Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults

Sitafloxacin has a potent activity for eradication of extended spectrum β-lactamase-producing fluoroquinolone-resistant Escherichia coli forming intracellular bacterial communities in uroepithelial cells

INTRODUCTION

Eradication of asymptomatic bacteriuria (ASB) before urological procedures is important to reduce the risk for infectious complications after surgery. However, the appropriate regimen for antimicrobial treatment has not been fully determined. We experienced continuous (over 10 months) isolation of extended spectrum β-lactamase (ESBL)-producing fluoroquinolone-resistant Escherichia coli from urine of an asymptomatic patient. The four isolates obtained (SMESC1 to 4) were international high-risk clones of O25b:H4-ST131-H30R, and originated from one strain, as revealed by the whole genome sequences. Although the patient received meropenem (MEPM) and fosfomycin (FOM), to which the strains were susceptible before the urological procedures, they could not be eradicated.

METHODS

To explore the reason for the continuous isolation even after MEPM and FOM administration, antimicrobial killing of adherent and/or intracellular bacterial communities (IBC) formed by coculture of the E. coli cells and T24 bladder epithelial cells were examined.

RESULTS

FOM and levofloxacin did not decrease viable E. coli cells compared with gentamicin. MEPM partly decreased them, and sitafloxacin (STFX) decreased them most potently. These observations indicate that E. coli can survive in the urinary tract under antimicrobial administration, and some antimicrobials such as FOM and MEPM cannot eradicate E. coli in uroepithelial cells. Adhesion on urinary epithelial cells and/or IBC formation might result in continuous isolation from the urinary tract and recurrence of ASB and urinary tract infections.

CONCLUSIONS

The present study suggests that STFX is a promising optional agent for the eradication of ESBL-producing fluoroquinolone-resistant E. coli in the urinary tract before urological procedures.

How Testing Drives Treatment in Asymptomatic Patients: Level of Pyuria Directly Predicts Probability of Antimicrobial Prescribing

BACKGROUND

Urinalysis is a readily available test often used for screening. Pyuria is a common finding in asymptomatic patients; however, it is unknown how often identification of pyuria in the absence of confirmatory cultures leads to antimicrobial prescribing. The objective of this study was to measure the association between pyuria and antimicrobial initiation during the perioperative period and assess harms versus benefits of treatment.

METHODS

A retrospective cohort of preoperative patients within the national healthcare system during the period 1 October 2008-30 September 2013 who had a urinalysis performed during the 30-day preoperative period was created; patients with positive urine cultures were excluded. The primary exposure was pyuria on preoperative urinalysis. The primary outcome was antimicrobial initiation. Secondary outcomes included postoperative surgical site (SSI), urinary tract (UTI), and Clostridioides difficile infections. Trend and logistic regression analyses were performed.

RESULTS

Among 41 373 patients, 3617 had pyuria. 887 (24.5%) patients with pyuria received antimicrobials versus 1918 (5.1%) patients without pyuria. As the degree of pyuria increased, the odds of receiving antimicrobials also increased linearly (low, 14.7%; moderate, 24.0%; high pyuria, 37.4%). Preoperative pyuria was associated with postoperative C. difficile infections (aOR, 1.7; 95% CI, 1.2-2.4); risk was higher in patients who received antimicrobials (aOR, 2.4; 1.7-3.4). Pyuria was not associated with SSI but was associated with increases in UTI after orthopedic and vascular procedures; this risk was not mitigated by antimicrobial therapy.

CONCLUSIONS

Urine screening during the preoperative period is a low-value intervention that increases antimicrobial exposure but does not improve postoperative outcomes.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Antimicrobial resistance and recurrent bacterial urinary tract infections in hospitalized patients following kidney transplantation: A single-center experience

PURPOSE

The burden of urinary tract infections (UTIs) and risk factors for developing infections with multidrug resistant organisms (MDROs) post-kidney transplantation (KT) are poorly understood.

METHODS

Single-center retrospective cohort study (January 2015-December 2017) evaluating first and recurrent episodes of bacteriuria and subsequent analysis of episodes caused by MDROs up to 6 months post-KT. Donor and recipient variables were reviewed.

RESULTS

A total of 743 adults underwent single KT during the study period, and 106 patients were hospitalized with bacteriuria. 45% were asymptomatic in their first episode. 73.6% had a single episode, and 26.4% had 2 or more episodes. A total of 28 patients had recurrent episodes; 64.3% had an MDRO on the first episode and 78.6% on the second episode. Escherichia coli was the most common organism isolated, 88.5% were resistant to trimethoprim-sulfamethoxazole (TMP-SMX), 9.3% were extended-spectrum beta-lactamase (ESBL) producers, and 38.1% were MDROs. Body mass index ≥30 was significantly associated with the presence of MDROs in both univariate and multivariate analyses (RR 1.37, 95% CI 1.01-1.88; OR 3.26, CI 1.29-8.25). A total of 12 donors had bacteremia or bacteriuria and 6 (50%) with E coli. A total of 10 KT recipients received antibiotic prophylaxis to prevent donor-derived infections.

CONCLUSIONS

Our results suggest that a significant proportion of patients develop recurrent bacteriuria post-transplantation; of those, more than half caused by MDROs. There is a possible association between obesity and MDROs in KT recipients that merits further investigation. With the global crisis in antimicrobial resistance, innovative strategies are needed to prevent and treat UTIs in KT patients.

Multi-drug resistant and extended-spectrum β-lactamases producing bacterial uropathogens among pregnant women in Northwest Ethiopia

INTRODUCTION

Above 80% of urinary tract infections are caused by enteric bacteria, which are known for years by their drug-resistant ability. Though the prevalence of drug-resistant strains is increasing in the world, it is not well known in low-income countries. The aim of this study was to assess the prevalence of Multi-drug resistance, Extended-spectrum β-lactamases production, and associated risk factors among pregnant women in Northwest Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted among pregnant women from March to May 2017. A total of 384 clean-catch midstream urine sample was collected from study participants. Bacterial identification and drug susceptibility testing were done following standard microbiological techniques; Extended-spectrum β-lactamase production was screened using a disc diffusion test and confirmed by a combination disc test. The data were entered and analyzed by using SPSS version 20, and a p-value of less than 0.05 was considered as statistically significant.

RESULT

The overall prevalence of urinary tract infection was 15.9% (95% CI 12.8-20.1%). E. coli (49.2%), CoNS (27.9%), and S. aureus (18%) were the main uropathogens. The prevalence of MDR uropathogens was 60.65%. The prevalence of ESBLs production among cases caused by Enterobacteriaceae was 18.2%. The drug resistance rate of Gram-negative isolates was higher for ampicillin (90.9%), cephalothin (84.8%), and augmentin (57.6%). The drug nitrofurantoin showed the highest activity (100%) against Gram-negative isolates. Gram-positive isolates were showed low susceptibility to penicillin (89.3%) and cotrimoxazole (75%); however highest susceptibility rate for gentamicin (100%), amikacin (100%), and nitrofurantoin (98.36%) was recorded. Prior antibiotic therapy (AOR = 5.46, 95% CI 1.38-21.65) was a risk factor for the presence of multi-drug resistant bacteria.

CONCLUSION AND RECOMMENDATION

The multi-drug resistance prevalence was high among uropathogen, thus treatment of urinary tract infection during pregnancy; should be based on the antibacterial susceptibility testing result. The isolation of drug-resistant strains like Extended-spectrum β-lactamases in this study calls for the need of periodic and continuous follow-up of antibiotic usage among pregnant women. Nitrofurantoin, gentamicin, amikacin, and ciprofloxacin/norfloxacin showed higher activity against bacterial uropathogen.

Leucocytosis and Asymptomatic Urinary Tract Infections in Sickle Cell Patients at a Tertiary Hospital in Zambia

Sickle cell anaemia (SCA) is an inherited disease resulting from mutations in the β-globin chain of adult haemoglobin that results in the formation of homozygous sickle haemoglobin. It is associated with several complications including an altered blood picture and damage in multiple organs, including the kidneys. Kidney disease is seen in most patients with SCA and may affect glomerular and/or tubular function, thereby putting these patients at risk of urinary tract infections. However, there is a paucity of data on the prevalence of urinary tract infections (UTIs) among SCA patients in Zambia. This study aimed to determine the prevalence of UTIs and haematological and kidney function profiles among SCA patients at the University Teaching Hospitals, Lusaka, Zambia. This was a cross-sectional study conducted between April and July 2019 involving 78 SCA patients who presented at the UTH. Blood and midstream urine samples were collected from each participant using the standard specimen collection procedures. Full blood counts and kidney function tests were determined using Sysmex XT-4000i haematology analyser and the Pentra C200 by Horiba, respectively. Bacterial profiles of the urine samples were determined using conventional microbiological methods. We found that all the measured patients' haemoglobin (Hb) levels fell below the WHO-recommended reference range with a minimum of 5 g/dl, a maximum of 10.5 g/dl, and a mean of 8 ± 1 g/dl. Fifty percent of the participants had moderate anaemia, while the other 50% had severe anaemia. The minimum WBC count of the participants was 0.02 × 10⁹/L with a maximum of 23.36 × 10⁹/L and a mean of 13.48 ± 3.87 × 10⁹/L. Using the one-way analysis of variance test, we found no significant difference in mean WBC count and Hb concentration across various age-group categories that we defined. Bacteriuria was found in 25% of participants. The most common bacterial isolates were Staphylococcus aureus (32%) and coagulase-negative Staphylococci (32%). Klebsiella pneumoniae was 16%. We found no significant association between bacterial isolates and white blood cell count, age groups, sex, and anaemia severity p = 0.41. None of the participants were diagnosed with kidney disease. There was a high prevalence of asymptomatic UTIs among SCA patients at UTH, which, when coupled with the marked leukocytosis and anaemia, may negatively impact the clinical outcome of the patients. Therefore, we recommend close monitoring of sickle cell patients in Zambia for such conditions to improve patients' outcomes.

Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement

IMPORTANCE

The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood.

OBJECTIVE

To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults.

DESIGN

Retrospective analysis of overall means and clinician-level variation in performance on three new measures.

SUBJECTS

Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017.

MEASURES

Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication.

RESULTS

Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively.

CONCLUSIONS

Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

Reducing inappropriate urine cultures through a culture standardization program

BACKGROUND

The objective of this study was to evaluate the impact of a urine culture standardization program that included order indications and urinalysis (U/A) with reflexive culture. The program applied to all adult and pediatric inpatients at an academic medical center; emergency department and ambulatory clinic patients were excluded.

METHODS

The analysis compared outcomes in the pre-implementation (January 2015-May 2016) and post-implementation (July 2016-September 2017) periods. The primary outcomes were urine culture and U/A orders per 1,000 patient days, catheter-associated urinary tract infection (CAUTI) rate per 1,000 catheter days, and urine culture contamination rate per 1,000 patient days. Catheter standardized utilization ratios (SURs) were also examined.

RESULTS

The intervention was associated with a significant decrease in urine culture rates by 6.9 cultures per 1,000 patient days (95% CI -4.44, -9.44; P < .0001). The U/A testing rate per 1,000 patient days significantly increased pre-intervention, was not affected acutely by the intervention institution, and significantly decreased post-implementation. The CAUTI rate was not significantly changed by the intervention but did significantly increase post-implementation by 0.2 per 1,000 catheter days (95% CI 0.01, 0.47; P = .04); SURs significantly decreased (0.03; 95% CI -0.003, -0.05; P = .03); and the urine culture contamination rate per month showed no significant change. Sixty-four percent of urine cultures ordered using the reflexive test did not reflex to culture by U/A criteria.

CONCLUSIONS

A urine culture standardization program led to a significant reduction in urine cultures and did not lead to an increase in U/A testing rates. CAUTI rates increased post-implementation, which may have been confounded by reduced catheter utilization.

Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement

IMPORTANCE

The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood.

OBJECTIVE

To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults.

DESIGN

Retrospective analysis of overall means and clinician-level variation in performance on three new measures.

SUBJECTS

Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017.

MEASURES

Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication.

RESULTS

Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively.

CONCLUSIONS

Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

Effect of urinary tract infection on the risk of prosthetic joint infection: A systematic review and meta-analysis

PURPOSE

Urinary tract infection (UTI) are very common in the general population, however it is unclear whether UTI is a risk factor of prosthetic joint infection (PJI). Our purposes were: (1) To determine whether UTI is a risk factor of PJI after joint replacement, and (2) to determine whether the microorganisms causing PJI and UTI are the same.

METHODS

PubMed, Web of Science, the Cochrane Library, and EMBASE were searched systematically for studies. The effect sizes of RR were calculated for included studies that reported raw counts with 95% CIs. The aim 1 of the study is a meta-analysis; the aim 2 is a systematic review.

RESULTS

The aim 1 indicated that the risk of PJI was significantly higher in the UTI group than in the control group (RR = 3.17; 95% CI, 2.19-4.59). The aim 2 indicated that the microorganisms of UTI and PJI were the same in the same patient, and these included Enterococcus faecalis, and Pseudomonas, which supports the theory of PJI occurring via the haematogenous route from the genitourinary tract that harbours bacteria in UTI.

CONCLUSION

This study identified UTI as being significantly associated with PJI after joint arthroplasty and PJI occurring via the haematogenous route from the genitourinary tract harbouring bacteria in UTI. Therefore, postponing surgery and even treating patients with known UTI preoperatively are recommended.

Diagnostic uncertainty and urinary tract infection in the emergency department: a cohort study from a UK hospital

BACKGROUND

Suspected urinary tract infection (UTI) syndromes are a common reason for empirical antibiotics to be prescribed in the Emergency Department (ED), but differentiating UTI from other conditions with a similar presentation is challenging. We investigated how often an ED diagnosis of UTI is confirmed clinically/microbiologically, and described conditions which present as UTI syndromes.

METHODS

Observational study using electronic health records from patients who attended the ED with suspected UTI and had a urine sample submitted for culture. We compared the ED diagnosis to diagnosis at discharge from hospital (ICD-10 codes), and estimated the proportion of cases with clinical/microbiological evidence of UTI.

RESULTS

Two hundred eighty nine patients had an ED diagnosis of UTI syndrome comprising: lower UTI (191), pyelonephritis (56) and urosepsis (42). In patients admitted to hospital with an ED diagnosis of lower UTI, pyelonephritis or urosepsis, clinical/microbiological evidence of UTI was lacking in 61/103, 33/54 and 31/42 cases respectively. The ED diagnosis was concordant with the main reason for admission in less than 40% of patients with UTI syndromes, and antibiotics were stopped within 72 h in 37/161 patients.

CONCLUSIONS

Clinical/microbiological evidence of UTI was lacking in 60-70% of patients, suggesting scope to revise empirical prescribing decisions for UTI syndromes in light of microbial culture and clinical progression.

Antibiotics can be used to contain drug-resistant bacteria by maintaining sufficiently large sensitive populations

Standard infectious disease practice calls for aggressive drug treatment that rapidly eliminates the pathogen population before resistance can emerge. When resistance is absent, this elimination strategy can lead to complete cure. However, when resistance is already present, removing drug-sensitive cells as quickly as possible removes competitive barriers that may slow the growth of resistant cells. In contrast to the elimination strategy, a containment strategy aims to maintain the maximum tolerable number of pathogens, exploiting competitive suppression to achieve chronic control. Here, we combine in vitro experiments in computer-controlled bioreactors with mathematical modeling to investigate whether containment strategies can delay failure of antibiotic treatment regimens. To do so, we measured the "escape time" required for drug-resistant Escherichia coli populations to eclipse a threshold density maintained by adaptive antibiotic dosing. Populations containing only resistant cells rapidly escape the threshold density, but we found that matched resistant populations that also contain the maximum possible number of sensitive cells could be contained for significantly longer. The increase in escape time occurs only when the threshold density-the acceptable bacterial burden-is sufficiently high, an effect that mathematical models attribute to increased competition. The findings provide decisive experimental confirmation that maintaining the maximum number of sensitive cells can be used to contain resistance when the size of the population is sufficiently large.

Recurrent bladder cystitis: who takes the role?

PURPOSE

In this review, we discuss how the approach should be throughout the symptomatic and diagnostic process of recurrent bladder cystitis.

METHODS AND RESULTS

The available literature regarding recurrent bladder cystitis in the PubMed database has been reviewed. While urinary tract infections (UTIs) are amongst the most commonly seen diseases in society, the probability of having a UTI in women within a year is 15%. Within a lifetime, it is above 50%. In addition to the related comorbidities and decreased quality of life, the resulting cost constitutes a serious burden on national economies. Recurrent UTI (rUTI) refers to a group of patients who have suffered from a UTI at least three times in the last 12 months or at least two times during the previous 6 months and have diminished quality of life. During this chronic and bothersome process, it is also complicated as to who is going to make the diagnosis of patients and by whom treatment or follow-up will be provided.

CONCLUSION

Although there is no clear answer to this issue in the literature, the urologist might be the moderator of this chronic process as the physician who most frequently faces this condition in daily practice, is most aware of the uroanatomy as well as the pathophysiology and performs relevant operations in cases of necessity. At this point, rather than limiting the evaluation and treatment to a single specialty, it is crucial to solve the problem by using a multidisciplinary approach.

Assessment of asymptomatic bacteriuria and sterile pyuria among antenatal attendants in hospitals in northern Ghana

BACKGROUND

Asymptomatic bacteriuria (ASB) and sterile pyuria (SP) are complexities of UTI whose prevalence are not known in the northern sector of Ghana. Our aim was to determine the occurrence of sterile pyuria and asymptomatic bacteriuria among pregnant women accessing antenatal care at a secondary and tertiary care hospitals in Tamale, northern Ghana.

METHODS

A cross sectional study was conducted by screening 530 pregnant women with no signs of acute urinary tract infection attending antenatal clinic for a period of 6 months. Midstream urine was collected for microscopy, quantitative urine culture and antibiotic susceptibility testing. Data analysis was carried out using the Statistical Package for Social Sciences version 20.

RESULTS

Asymptomatic bacteriuria was respectively 20 and 35.5% at Tamale Central and Tamale Teaching Hospital out of the 390 and 90 women screened. Sterile pyuria was found among 66% of the 50 women presenting at Tamale Central Hospital. More than 64% of isolates recovered from ASB patients were S. aureus and coagulase negative Staph. (CoNS). Escherichia coli was the dominant species among members of the enterobacteriaceae isolated. Highest susceptibility was recorded against gentamicin and amikacin while most resistance was to Ampicillin, cotrimoxazole, chloramphenicol and nitrofurantoin. Resistance to imipenem and vancomycin were 28.8 and 52%, with strains showing multiple drug resistance of between 81 and 92%.

CONCLUSION

The prevalence of asymptomatic bacteriuria is appreciably higher (20-35.5%) than documented rates in the southern sector of the country. The presence of sterile pyuria which may be an indication of asymptomatic renal impairment and most often overlooked in antenatal management is 66%. Empirical treatment of UTIs at the Tamale Central and Teaching Hospital without confirmation of susceptibility may result in treatment failure. It is necessary to screen and treat pregnant women for ASB and SP due to the complications associated with these conditions.

Improving Value of Care: Cessation of Screening Urine Culture Prior to Orthopedic and Spinal Surgery

Objective

To assess the impact of cessation of screening urine cultures on surgical site infection (SSI) incidence in clinical practice.

Patients and Methods

Our study included patients undergoing hip replacement, knee replacement, spinal fusion, and laminectomy 12 months before (preintervention) and after (postintervention) cessation of preoperative screening urine cultures on June 1, 2017, at our institution. Urine cultures and urinalyses performed within 30 days before surgery during the 12 months before and after cessation were reviewed. SSI surveillance was performed in accordance with the methods of the National Healthcare Safety Network.

Results

A total of 2754 patients were included (1286 preintervention and 1468 postintervention). In the preintervention period, 1141 urine cultures were performed, compared to 153 in the postintervention period; 35 and 6 episodes of asymptomatic bacteriuria were treated, respectively. The occurrence of SSI did not differ noticeably between time periods (1.2% vs 0.7%, P=.24), and quarterly incidences of SSI were unchanged. The rate of SSI was significantly lower in the postintervention period for laminectomy (3.0% vs 0.3%, P=.02).

Conclusion

An 86.6% (153 vs 1141) reduction in screening urine cultures over a 12-month period was associated with a reduction of 988 unnecessary urine cultures, an 82.8% (6 vs 35) decline in inappropriate antibiotic treatment of asymptomatic bacteriuria, and no increase in SSI incidence after hip replacement, knee replacement, spinal fusion, or laminectomy procedures. No value of screening urine cultures before clean surgery was identified.

The Urine Microbiome of Healthy Men and Women Differs by Urine Collection Method

PURPOSE

Compared to the microbiome of other body sites, the urinary microbiome remains poorly understood. Although noninvasive voided urine specimens are convenient, contamination by urethral microbiota may confound understanding of the bladder microbiome. Herein we compared the voiding- versus catheterization-associated urine microbiome of healthy men and women.

METHODS

An asymptomatic, healthy cohort of 6 women and 14 men underwent midstream urine collection, followed by sterile catheterization of the bladder after bladder refilling. Urine samples underwent urine dipstick testing and conventional microscopy and urine cultures. Samples also underwent Illumina MiSeq-based 16S ribosomal RNA gene amplification and sequencing.

RESULTS

All organisms identified by urine culture were also identified by 16S amplification; however, next-generation sequencing (NGS) also detected bacteria not identified by cultivation. Lactobacillus and Streptococcus were the most abundant species. Abundances of the 9 predominant bacterial genera differed between the urethra and bladder. Voided and catheterized microbiomes share all dominant (>1%) genera and Operational Taxonomic Units but in similar or different proportions. Hence, urethra and bladder microbiomes do not differ in taxonomic composition, but rather in taxonomic structure. Women had higher abundance of Lactobacillus and Prevotella than men.

CONCLUSION

Our findings lend credence to the hypothesis that Lactobacilli are important members of the healthy urine microbiome. Our data also suggest that the microbiomes of the urethra and bladder differ from one another. In conclusion, urine collection method results in different 16S-based NGS data, likely due to the sensitivity of NGS methods enabling detection of urethral bacteria present in voided but not catheterized urine specimens.

Treatment of urinary tract infections in the old and fragile

INTRODUCTION

Urinary tract infection (UTI) is highly prevalent in the frail elderly population. This review aimed to outline the diagnostic, treatment, and prevention of UTI in the frail aging population.

METHODS

Pubmed and Web of Science search to identify publications until March 2019 relating to the management of UTI in the elderly population was performed. A narrative review of the available literature was performed.

RESULTS

64 publications were considered as relevant and included in this review. The diagnosis of symptomatic UTI in the old and fragile could be challenging. Routine screening and antimicrobial therapy for asymptomatic bacteriuria should not be recommended for frail elderly patients. Cautious choice of antibiotics should be guided by uropathogen identified by culture and sensitivity. Understanding local antibiotic resistance rates plays a fundamental part in selecting appropriate antimicrobial treatment. Impact of associated adverse effect, in particular those with effects on cognitive function, should be considered when deciding choice of antibiotics for symptomatic UTI in the elderlies. Optimal management of comorbidities such as diabetes mellitus, adequate treatment of urinary incontinence, and judicious use of urinary catheter is essential to reduce the development of UTI.

CONCLUSION

UTI is a significant but common problem in elderly population. Physicians who care for frail elderly patients must be aware of the challenges in the management of asymptomatic UTI, and identifying symptomatic UTI in this population, and their appropriate management strategies. There is strong need in studies to evaluate nonantimicrobial therapies in the prevention of UTI for the frail elderly population.

Effect of Empiric Treatment of Asymptomatic Bacteriuria in Neurosurgical Trauma Patients on Surgical Site and Clostridium difficile Infection

BACKGROUND

Although empiric treatment of urinary tract colonized patients remains a frequent practice in neurosurgery, the value of this practice remains debatable.

OBJECTIVE

To analyze the effect of screening and treatment of bacteriuria on surgical site infections, incidence of Clostridium difficile, and mortality in neurosurgical trauma patients.

METHODS

Database queries and direct patient chart reviews were used to gather patient chart data. T-tests, chi-square tests, binary logistic regressions, and propensity matched cohorts comparisons were performed.

RESULTS

A total of 3563 admitted neurosurgical trauma patients were identified over an 8 yr period (1524 cranial, 1778 spinal, and 261 combined craniospinal diagnoses). Nine hundred ninety-one patients underwent an operative neurosurgical procedure. Urinalysis was significantly associated with antibiotics exposure in both operative and nonoperative patients (P < .001). Operative patients treated with empiric antibiotics did not have a reduced risk of wound infection (P = .21), including in a propensity matched cohort (P = .52). Patients treated with empiric antibiotics had significantly increased rates of C. difficile infection (P < .001). At last follow-up, neurosurgical trauma patients that developed C. difficile had an increased risk of death (P < .005); antibiotic exposure and death were also significantly associated (P = .018). The association of C. difficile with empiric antibiotics remained significant in a propensity-matched cohort (P = .0024).

CONCLUSION

The routine use of urinalysis and empiric urinary antibiotics for bacteriuria in neurosurgical trauma patients without urinary symptoms increases risk of exposure to antibiotics does not decrease rates of wound infection, and is associated with increased rates of C. difficile infection and death.

Treatment of recurrent urinary tract infections in anuric hemodialysis patient, do we really need antimicrobial urinary concentration?

Providing care for patients with chronic kidney disease requires considerations that are unique to this population. Several references recommend the treating urinary tract infections with antibiotics that achieve considerable concentrations in urine however this is not applicable in anuric patients undergoing hemodialysis who are unable to excrete antibiotics significantly in urine. We report successful treatment of several episodes of urinary tract infections in hemodialysis patient highlighting the questionable need for antimicrobial urine concentration.

Host and microbial factors in kidney transplant recipients with Escherichia coli acute pyelonephritis or asymptomatic bacteriuria: a prospective study using whole-genome sequencing

BACKGROUND

Urinary tract infection is the most common infection among kidney transplant recipients (KTRs). Many transplant physicians fear that host compromise will allow low-virulence strains to cause pyelonephritis in KTRs, so they often treat asymptomatic bacteriuria with antibiotics. Identification of the host/microbe factors that determine the clinical presentation (i.e. pyelonephritis versus asymptomatic bacteriuria) once an Escherichia coli strain enters a KTRs bladder could inform management decisions.

METHODS

We prospectively collected all E. coli isolates causing either pyelonephritis or asymptomatic bacteriuria in KTRs at our institution (December 2012-June 2015). Whole-genome sequencing was used to assess bacterial characteristics (carriage of 48 virulence genes and phylogenetic and clonal background). Host parameters were also collected.

RESULTS

We analysed 72 bacteriuria episodes in 54 KTRs (53 pyelonephritis, 19 asymptomatic bacteriuria). The pyelonephritis and asymptomatic bacteriuria isolates exhibited a similar total virulence gene count per isolate [median 18 (range 5-33) and 18 (5-30), respectively; P = 0.57] and for individual virulence genes differed significantly only for the prevalence of the pap operon (pyelonephritis 39%,versus asymptomatic bacteriuria 0%; P = 0.002). No other significant between-group differences were apparent for 86 other bacterial and host variables.

CONCLUSIONS

Our findings suggest that bacterial adherence plays a role in the pathogenesis of pyelonephritis in KTRs despite significantly altered host urinary tract anatomy and weakened immunity. Whether KTRs might benefit from targeted therapies (e.g. vaccination or inhibitors of fimbrial adhesion) has yet to be studied.

Dielectrophoresis assisted rapid, selective and single cell detection of antibiotic resistant bacteria with G-FETs

The rapid increase in antibiotic resistant pathogenic bacteria has become a global threat, which besides the development of new drugs, requires rapid, cheap, scalable, and accurate diagnostics. Label free biosensors relying on electrochemical, mechanical, and mass based detection of whole bacterial cells have attempted to meet these requirements. However, the trade-off between selectivity and sensitivity of such sensors remains a key challenge. In particular, point-of-care diagnostics that are able to reduce and/or prevent unneeded antibiotic prescriptions require highly specific probes with sensitive and accurate transducers that can be miniaturized and multiplexed, and that are easy to operate and cheap. Towards achieving this goal, we present a number of advances in the use of graphene field effect transistors (G-FET) including the first use of peptide probes to electrically detect antibiotic resistant bacteria in a highly specific manner. In addition, we dramatically reduce the needed concentration for detection by employing dielectrophoresis for the first time in a G-FET, allowing us to monitor changes in the Dirac point due to individual bacterial cells. Specifically, we realized rapid binding of bacterial cells to a G-FET by electrical field guiding to the device to realize an overall 3 orders of magnitude decrease in cell-concentration enabling a single-cell detection limit, and 9-fold reduction in needed time to 5 min. Utilizing our new biosensor and procedures, we demonstrate the first selective, electrical detection of the pathogenic bacterial species Staphylococcus aureus and antibiotic resistant Acinetobacter baumannii on a single platform.

Differentiating Asymptomatic Bacteriuria From Urinary Tract Infection in the Pediatric Neurogenic Bladder Population: NGAL As a Promising Biomarker

Objective: To evaluate whether urinary antimicrobial peptides (AMPs) can discriminate between asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) in pediatric patients with neurogenic bladder (NGB). Design/Methods: Bladder urine was collected from pediatric patients (≤18 years old) with NGB without augmentation cystoplasty. Patients were divided into the following groups based on symptomatology and results of urinalysis/urine culture: (a) UTI, (b) ASB, and (c) sterile. Urine AMPs β defense 1 (BD-1), neutrophil gelatinase-associated lipocalin (NGAL), cathelicidin (LL-37), hepatocarcinoma-intestine-pancreas/pancreatitis-associated protein (HIP/PAP), and human α defensin 5 (HD-5) were compared between groups by enzyme-linked immunosorbent assays. In addition, urines from pediatric controls without NGB or UTI were also analyzed. Significance was determined using Student's t test for parametric or Mann-Whitney U test for nonparametric data. A p value of <.05 was considered significant. Results: Thirty-six patients with NGB from a spinal dysraphism were evaluated: UTI, n = 6; ASB, n = 18; sterile, n = 12. These groups did not differ significantly by age but did significantly differ by gender (p = .0139). NGAL significantly differed between UTI and ASB groups (median 38.5 ng/mg vs 15.5 ng/mg, respectively; p = .0197) with a sensitivity and specificity of 82.4% and 83.3%, respectively. HIP/PAP, BD-1, HD-5, LL-37, and NGAL levels were all significantly higher in sterile NGB urines compared to 17 non-NGB pediatric controls (p < .0001, p = .0020, p = .0035, p = .0006, and p = .0339, respectively). Conclusion: All five urinary AMPs evaluated were significantly elevated in NGB patients compared to controls. NGAL levels may help differentiate between UTI and ASB in pediatric NGB patients.

Diagnosis of Urinary Tract Infection in the Neuropathic Bladder: Changing the Paradigm to Include the Microbiome

Bacteriuria, a non-specific term that refers to the presence of bacteria in the urine, is common in people with neuropathic bladders. However, accurately determining when bacteriuria represents a urinary tract infection (UTI) as opposed to asymptomatic bacteriuria is difficult. There is currently no widely accepted definition of what constitutes a UTI in people with neuropathic bladders. As a result, there is significant variation in care, which likely leads to unnecessary use of antibiotics for bacteriuria. To improve the clinical management of people with neuropathic bladders, it is important to be able to accurately diagnose and treat UTIs. In this article, we review the difficulties associated with accurately diagnosing UTIs and then review proposed definitions. Finally, we discuss the emerging literature of the urinary microbiome and how this may assist in accurately diagnosing UTIs in people with neuropathic bladders.

Impact of a pharmacist-driven education initiative on treatment of asymptomatic bacteriuria

PURPOSE

The results and methods of a pharmacist-driven multifaceted educational intervention on the appropriate management of asymptomatic bacteriuria (ABU) within an emergency department (ED) are reported.

METHODS

A retrospective, single-center cohort study was conducted to evaluate the effects of an educational intervention aimed at reducing the rates of mismanaged ABU within an ED at a Level 1 trauma center. The education involved a multifaceted approach directed by pharmacists and involved a handout and algorithm communicated through in-person discussions, emails, and general distribution. In order to evaluate the effectiveness of this education the preintervention and postintervention rates of inappropriate treatments were determined through a retrospective chart review. The primary outcome was the difference in the frequency of inappropriately treated ABU between the preintervention and postintervention periods.

RESULTS

A total of 268 patients were included in the study for review (134 in each group). There was a 16.5% reduction in the frequency of patients that had ABU inappropriately treated as a urinary tract infection in the postintervention period compared with the preintervention period (31 [23.1%] versus 53 [39.6%], p = 0.004).

CONCLUSION

Pharmacist-driven education was effecitive in reducing the rates of inappropriately used antibiotics for ABU within an ED.

Characteristics associated with bacterial growth in urine in 451 proteinuric dogs (2008-2018)

Background

Urine cultures are frequently recommended to rule out infection as a postrenal cause of proteinuria.

Objective

Identify characteristics associated with bacterial growth in urine in proteinuric dogs.

Animals

Four hundred and fifty‐one dogs admitted to a teaching hospital between January 2008 and January 2018 with urine protein‐to‐creatinine ratios (UPCs) >0.5.

Methods

Retrospective study included dogs with a UPC, urinalysis, and quantitative urine culture (QUC) performed within a 72‐hour period by searching electronic records. Dogs with recent antimicrobial therapy, urine collected by methods other than cystocentesis, or UPC ≤0.5 were excluded. Signalment, comorbidities, serum BUN and creatinine concentrations, urinalysis findings, and QUC results were recorded. The association between these characteristics and presence of bacterial growth in urine was assessed by univariable and multivariable analysis.

Results

Thirty of four hundred fifty‐one dogs (6.7%) had bacterial growth in urine. Of these, 18 (60.0%) had active urine sediment. Bacterial growth in urine was associated with pyuria (odd ratio [OR] 25.1, 95% confidence interval [CI] 7.9‐79.6, P < .001), bacteriuria (OR 11.1, 95% CI 3.2‐39.1, P < .001), and lower urinary tract disease (OR 6.7, 95% CI 1.9‐23.0; P = .0028). If QUC was prompted based on these criteria, 8/451 (1.8%) of proteinuric dogs would have had undetected bacterial growth.

Conclusions and Clinical Importance

The proportion of proteinuric dogs with both inactive urine sediment and bacterial growth in urine was low, suggesting that QUC might not be necessary in the evaluation of all proteinuric dogs. An active urine sediment or lower urinary tract disease should prompt QUC for proteinuric dogs.

Epidemiology of urological infections: a global burden

INTRODUCTION

Urinary tract infections (UTIs) are among the most frequent infections in clinical practice worldwide. Their frequency and burden must be higher than available data suggest because they are not among mandatory diseases to be notified.

CLASSIFICATION OF URINARY INFECTIONS

Although there are many different proposals for classifying UTIs, classifications based on acquisition settings and complication status are more widely used. These include community- acquired UTIs (CAUTIs) or healthcare-associated UTIs (HAUTIs) and uncomplicated or complicated UTIs.

EPIDEMIOLOGY OF UROLOGICAL INFECTIONS AND GLOBAL BURDEN

As the most frequently seen infectious disease, CAUTIs affect more than 150 million people annually. Complicated UTIs in particular constitute a huge burden on healthcare systems as a frequent reason for hospitalization. The prevalence of HAUTIs ranges between 1.4% and 5.1%, and the majority of them are catheter-related UTIs. Community-onset HAUTIs have gained importance in recent years.

CONCLUSION

As frequent infectious diseases, UTIs create clinical and economic burdens on healthcare systems, and they also affect quality of life determinants.

Risk factors for third-generation cephalosporin resistant Enterobacteriaceae in gestational urine cultures: A retrospective cohort study based on centralized electronic health records

Third-generation-cephalosporin resistant Enterobacteriaceae (3GCR-EB) carriage in pregnant women poses challenges for infection control and therapeutic decisions. The factors associated with multidrug resistant Enterobacteriaceae carriage in the gestational period are not well documented. The aim of our study was to identify risk factors associated with 3GCR-EB isolation in gestational urine cultures. The study was designed as retrospective cohort based on centralized electronic health records database. Women delivered in Clalit Health Services hospitals in Israel in 2009–2013 and provided urine culture(s) during pregnancy were included. Multivariable analysis using the Generalized Estimating Equations model was used to assess risk factors for 3GCR-EB isolation in gestational urine cultures. The study included 15,282 pregnant women with urine cultures yielding Enterobacteriaceae (EB). The proportion of 3GCR-EB in EB isolates was 3.9% (n = 603). The following risk factors were associated with 3GCR-EB isolation: multiple hospital admissions during the year before delivery (OR,1.47;95% CI,1.21–1.79), assisted fertilization procedure (OR,1.53; 95% CI,1.12–2.10), Arab ethnicity (OR,1.22; 95% CI,1.03–1.45), multiple antibiotic courses (OR,1.76; 95% CI,1.29–2.40), specifically, cephalosporins (OR,1.56; 95% CI,1.26–1.95), fluoroquinolones (OR,1.34; 95% CI,1.04–1.74), or nitrofurantoin (OR,1.29; 95% CI,1.02–1.64). The risk factors identified by this study for 3GCR-EB in gestation, can be easily generalized for pregnant women in the Israeli population. Moreover, these risk factors, other than ethnicity, are applicable to pregnant women worldwide. The information of previous antibiotic treatments, hospitalization in the last year and assisted fertilization procedure can be easily accessed and used for appropriate infection control practices and antimicrobial therapy.

The Role of Gram-Negative Bacteria in Urinary Tract Infections: Current Concepts and Therapeutic Options

Urinary tract infections (UTIs) are some of the most common infections in human medicine worldwide, recognized as an important public health concern to healthcare systems around the globe. In addition, urine specimens are one of the most frequently submitted samples for culture to the clinical microbiology laboratory, exceeding the number of most of the other sample types. The epidemiology, species-distribution and susceptibility-patterns of uropathogens vary greatly in a geographical and time-dependent manner and it also strongly correlated with the reported patient population studied. Nevertheless, many studies highlight the fact that the etiological agents in UTIs have changed considerably, both in nosocomial and community settings, with a shift towards "less common" microorganisms having more pronounced roles. There is increasing demand for further research to advance diagnostics and treatment options, and to improve care of the patients. The aim of this review paper was to summarize current developments in the global burden of UTI, the diagnostic aspects of these infectious pathologies, the possible etiological agents and their virulence determinants (with a special focus on the members of the Enterobacterales order), current guidelines and quality indicators in the therapy of UTIs and the emergence of multidrug resistance in urinary pathogens.

Controversies in Treating Asymptomatic Bacteriuria and Urinary Tract Infection: A Case Based Review of Antibiotic Use in Renal Transplant Patients and its Impact on the Development of Resistance

There is excessive use of both broad spectrum and niched antibiotics for urinary tract infections (UTIs) in hospital and ambulatory setting in spite of clear guidelines on appropriate use. Majority of antibiotics prescribed in United States for UTIs are for nonspecific indications such as positive urine cultures in the absence of symptoms, etc. For these conditions especially asymptomatic bacteriuria, a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Asymptomatic bacteriuria (ASB) is a common finding in healthy women and persons with underlying urological abnormalities. Guidelines from Infectious Diseases Society of America (IDSA) clearly define the use of antibiotics in ASB only in pregnant patients and in individuals prior to undergoing invasive urological procedures. IDSA updated the guidelines in 2019 on the use of antibiotics for UTI in special groups such as patients with neutropenia, solid organ transplants, and non-urologic surgery. Considering the implications of antibiotic resistance in the setting of indiscriminate use, there is definitely a need to improve their use in asymptomatic bacteriuria as well as in UTIs. In this review, we follow case-based approach to identify the barriers to appropriate antibiotic prescribing practices in renal transplant recipients.

The State of the Science of Preterm Birth: Assessing Contemporary Screening and Preventive Strategies

Preterm birth remains a leading cause of morbidity and mortality during the perinatal and neonatal periods. Now affecting approximately 1 in 10 births in the United States, preterm birth often occurs spontaneously and without a clear etiology. Careful assessment of risk factors, however, identifies vulnerable women allowing targeted interventions such as progestogen therapy and cerclage. This article is intended to highlight preterm birth risk factors and current predictive and preventive strategies for midwives, nurse practitioners, clinical nurse specialists, and perinatal nurses.

Effects of electroacupuncture on patients with chronic urinary retention caused by a lower motor neuron lesion: An exploratory pilot study

Chronic urinary retention (CUR) is defined as a non-painful bladder that remains palpable or percussible after the patient has passed urine. Acupuncture may decrease PVR and improve bladder function in patients with neurogenic CUR. The aim of this study was to preliminarily observe the effectiveness of electroacupuncture (EA) for patients with CUR caused by a lower motor neuron lesion and to provide some therapeutic data for further study.This study was a pilot study of 30 patients with CUR caused by a lower motor neuron lesion. Patients were treated with EA for 12 weeks with 36 sessions of EA.Responders were defined as participants with a decline in postvoid residual urine (PVR) volume after spontaneous urination of ≥50% from baseline. The proportion of responders, change in PVR volume from baseline after spontaneous urination, and the proportion of patients with severe difficulty with urination, who required assistance with bladder emptying and with stool retention, were measured at weeks 4, 8, and 12.Thirty patients were included in this study, and 23 completed 12 weeks of treatment. The proportion of responders at weeks 4, 8, and 12 was 6.67%, 28%, and 43.48%, respectively. Decrease in PVR volume, compared with baseline, was significant at all asessment timepoints. The proportion of patients with severe difficulty with urination, who required assistance with bladder emptying and with stool retention, decreased after treatment.EA is a potential treatment for improving bladder function in patients with CUR caused by a lower motor neuron lesion.

Urinary tract infections in pregnancy in a rural population of Bangladesh: population-based prevalence, risk factors, etiology, and antibiotic resistance

BACKGROUND

Urinary tract infection (UTI) in pregnancy, including asymptomatic bacteriuria, is associated with maternal morbidity and adverse pregnancy outcomes, including preterm birth and low birthweight. In low-middle income countries (LMICs), the capacity for screening and treatment of UTIs is limited. The objective of this study was to describe the population-based prevalence, risk factors, etiology and antimicrobial resistance patterns of UTIs in pregnancy in Bangladesh.

METHODS

In a community-based cohort in Sylhet district, Bangladesh, urine specimens were collected at the household level in 4242 pregnant women (< 20 weeks gestation) for culture and antibiotic susceptibility testing. Basic descriptive analysis was performed, as well as logistic regression to calculate adjusted odds ratios (aOR) for UTI risk factors.

RESULTS

The prevalence of UTI was 8.9% (4.4% symptomatic UTI, 4.5% asymptomatic bacteriuria). Risk factors for UTI in this population included maternal undernutrition (mid-upper arm circumference <23 cm: aOR= 1.29, 95% CI: 1.03-1.61), primiparity (aOR= 1.45, 95% CI: 1.15-1.84), and low paternal education (no education: aOR= 1.56, 95% CI: 1.09-2.22). The predominant uro-pathogens were E. coli (38% of isolates), Klebsiella (12%), and staphyloccocal species (23%). Group B streptococcus accounted for 5.3% of uro-pathogens. Rates of antibiotic resistance were high, with only two-thirds of E. coli susceptible to 3rd generation cephalosporins.

CONCLUSIONS

In Sylhet, Bangladesh, one in 11 women had a UTI in pregnancy, and approximately half of cases were asymptomatic. There is a need for low-cost and accurate methods for UTI screening in pregnancy and efforts to address increasing rates of antibiotic resistance in LMIC.

Improved Antibiotic Prescribing within a Veterans Affairs Primary Care System through a Multifaceted Intervention Centered on Peer Comparison of Overall Antibiotic Prescribing Rates

Reducing inappropriate outpatient antibiotic use is an important national goal. Limited data exist on targeted education and peer comparison of overall antibiotic prescribing rates as an antimicrobial stewardship strategy. Primary care professionals (PCPs) from all seven clinics within our health care system were offered an education session, followed by monthly e-mails with their antibiotic prescribing rate, peer prescribing rates, and a system target. A pre-post analysis was conducted to compare prescribing rates during the intervention period (January to June 2017) to a seasonal baseline (January to June 2016) using a regression model. A random sample of prescriptions was reviewed for adherence to consensus guidelines. Educational sessions were attended by 68.5% (50/73) of PCPs. From the baseline to the intervention period, the mean rate of monthly antibiotic prescriptions declined from 76.9 to 49.5 per 1,000 office visits (35.6% reduction [P < 0.001]). Among reviewed cases, unnecessary antibiotic prescribing declined (58.8% [80/136] versus 38.9% [70/180]; 33.9% reduction [P = 0.0006]), and the rate of optimally prescribed antibiotics increased (19.9% [27/136] versus 30% [54/180]; 50.8% increase [P = 0.05]). If an antibiotic was indicated, there were no significant differences in prescribing of guideline-discordant agents (21.4% [12/56] versus 19.1% [21/110] [P = 0.8]) or guideline-concordant agents for a guideline-discordant duration (38.6% [17/44] versus 39.3% [35/89] [P = 1]). There were significant reductions in azithromycin and fluoroquinolone prescriptions (50.9% and 59.4% [P values of <0.001], respectively), but most prescriptions for these agents in the intervention period remained inappropriate. Initial education followed by monthly peer comparison of overall antibiotic prescribing rates reduced total and unnecessary antibiotic prescribing in primary care clinics.

Systematic review and meta-analysis of asymptomatic bacteriuria after renal transplantation: incidence, risk of complications, and treatment outcomes

BACKGROUND

Routine treatment for asymptomatic bacteriuria (ASB) after renal transplantation (RT) represents nowadays a controversial topic, being unknown its impact on the overall prognosis of the transplanted patient.

METHODS

Studies published during 1970-2019 that evaluated the benefit of treating ASB after RT regarding the risk of renal complications were included. The primary outcome was to assess whether the treatment is associated with a lower risk of symptomatic urinary tract infection (UTI) or an improved renal function at the end of the follow-up period. The secondary outcome was the risk of acute graft rejection (AGR). A meta-analysis with a random-effect model was performed. Heterogeneity was assessed with the I² measure.

RESULTS

Fifteen studies were included. The incidence of ASB in the first month and the first year after RT was 22% and 30%, respectively. ASB was not correlated to AGR (OR 1.18; 95% CI, 0.78-1.79). Eight studies compared the outcomes of ASB treatment, finding no benefit of treating regarding the risk of symptomatic UTI (OR 1.08; 95% CI, 0.63-1.84; I²  = 35%) or the change in renal function (mean difference in serum creatinine concentration-0.03 mg/dL,95% CI-0.15-0.10; I²  = 53%).

CONCLUSIONS

Asymptomatic bacteriuria represents a frequent finding after RT, highlighting the need for appropriate management of this condition. Considering that its treatment did not decrease the risk of the studied complications, antibiotic therapy should start to be questioned, as it has been related to higher rates of antimicrobial resistance and high economic costs.

In-hospital management of acute complicated urinary tract infections

Upper tract urinary tract infections that require hospitalization have been the focus of national recommendations in 2018 by the French society of infectious diseases (Spilf). We here propose to discuss several complex-challenging situations: severe infection with sepsis, pyelonephritis in the pregnant woman, management of infections involving multiresistant bacteria and infection in polycystic kidney disease.

Risk of infection in patients undergoing urologic surgery based on the presence of asymptomatic bacteriuria: A prospective study

BACKGROUND

Treatment of asymptomatic bacteriuria (ASB) is recommended in pregnant women and prior to urologic procedures with anticipated mucosal disruption. However, there is still insufficient evidence of the usefulness of treating ASB prior to urologic procedures. Therefore, the aim of this study was to ascertain the risk of infections in patients undergoing urologic surgery based on the presence of ASB.

METHODS

We conducted a cohort study among patients undergoing urologic surgery at a single center located in Medellín, Colombia. All patients were screened for ASB prior to their procedures. Patients were evaluated for the development of any postoperative infectious complications for up to 30 days after the procedure.

RESULTS

A total of 149 patients were included in this cohort. Incidence of ASB was 14.8%. Thirteen patients (8.72%) developed infectious complications: 3 (13.64%) with ASB and 10 (7.87%) without ABS. Factors associated with postoperative infectious complications included urologic cancers (hazard ratio [HR], 5.26; 95% confidence intervals [CI], 1.24-22.37), urologic interventions in the preceding 3 months (HR, 3.72; 95% CI, 1.02-13.51), and use of antibiotics 3 months prior to surgery (HR, 3.83; 95% CI, 1.01-15.49). Presence of ASB was not associated with postsurgical infectious complications (HR, 1.02; 95% CI, 0.26-3.96).

CONCLUSIONS

There was no association between ASB and postoperative infectious complications. There were other factors associated with infectious complications, such as urologic cancer, previous history of urologic manipulation, and antibiotic use.

Clinical Validation of Innovative Optical-Sensor-Based, Low-Cost, Rapid Diagnostic Test to Reduce Antimicrobial Resistance

The antibiotic susceptibility test determines the most effective antibiotic treatment for bacterial infection. Antimicrobial stewardship is advocated for the rational use of antibiotics to preserve their efficacy in the long term and provide empirical therapy for disease management. Therefore, rapid diagnostic tests can play a pivotal role in efficient and timely treatment. Here, we developed a novel, rapid, affordable, and portable platform for detecting uropathogens and reporting antibiogram to clinicians in just 4 h. This technology replicates the basic tenets of clinical microbiology including bacterial growth in indigenously formulated medium, and measurement of inhibition of bacterial growth in presence of antibiotic/s. Detection is based on chromogenic endpoints using optical sensors and is analyzed by a lab-developed algorithm, which reports antibiotic sensitivity to the antibiotics panel tested. To assess its diagnostic accuracy, a prospective clinical validation study was conducted in two tertiary-care Indian hospitals. Urine samples from 1986 participants were processed by both novel/index test and conventional Kirby Bauer Disc Diffusion method. The sensitivity and specificity of this assay was 92.5% and 82%, respectively (p < 0.0005). This novel technology will promote evidence-based prescription of antibiotics and reduce the burden of increasing resistance by providing rapid and precise diagnosis in shortest possible time.

Factors associated with multidrug-resistant bacteria in a cohort of patients with asymptomatic bacteriuria who underwent urological surgery

BACKGROUND

Although the factors associated to bacterial resistance in patients with asymptomatic bacteriuria (ASB) have been studied in pregnant, fertile age women, patients with spinal cord injury, and those with urogynecological disorders, nothing is known about the factors associated with multidrug-resistant (MDR) bacteria in patients with ASB and planned urological procedures. This study therefore sought to identify the sociodemographic and clinical factors associated with MDR bacteria in a cohort of patients with ASB scheduled for urological procedures.

METHODS

We conducted a nested case-control study on a cohort of patients with ASB and planned urological procedures at 3 Colombian medical centers. Cases were patients with MDR bacteria and controls were patients without MDR bacteria.

RESULTS

A total of 184 patients were included, 41.8% (n = 77) of whom presented ASB with MDR bacteria. The factors linking ASB with MDR bacteria were: advanced age (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and hospitalization within the 3-month period before surgery (odds ratio, 2.35; 95% confidence interval, 1.08-5.21).

CONCLUSIONS

Bacterial resistance is frequent among patients with ASB and planned urological procedures. Advanced age and prior hospitalization should be borne in mind for patients with planned urological procedures because they are factors associated with the presence of MDR bacteria.

Prevalencia etiológica de infección del tracto urinario en gestantes sintomáticas, en un hospital de alta complejidad de Medellín, Colombia, 2013-2015

Objective

To determine the prevalence of urinary tract infections (UTIs), the microbiological profile and antibiotic resistance in pregnant women with suspected urinary tract infection.

Materials and methods

Cross-sectional study of pregnant women with suspected community- acquired urinary tract infection referred to the outpatient clinic by prenatal care practitioners or seen in the emergency room, and hospitalized be- tween August 2013 and September 2015 in a referral teaching hospital located in Medellin, Colombia. Pregnant women who had received antibiotics on the day before admission were excluded. Random sampling. Measured variables: sociodemographic, clinical and bacteriological. Descriptive statistics were applied.

Results

The prevalence of urinary tract infections was 29%. Gram negative bacteria isolates were found predominantly, the main ones being E. coli and K. pneumoniae at 57.7 and 11.4%, respectively. Resistance to trimethoprim- sulfamethoxazole and to ampicillin-sulbactam was observed in 19.5% and 17.5% of isolates, respectively.

Conclusions

Population-based studies are needed to provide a better approach to bacterial resistance in community-acquired UTIs. On the other hand, the high resistance observed may suggest that some of the exposed antibiotics might not be included in the local guidelines for the management of UTIs.

Drinking water improvements and rates of urinary and gastrointestinal infections in Galápagos, Ecuador: Assessing household and community factors

OBJECTIVES

The Galápagos provides an important setting to investigate the health impacts of a new drinking water treatment plant (DWTP) in a limited resource environment. We examine how household perceptions and practices affect the relationship between water quality and infections before and after DWTP.

METHODS

Ethnographic data and self-reported infections were collected from 121 mothers and 168 children ages 2 to 10 from Isla San Cristóbal. Household tap water samples were tested for levels of fecal contamination. Community level infection rates were estimated using discharge records from the Ministry of Public Health. The effects of the new DWTP and fecal contamination levels on infections were tested using logistic and Poisson models.

RESULTS

Perceptions of water quality and household practices influenced exposures to contaminated tap water. We found minimal change in drinking water sources with 85% of mothers sampled before the DWTP and 83% sampled after using bottled water, while >85% from the pooled sample used tap water for cooking and hygiene practices. The DWTP opening was associated with lower odds of fecal contamination in tap water, reported urinary infections, and community level rates of urinary and gastrointestinal infections. The household practice of recently washing the cistern contributed to higher contamination levels after the DWTP opened.

CONCLUSIONS

To ensure access to clean water, public health works need to consider how household perceptions and practices influence tap water use and quality, in addition to infrastructure improvements. Exposures to contaminated tap water contribute to the burden of infectious disease in environments with inadequate water infrastructure.

Dilemmas in Management of the Geriatric Bladder

Purpose of review

In this article, we will review current dilemmas regarding evaluation and management of the geriatric bladder incorporating concepts of normal changes of aging as well as common lower urinary tract dysfunction.

Recent findings

Increasing age leads to functional changes in essentially all organ systems including the genitourinary system. Understanding the natural changes with age of the bladder as well as the signs and symptoms of pathologic conditions is paramount to diagnosis and treatment of urologic conditions in the geriatric population.

Summary

There are several conundrums in the diagnosis and evaluation of the geriatric bladder including the ability of the bladder to store, empty, as well as sensitivity disturbances. Diagnostic testing and goals of treatment should be individualized for each patient and personalized to consider patient comorbidities, limitations, and expectations.

Risk Factors and Outcomes Associated With Treatment of Asymptomatic Bacteriuria in Hospitalized Patients

IMPORTANCE

Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined.

OBJECTIVE

To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis.

EXPOSURES

One or more antibiotic dose for treatment of ASB.

MAIN OUTCOMES AND MEASURES

Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post-acute care settings, Clostridioides difficile infection (formerly known as Clostridium difficile) at 30 days, and duration of hospitalization after urine testing.

RESULTS

Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting.

CONCLUSIONS AND RELEVANCE

Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.

In situ synthesis of biocompatible imidazolium salt hydrogels with antimicrobial activity

Infection with antibiotic-resistant bacteria is becoming a significant public health risk. In this study, we synthesized a series of imidazolium salt (IMS)-containing polymers and hydrogels and tested their antimicrobial properties against both gram-positive (Staphylococcus aureus and MRSA) and gram-negative (Escherichia coli and PA01) bacteria. IMSs were either grafted as side chains or functionalized in the main chain of linear polymers, which demonstrated antimicrobial properties with minimum inhibitory concentrations as low as 2 μg/mL. Similarly, the optimized IMS-containing hydrogel effectively killed MRSA with a 96.1% killing efficiency and inhibited the growth of PA01. These hydrogels also demonstrated high performance in terms of mechanical property (compressive strength >2 MPa) and were noncytotoxic toward human dermal fibroblasts. STATEMENT OF SIGNIFICANCE: A series of polyimidazolium hydrogels were fabricated with acrylamide monomer and poly(ethylene glycol) dimethacrylate by thermal-initiated polymerization. These hydrogels completely killed methicillin-resistant Staphylococcus aureus and inhibited the growth of Pseudomonas aeruginosa. More importantly, these hydrogels demonstrated adequate mechanical property and biocompatibility. These antimicrobial hydrogels have the potential as biomaterials for preventing infections associated with multidrug-resistant bacteria.