxacin (R = 45.36%); the most frequent Gram-positive pathogen was Enterococcus spp. (19.73%) with the highest sensitivity for vancomycin (S = 93.75%) and fosfomycin (S = 87.5%) and considerable resistance to penicillin (R = 33.52%) and levofloxacin (R = 42.04%). The findings are an important tool in managing UTIs and should be acknowledged as reference research not only for clinicians from Romania but for all physicians treating male UTIs.

Respiratory and Blood Stream Infections are Associated with Subsequent Venous Thromboembolism After Primary Intracerebral Hemorrhage

BACKGROUND

Infection and venous thromboembolism (VTE) are associated with worse outcomes after intracerebral hemorrhage (ICH). The relationship between infection and VTE in ICH patients is unclear. We hypothesized that infection would be associated with subsequent VTE after ICH.

METHODS

We retrospectively studied consecutively admitted spontaneous primary ICH patients from 2009 to 2018 surviving beyond 24 h. The primary predictor variable was infection, diagnosed prior to VTE. The primary outcome was VTE. We used multivariable logistic regression models to estimate the odds ratios and 95% confidence intervals (OR, 95% CI) for VTE risk after infection of any type, after adjusting for ICH score, length of stay and days to deep venous thrombosis (DVT) prophylaxis. Similar analysis was done to estimate the association of infection subtypes, including respiratory and urinary and blood stream infections (BSI) with VTE.

RESULTS

There were 414 patients (mean age 65 years, 47% female) that met were analyzed. Infection was diagnosed in 181 (44%) patients. Incident VTE was diagnosed in 36 (9%) patients, largely comprised of DVT (n = 32; 89%). Infection overall was associated with increased risk of subsequent VTE (adjusted OR 4.5, 95% CI 1.6-12.6). Respiratory (adjusted OR 5.7, 95% CI 2.8-11.7) and BSI (adjusted OR 4.0, 95% CI 1.3-11.0) were associated with future VTE. Urinary and other infections were not associated with subsequent VTE.

CONCLUSIONS

Infections are associated with subsequent risk of VTE among patients with ICH. Further investigation is required to elucidate mechanisms behind this association and to improve VTE prevention after ICH.

Risk factors for hospital-acquired non-catheter-associated urinary tract infection

BACKGROUND AND PURPOSE

Nosocomial urinary tract infection in patients with no Foley catheter [non-catheter-associated urinary tract infection (non-CAUTI)] has been a serious health issue that is associated with an increase in the cost of care, morbidity, and mortality. Identifying the risk factors of non-CAUTI would help determine patients at high risk and prevent complications. This study aims to identify the risk factors of non-CAUTI.

METHOD

This study was conducted in four hospitals in three Middle Eastern countries: Jordan, Qatar, and Saudi Arabia. A convenience sample of 189 participants was recruited, of which 83 had non-CAUTI. Case-control design was used. Patients who had non-CAUTI while hospitalized were compared with others who did not. A questionnaire was developed based on the non-CAUTI diagnostic criteria from the Centers for Disease Control and Prevention. The questionnaire contained two parts: part one included participants' characteristics and part two assessed the symptoms of non-CAUTI.

CONCLUSION

Comorbidity is associated with a higher risk of having nosocomial non-CAUTI among hospitalized patients. This study showed that the diagnosis and management of comorbidity is important in lowering the risk of non-CAUTI in hospitalized patients. Age and antibiotic administration were statistically significant; however, their effects were small and were unlikely to have any clinical significance.

IMPLICATION FOR PRACTICE

Identifying patients at high risk is imperative to prevent the development of non-CAUTI. Nurse practitioners may implement an early intervention for patients with comorbidity to counteract its effect on patients' health.

Prevalence and Antimicrobial Susceptibility Patterns of Bacterial Pathogens in Urinary Tract Infections in University Hospital of Campania "Luigi Vanvitelli" between 2017 and 2018

Urinary tract infections (UTIs) are the most common and expensive health problem globally. The treatment of UTIs is difficult owing to the onset of antibiotic-resistant bacterial strains. The aim of this study was to define the incidence of infections, identify the bacteria responsible, and identify the antimicrobial resistance profile. Patients of all ages and both sexes were included in the study, all admitted to University Hospital of Campania “Luigi Vanvitelli”, between January 2017 and December 2018. Bacterial identification and antibiotic susceptibility testing were performed using matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and Phoenix BD. Among the 1745 studied patients, 541 (31%) and 1204 (69%) were positive and negative for bacterial growth, respectively. Of 541 positive patients, 325 (60%) were females, while 216 (39.9%) were males. The largest number of positive subjects was recorded in the elderly (>61 years). Among the pathogenic strains, 425 (78.5%) were Gram-negative, 107 (19.7%) were Gram-positive, and 9 (1.7%) were Candida species. The most isolated Gram-negative strain is Escherichia coli (E. coli) (53.5%). The most frequent Gram-positive strain was Enterococcus faecalis (E. faecalis) (12.9%). Gram-negative bacteria were highly resistant to ampicillin, whereas Gram-positive bacteria were highly resistant to erythromycin.

Risk Factors of Bacteremia following Multiple Traumas

Background

Bacteremia is a major nosocomial infection that frequently occurs in trauma patients, increasing morbidity and mortality. The aim of this study was to identify risk factors and to describe epidemiological patterns for early onset (EOB) and late onset (LOB) bacteremia after trauma.

Methods

We retrospectively reviewed medical records of all trauma patients admitted to the surgical intensive care unit and general ward between January 2011 and December 2015. The information was collected for each patient and recorded in a computer database: early onset bacteremia (EOB) was defined as when onset occurred within 7 days after trauma, and late onset bacteremia (LOB) was defined as when onset occurred after 7 days from trauma.

Results

Thirty-four patients of 859 (4%) developed bacteremia during their hospital stay: 4 (11.8%) developed EOB, 26 (76.4%) LOB, and 4 (11.8%) patients developed both of them. Sixty events of bacteremia happened to these patients: 9 (15.0%) EOB and 51 (85.0%) LOB. Gram-positive cocci were isolated more frequently than Gram-negative bacilli in both groups. Gram-positive cocci were more frequently isolated in EOB than in LOB; otherwise, there was no statistical significance (77.8% vs. 64.7%, p=0.683). Central line-associated blood stream infection (CLABSI) and surgical site infection (SSI) were the most common identified source for LOB. Presence of liver (OR: 2.66, p=0.035) and pelvic injury (OR: 2.25, p=0.038), gastrointestinal tract perforation (OR: 5.48, p=0.002), and massive transfusion (OR: 3.36, p=0.006) represented risk factors for bacteremia.

Conclusions

Presence of pelvic and liver injury on arrival in emergency department, gastrointestinal tract perforation, and massive transfusion within the first 24 hours after trauma appears to be significant risk factors for bacteremia.

Impact of a urinary tract infection diagnostic and treatment algorithm for psychiatric inpatients with a communication barrier

INTRODUCTION

Differentiating between a urinary tract infection and asymptomatic bacteriuria is an important distinction to make, especially in noncommunicative patients. An algorithm meant to aid in the diagnosis and treatment of urinary tract infections in this population was implemented within a psychiatric emergency department in January 2019. The primary objective of this project was to assess the impact of the algorithm (the intervention) regarding symptom documentation and antibiotic use. Secondary objectives included assessing changes in inappropriate prescribing and urine culture orders.

METHODS

Preintervention outcomes were measured from August 1, 2018, through November 30, 2018, while the postintervention cohort included patients admitted after January 31, 2019 and discharged before June 1, 2019. Adults admitted to psychiatry with a urinalysis ordered in the emergency department and an ICD-10 code representing dementia, delirium, autism spectrum disorder, or intellectual disability were included; pregnant patients were excluded.

RESULTS

The preintervention (n = 56) and postintervention (n = 34) cohorts were well balanced with an average age of 66.5 and 70 years, respectively. Neurocognitive disorder was the diagnosis for inclusion in approximately two-thirds of both groups. Numerically, postalgorithm implementation, symptoms were documented more frequently (20.6% vs 10.7%, P = .23) and antibiotics used less often (2.9% vs 14.3%, P = .15). Inappropriate prescribing occurred in 12.5% of preintervention cohort compared to no patients postintervention (P = .04).

DISCUSSION

The creation and implementation of an algorithm assisting in the diagnosis and treatment of urinary tract infections in noncommunicative patients was associated with a trend toward increased symptom documentation and decreased overall antibiotic use, and significantly increased appropriate antibiotic prescribing.

Creation and implementation of a urinary tract infection diagnostic and treatment algorithm for psychiatric inpatients with a communication barrier

Background

Urinary tract infection (UTI) is considered a common cause of mental status changes, particularly in elderly patients and patients with a psychiatric condition. Genitourinary symptoms are essential to confirm UTI diagnosis but may be unobtainable in patients with a communication barrier. Sparse guidance suggests assessing specific symptoms that do not rely on patient report. The primary objective of this project was to provide assistance in diagnosis and treatment of UTIs in noncommunicative patients through the creation of an algorithm.

Algorithm Creation and Implementation

Through extensive interdisciplinary collaboration, the authors developed criteria to identify UTI symptoms that do not require communication. In order to make the algorithm comprehensive, we chose to include general information related to UTI diagnosis and treatment. The algorithm was implemented within the psychiatric emergency department as this is where patients are evaluated to determine need for psychiatric admission. Providers in the psychiatric emergency department were provided with detailed education on the algorithm as well as information about UTI diagnosis and treatment.

Discussion

Creating an algorithm within our institution required significant interdisciplinary collaboration. Providers were receptive to and appreciative of a comprehensive resource to assist in this difficult clinical situation. The authors plan to study the effects of algorithm implementation, specifically assessing changes in symptom documentation and antibiotic use.

Function and Caregiver Support Associated With Readmissions During Home Health for Individuals With Dementia

OBJECTIVE

The purpose of this study was to determine the association between mobility, self-care, cognition, and caregiver support and 30-day potentially preventable readmissions (PPR) for individuals with dementia.

DESIGN

This retrospective study derived data from 100% national Centers for Medicare and Medicaid Services data files from July 1, 2013, through June 1, 2015.

PARTICIPANTS

Criteria from the Home Health Claims-Based Rehospitalization Measure and the Potentially Preventable 30-Day Post Discharge Readmission Measure for the Home Health Quality Reporting Program were used to identify a cohort of 118,171 Medicare beneficiaries.

MAIN OUTCOME MEASURE

The 30-day PPR rates with associated 95% CIs were calculated for each patient characteristic. Multilevel logistic regression was used to study the relationship between mobility, self-care, caregiver support, and cognition domains and 30-day PPR during home health, adjusting for patient demographics and clinical characteristics.

RESULTS

The overall rate of 30-day PPR was 7.6%. In the fully adjusted models, patients who were most dependent in mobility (odds ratio [OR], 1.59; 95% CI, 1.47-1.71) and self-care (OR, 1.73; 95% CI, 1.61-1.87) had higher odds for 30-day PPR. Patients with unmet caregiving needs had 1.11 (95% CI, 1.05-1.17) higher odds for 30-day PPR than patients whose caregiving needs were met. Patients with cognitive impairment had 1.23 (95% CI, 1.16-1.30) higher odds of readmission than those with minimal to no cognitive impairment.

CONCLUSIONS

Decreased independence in mobility and self-care tasks, unmet caregiver needs, and impaired cognitive processing at admission to home health are associated with risk of 30-day PPR during home health for individuals with dementia. Our findings indicate that deficits in mobility and self-care tasks have the greatest effect on the risk for PPR.

Multiplex PCR Based Urinary Tract Infection (UTI) Analysis Compared to Traditional Urine Culture in Identifying Significant Pathogens in Symptomatic Patients

OBJECTIVE

To evaluate whether multiplex PCR-based molecular testing is noninferior to urine culture for detection of bacterial infections in symptomatic patients.

METHODS

Retrospective record review of 582 consecutive elderly patients presenting with symptoms of lower urinary tract infection (UTI) was conducted. All patients had traditional urine cultures and PCR molecular testing run in parallel.

RESULTS

A total of 582 patients (mean age 77; range 60-95) with symptoms of lower UTI had both urine cultures and diagnostic PCR between March and July 2018. PCR detected uropathogens in 326 patients (56%, 326/582), while urine culture detected pathogens in 217 patients (37%, 217/582). PCR and culture agreed in 74% of cases (431/582): both were positive in 34% of cases (196/582) and both were negative in 40% of cases (235/582). However, PCR and culture disagreed in 26% of cases (151/582): PCR was positive while culture was negative in 22% of cases (130/582), and culture was positive while PCR was negative in 4% of cases (21/582). Polymicrobial infections were reported in 175 patients (30%, 175/582), with PCR reporting 166 and culture reporting 39. Further, polymicrobial infections were identified in 67 patients (12%, 67/582) in which culture results were negative. Agreement between PCR and urine culture for positive cultures was 90%, exceeding the noninferiority threshold of 85% (95% conflict of interest 85.7%-93.6%).

CONCLUSION

Multiplex PCR is noninferior to urine culture for detection and identification of bacteria. Further investigation may show that the accuracy and speed of PCR to diagnose UTI can significantly improve patient outcomes.

Treatment outcomes in patients with pyogenic vertebral osteomyelitis who have cirrhosis

Early diagnosis and proper treatment of pyogenic vertebral osteomyelitis (PVO) in patients with cirrhosis is challenging to clinicians, and the mortality rate is expected to be high. A retrospective study was conducted to investigate the treatment outcome in PVO patients with cirrhosis and to identify the predictors of their mortality. Mortality was divided into two categories, 30-day and 90-day mortality. A stepwise multivariate logistic regression model was used to identify predictors of mortality. Eighty-five patients were identified after initial exclusion. The patients’ mean age was 60.5 years, and 50 patients were male. The early mortality rates within 30 and 90 days were 17.6% and 36.5%, respectively. Multivariate analysis revealed that increased age, CTP class C, and bacteremia at the time of PVO diagnosis were predictors of 30-day mortality, while higher MELD score, presence of combined infection, and multiple spinal lesions were predictors of 90-day mortality. Attention should be paid to the high mortality between 30 and 90 days after PVO diagnosis (18.8%), which was higher than the 30-day mortality. Liver function was consistently a strong predictor of mortality in PVO patients with cirrhosis. The high-risk patients should be targeted for an aggressive diagnostic approach, using spinal MRI and intensive monitoring and treatment strategies.

Diagnosis of urinary tract infection in older persons in the emergency department: To pee or not to pee, that is the question

Doreen is a 79-year-old woman referred by her general practitioner to the ED for intravenous antibiotics for a urinary tract infection (UTI). She lives in a residential aged care facility (RACF) and staff report malodourous and cloudy urine. She denies dysuria or frequency. On examination Doreen is frail with vital signs of: temperature 37.7°C, pulse 87 bpm, blood pressure 130/70; there is no suprapubic or flank tenderness. Do you perform a dipstick test on Doreen’s urine for a suspected UTI?

Possible role of L-form switching in recurrent urinary tract infection

Recurrent urinary tract infection (rUTI) is a major medical problem, especially in the elderly and infirm, but the nature of the reservoir of organisms responsible for survival and recolonisation after antibiotic treatment in humans is unclear. Here, we demonstrate the presence of cell-wall deficient (L-form) bacteria in fresh urine from 29 out of 30 older patients with rUTI. In urine, E. coli strains from patient samples readily transition from the walled state to L-form during challenge with a cell wall targeting antibiotic. Following antibiotic withdrawal, they then efficiently transition back to the walled state. E. coli switches between walled and L-form states in a zebrafish larva infection model. The results suggest that L-form switching is a physiologically relevant phenomenon that may contribute to the recurrence of infection in older patients with rUTI, and potentially other infections.

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool

Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.

Evaluation of methenamine for urinary tract infection prevention in older adults: a review of the evidence

Urinary tract infections (UTI) commonly occur in older adults and can lead to more severe, life-threatening infections. Physiological factors that change with age are thought to contribute to the increased frequency of UTI recurrence in older adults. Unfortunately, there are limited methods to prevent UTI in older adults, and utilization of antimicrobial agents for prevention can have many negative consequences. Methenamine has been proposed as a useful drug for the prevention of UTI as it works as a urinary antiseptic, safely producing formaldehyde to prevent bacterial growth while avoiding bacterial resistance. The objective of this review is to evaluate the existing literature and discuss the use of methenamine in older adults for prevention of UTI. A PubMed search was conducted to identify studies evaluating the effectiveness of methenamine to prevent UTI in older adults, and 10 publications were selected based on relevant criteria. Based on the literature, methenamine appears to be a safe and effective option to prevent UTI in older adults with recurrent UTI, genitourinary surgical procedures, and potentially long-term catheterization. Studies have not evaluated the safety of methenamine in patients with impaired renal function or CrCl <30 ml/min. When selecting a treatment approach to preventing UTI in older adults with adequate renal function, clinicians may consider methenamine as a viable option.

National trends in the treatment of urinary tract infections among Veterans' Affairs Community Living Center residents

OBJECTIVE

To describe urinary tract infection (UTI) treatment among Veterans' Affairs (VA) Community Living Centers (CLCs) nationally and to assess related trends in antibiotic use.

DESIGN

Descriptive study.

SETTING AND PARTICIPANTS

All UTI episodes treated from 2013 through 2017 among residents in 110 VA CLCs. UTI episodes required collection of a urine culture, antibiotic treatment, and a UTI diagnosis code. UTI episodes were stratified into culture-positive and culture-negative episodes.

METHODS

Frequency and rate of antibiotic use were assessed for all UTI episodes overall and were stratified by culture-positive and culture-negative episodes. Joinpoint software was used for regression analyses of trends over time.

RESULTS

We identified 28,247 UTI episodes in 14,983 Veterans. The average age of Veterans was 75.7 years, and 95.9% were male. Approximately half of UTI episodes (45.7%) were culture positive and 25.7% were culture negative. Escherichia coli was recovered in 34.1% of culture-positive UTI episodes, followed by Proteus mirabilis and Klebsiella spp, which were recovered in 24.5% and 17.4% of culture-positive UTI episodes, respectively. The rate of total antibiotic use in days of therapy (DOT) per 1,000 bed days decreased by 10.1% per year (95% CI, -13.6% to -6.5%) and fluoroquinolone use (ciprofloxacin or levofloxacin) decreased by 14.5% per year (95% CI, -20.6% to -7.8%) among UTI episodes overall. Similar reductions in rates of total antibiotic use and fluoroquinolone use were observed among culture-positive UTI episodes and among culture-negative UTI episodes.

CONCLUSION

Over a 5-year period, antibiotic use for UTIs significantly decreased among VA CLCs, as did use of fluoroquinolones. Antibiotic stewardship efforts across VA CLCs should be applauded, and these efforts should continue.

Comparison of eVisit Management of Urinary Symptoms and Urinary Tract Infections with Standard Care

Background: Urinary symptoms and urinary tract infections (UTIs) are common complaints for which women seek health care. Evolving modalities of care delivery have shifted management of these complaints from in-person face-to-face (F2F) visits, to nurse phone protocol management, and recently to online assessment via eVisit. While research has vetted the use of nurse phone protocol management, eVisit management outcomes have not been thoroughly studied. Purpose: To compare antibiotic prescribing, follow-up rates, and clinical outcomes between F2F visits at a retail clinic, nurse phone protocol encounters, and eVisits for the assessment and management of urinary symptoms and UTIs. Methods: A retrospective chart review of primary care empaneled patients at Mayo Clinic Rochester was conducted of females, 18 to 65 years old, who sought care for urinary symptoms via phone, eVisit, or F2F visit from August 1, 2016, through May 1, 2017. A total of 450 encounters, 150 from each of the 3 encounter types, were manually reviewed and compared for antibiotic prescribing rates, clinical outcomes, and 30-day follow-up rates. Results: Antibiotic prescribing rates for all three encounter types were similar. Referral for follow-up at initial encounter was more likely to be recommended from phone and eVisit encounters than F2F. No significant differences in follow-up rates or clinical outcomes were noted between the three encounter types. Conclusions: eVisits for urinary symptoms and UTI offer patients a convenient option for care without an increased use of antimicrobials, follow-up, or adverse clinical outcomes when compared with F2F visits or nurse-administered phone protocols.

Elevated urine IL-10 concentrations associate with Escherichia coli persistence in older patients susceptible to recurrent urinary tract infections

Background

Age is a significant risk factor for recurrent urinary tract (rUTI) infections, but the clinical picture is often confused in older patients who also present with asymptomatic bacteriuria (ASB). Yet, how bacteriuria establishes in such patients and the factors underpinning and/or driving symptomatic UTI episodes are still not understood. To explore this further a pilot study was completed in which 30 male and female community based older patients (mean age 75y) presenting clinically with ASB / rUTIs and 15 control volunteers (72y) were recruited and monitored for up to 6 months. During this period symptomatic UTI episodes were recorded and urines collected for urinary cytokine and uropathogenic Escherichia coli (UPEC) analyses.

Results

Eighty-six per cent of patients carried E. coli (10² ≥ 10⁵ CFU/ml urine) at some point throughout the study and molecular typing identified 26 different E. coli strains in total. Analyses of urine samples for ten different cytokines identified substantial patient variability. However, when examined longitudinally the pro-inflammatory markers, IL-1 and IL-8, and the anti-inflammatory markers, IL-5 and IL-10, were significantly different in the patient urines compared to those of the controls (P < 0.0001). Furthermore, analysing the cytokine data of the rUTI susceptible cohort in relation to E. coli carriage, showed the mean IL-10 concentration to be significantly elevated (P = 0.04), in patients displaying E. coli numbers ≥10⁵ CFU/ml.

Conclusions

These pilot study data suggest that bacteriuria, characteristic of older rUTI patients, is associated with an immune homeostasis in the urinary tract involving the synthesis and activities of the pro and anti-inflammatory cytokines IL-1, IL-5, IL-8 and IL-10. Data also suggests a role for IL-10 in regulating bacterial persistence.