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

A Roadmap to Implementing Antimicrobial Stewardship Principles in Long-term Care Facilities (LTCFs): Collaboration Between an Acute-Care Hospital and LTCFs

Effective 28 November 2017, the Centers for Medicare & Medicaid Services (CMS) mandated long-term care facilities (LTCFs) to have antimicrobial stewardship programs (ASPs) in place. Although guidance exists for establishing ASPs in LTCFs, limited data exist on the "how." As comprehensive ASPs already exist in many acute-care hospitals (ACHs) and with the known "sharing of patients" between both settings, extending ACH ASP expertise to LTCFs will not only aid LTCFs in complying with the CMS mandate but will likely also facilitate in decreasing multidrug-resistant organisms and Clostridium difficile infection rates in patients at both organizations. Here, we provide a roadmap on how to implement ASPs in LTCFs, using examples from our own ACH's collaboration with local LTCFs to develop and sustain LTCF ASPs. We discuss critical elements to achieving successful LTCF ASPs, including the potential barriers and how to overcome them.

Impact of Beta-lactam Allergy on Treatment of Outpatient Infections

PURPOSE

The most commonly reported medication allergies in the United States involve beta-lactam antibiotics, creating an important consideration for prescribers when choosing optimal treatment of infections. Currently, few data exist on outpatient prescribing patterns in response to patients with a beta-lactam allergy. This study sought to evaluate the appropriateness of outpatient antibiotic therapy in patients with documented beta-lactam allergies within a Veterans Affairs health care system to evaluate areas of improvement in prescribing practices.

METHODS

Patients receiving outpatient oral antibiotics were prospectively identified through real-time electronic alerts from June 2017 through February 2018. Prescriptions were then reviewed retrospectively to identify appropriateness of antibiotic, drug choice, dose, and duration based on current guideline recommendations. Data were compared between patients with a listed beta-lactam allergy and patients without a beta-lactam allergy to determine the impact on prescribing patterns and outcomes. Baseline characteristics were compared by using descriptive statistics. Significant risk factors for inappropriate prescribing were identified through a multivariable analysis.

FINDINGS

The cohort included 1844 antibiotic prescriptions (documented beta-lactam allergy, 221; no beta-lactam allergy, 1623). Appropriate drug, dose, and duration for antibiotics prescribed in patients reporting a beta-lactam allergy versus nonallergic patients were 44.3% versus 53.0% (P = 0.02), 91.4% versus 86.2% (P = 0.03), and 75.1% versus 76.2% (P = 0.83), respectively. Patients with a reported beta-lactam allergy were 31% less likely to receive the correct drug for indication empirically (95% CI, 0.52-0.92) in the multivariable regression model when adjusted for fluoroquinolone use. In addition, patients reporting a beta-lactam allergy were 2.2 times (95% CI, 1.6-3.0) more likely to receive a fluoroquinolone antibiotic. Antibiotics were considered overall inappropriate based on at least one aspect of therapy in 79.6% of patients reporting a beta-lactam allergy and in 71% of nonallergic patients.

IMPLICATIONS

Antibiotic therapy in patients with a documented beta-lactam allergy was less likely to be appropriate overall, suggesting an area of improvement for prescribing habits. Future interventions should focus on prescriber education regarding first-line and alternative treatments for patients with beta-lactam allergies to ensure that optimal treatment is being provided.

Urinary tract infection and subclinical bacteriuria in cats: A clinical update

PRACTICAL RELEVANCE

Urinary tract infection (UTI) is an important cause of feline lower urinary tract disease (FLUTD), particularly in female cats older than 10 years of age. In addition to cats with typical clinical signs of FLUTD or upper UTI, many cats have subclinical bacteriuria, but the clinical relevance of this is currently uncertain. UTIs are one of the most important indications for antimicrobial use in veterinary medicine and contribute to the development of antimicrobial resistance. Adherence to treatment guidelines and confinement to a few first-line antimicrobial agents is imperative to avoid further deterioration of the antimicrobial resistance situation. The decision to treat with antimicrobials should be based on the presence of clinical signs, and/or concurrent diseases, and the results of urine culture and susceptibility testing.

CLINICAL CHALLENGES

Distinguishing between cats with bacterial cystitis, and those with idiopathic cystitis and concurrent clinical or subclinical bacteriuria, is challenging, as clinical signs and urinalysis results may be identical. Optimal treatment of subclinical bacteriuria requires clarification as there is currently no evidence that demonstrates a beneficial effect of routine treatment. Management of recurrent UTIs remains a challenge as evidence for most alternatives used for prevention in cats is mainly anecdotal, and no preventive treatment modality is currently recommended.

EVIDENCE BASE

This review draws on an extensive literature base in veterinary and human medicine, including the recently updated guidelines of the International Society for Companion Animal Infectious Diseases for the diagnosis and management of bacterial urinary tract infections in dogs and cats. Where published evidence is lacking, the authors describe their own approach; notably, for the bacteriuric cat with chronic kidney disease.

Which near-patient tests might improve the diagnosis of UTI in older people in urgent care settings? A mapping review and consensus process

PURPOSE

The aim of this study was to map out the existing knowledge on near-patient tests for urinary tract infections, and use a consensus building approach to identify those which might be worthy of further evaluation in the urgent care context, defined as clinically useful and feasible results available within 4-24 h.

METHODS

A systematic search for reviews describing diagnostic tests for UTI was undertaken in Medline, EMBASE, Cochrane database of systematic reviews and CINAHL selected reviews were retained according to a priori inclusion and exclusion criteria, and then graded for quality using the CASP tool for reviews. A consensus process involving microbiologists and chemical pathologists helped identify which test might conceivably be applied in the urgent care context (e.g. Emergency Department, giving results within 24 h).

RESULTS

The initial search identified 1079 papers, from which 26 papers describing 35 diagnostic tests were retained for review. The overall quality was limited, with only 7/26 retained papers scoring more than 50% on the CASP criteria. Reviews on urine dipstick testing reported wide confidence intervals for sensitivity and specificity; several raised concerns about urine dip testing in older people. A number of novel biomarkers were reported upon but appeared not to be helpful in differentiating infection from asymptomatic bacteriuria. Blood markers such as CRP and procalcitonin were reported to be helpful in monitoring rather than diagnosing UTI. The consensus process helped to refine the 35 test down to 17 that might be useful in the urgent care context: urinalysis (nitrites and leucocytes), uriscreen catalase test, lactoferrin, secretory immunoglobulin A, xanthine oxidase, soluble triggering receptor expressed on myeloid cells, A-1 microglobulin (a1 Mg) and a1 Mg/creatinine ratio, cytokine IL-6, RapidBac, MALDI-TOF, electronic noses, colorimetric sensor arrays, electro chemical biosensor, WBC count (blood), C-reactive peptide, erythrocyte sedimentation rate.

CONCLUSIONS

A wide range of diagnostic tests have been explored to diagnose UTI, but, in general, have been poorly evaluated or have wide variation in predictive properties. This study identified 17 tests for UTI that seemed to offer some primes and merit further evaluation for diagnosing UTI in older people in urgent care settings.

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?

Microbiologic profile and clinical practices in urinary tract infections in a tertiary care center in Southern India

Context:

Studies reported differences in clinical profiles of urinary tract infections (UTIs) in patients with and without type 2 diabetes mellitus (T2DM). Studies on the impact of the pattern of antibiotic resistance of organisms causing UTI on actual clinical practice are lacking.

Objectives:

1. To study the clinical and microbiologic profiles of UTIs. 2. To compare treatment given with the prevailing antimicrobial sensitivity.

Settings and Design:

This is a cross-sectional study conducted in a tertiary care hospital.

Methods and Materials:

Retrospective chart review of inpatients with UTI (N = 200, 100 each of patients with and without T2DM), aged >18 years with a positive urine culture.

Statistical Analysis:

We used the statistical package SPSS version 17. The categorical variables were analyzed by the Chi-square test. Data were considered significant if P value was less than 0.05.

Results:

Similar to previous Indian studies, T2DM patients with UTI had significantly more asymptomatic bacteriuria, asymptomatic bacteriuria (32% vs. 6%), previous history of UTI (25% vs. 2%), and prior catheterization (16% vs. 1%). Escherichia coli (E. coli) was the most common organism isolated and showed sensitivity pattern of meropenem > netilmicin > amikacin > nitrofurantoin. Ceftriaxone was the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. All ASB cases were treated unlike recommendations.

Conclusions:

Ceftriaxone is the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. Cases of ASB were treated unlike recommendations.

No. 276-Management of Group B Streptococcal Bacteriuria in Pregnancy

OBJECTIVE

To provide information regarding the management of group B streptococcal (GBS) bacteriuria to midwives, nurses, and physicians who are providing obstetrical care.

OUTCOMES

The outcomes considered were neonatal GBS disease, preterm birth, pyelonephritis, chorioamnionitis, and recurrence of GBS colonization.

EVIDENCE

Medline, PubMed, and the Cochrane database were searched for articles published in English to December 2010 on the topic of GBS bacteriuria in pregnancy. Bacteriuria is defined in this clinical practice guideline as the presence of bacteria in urine, regardless of the number of colony-forming units per mL (CFU/mL). Low colony counts refer to <100 000 CFU/mL, and high (significant) colony counts refer to ≥100 000 CFU/mL. Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. Searches were updated on a regular basis and incorporated in the guideline to February 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

Recommendations were quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care (Table).

BENEFITS, HARMS, AND COSTS

The recommendations in this guideline are designed to help clinicians identify pregnancies in which it is appropriate to treat GBS bacteriuria to optimize maternal and perinatal outcomes, to reduce the occurrences of antibiotic anaphylaxis, and to prevent increases in antibiotic resistance to GBS and non-GBS pathogens. No cost-benefit analysis is provided.

RECOMMENDATIONS

Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe

Background

Asymptomatic bacteriuria is frequent in kidney transplant recipients (KTRs). However, there is no consensus on diagnosis or management. We conducted a European survey to explore current practice related to the diagnosis and management of asymptomatic bacteriuria in adult KTRs.

Methods

A panel of experts from the European Renal Association-European Dialysis Transplant Association/Developing Education Science and Care for Renal Transplantation in European States working group and the European Study Group for Infections in Compromised Hosts of the European Society of Clinical Microbiology and Infectious Diseases designed this cross-sectional, questionnaire-based, self-administered survey. Invitations to participate were e-mailed to European physicians involved in the care of KTRs.

Results

Two hundred and forty-four participants from 138 institutions in 25 countries answered the survey (response rate 30%). Most participants [72% (176/244)] said they always screen for asymptomatic bacteriuria in KTRs. Six per cent (15/240) reported never treating asymptomatic bacteriuria with antibiotics. When antimicrobial treatment was used, 24% of the participants (53/224) said they would start with empirical antibiotics. For an episode of asymptomatic bacteriuria caused by a fully susceptible microorganism and despite no contraindications, a majority of participants (121/223) said they would use a fluoroquinolone (n = 56), amoxicillin/clavulanic acid (n = 38) or oral cephalosporins (n = 27).

Conclusions

Screening for and treating asymptomatic bacteriuria are common in KTRs despite uncertainties around the benefits and harms. In an era of antimicrobial resistance, further studies are needed to address the diagnosis and management of asymptomatic bacteriuria in these patients.

Top 10 evidence-based recommendations from the Brazilian Society of Infectious Diseases for the Choosing Wisely Project

The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.

Screening for Asymptomatic Bacteriuria in Adults: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Among the general adult population, women (across all ages) have the highest prevalence of asymptomatic bacteriuria, although rates increase with age among both men and women. Asymptomatic bacteriuria is present in an estimated 1% to 6% of premenopausal women and an estimated 2% to 10% of pregnant women and is associated with pyelonephritis, one of the most common nonobstetric reasons for hospitalization in pregnant women. Among pregnant persons, pyelonephritis is associated with perinatal complications including septicemia, respiratory distress, low birth weight, and spontaneous preterm birth.

OBJECTIVE

To update its 2008 recommendation, the USPSTF commissioned a review of the evidence on potential benefits and harms of screening for and treatment of asymptomatic bacteriuria in adults, including pregnant persons.

POPULATION

This recommendation applies to community-dwelling adults 18 years and older and pregnant persons of any age without signs and symptoms of a urinary tract infection.

EVIDENCE ASSESSMENT

Based on a review of the evidence, the USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in pregnant persons has moderate net benefit in reducing perinatal complications. There is adequate evidence that pyelonephritis in pregnancy is associated with negative maternal outcomes and that treatment of screen-detected asymptomatic bacteriuria can reduce the incidence of pyelonephritis in pregnant persons. The USPSTF found adequate evidence of harms associated with treatment of asymptomatic bacteriuria (including adverse effects of antibiotic treatment and changes in the microbiome) to be at least small in magnitude. The USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in nonpregnant adults has no net benefit. The known harms associated with treatment include adverse effects of antibiotic use and changes to the microbiome. Based on these known harms, the USPSTF determined the overall harms to be at least small in this group.

RECOMMENDATIONS

The USPSTF recommends screening pregnant persons for asymptomatic bacteriuria using urine culture. (B recommendation) The USPSTF recommends against screening for asymptomatic bacteriuria in nonpregnant adults. (D recommendation).

Latin American consensus on uncomplicated recurrent urinary tract infection-2018

An estimated 20-30% of adult women who experience an initial urinary tract infection (UTI) will have recurrent infection. In these patients, prophylaxis may be considered to improve their quality of life and control overuse of antibiotics. Despite this need, there is currently no Latin American consensus on the treatment and prophylaxis of recurrent UTIs. This consensus, signed by a panel of regional and international experts on UTI management, aims to address this need and is the first step toward a Latin American consensus on a number of urogynecological conditions. The panel agrees that antibiotics should be considered the primary treatment option for symptomatic UTI, taking into account local pathogen resistance patterns. Regarding prophylaxis, immunoactive therapy with the bacterial lysate OM-89 received a grade A recommendation and local estrogen in postmenopausal women grade B recommendation. Lower-grade recommendations include behavior modification and D-mannose; probiotics (Lactobacilli), cranberries, and hyaluronic acid (and derivatives) received limited recommendations; their use should be discussed with the patient. Though considered effective and receiving grade A recommendation, antimicrobial prophylaxis should be considered only following prophylaxis with effective non-antimicrobial measures that were not successful and chosen based on the frequency of sexual intercourse and local pathogen resistance patterns.

Prevalence of asymptomatic bacteriuria among kidney transplant recipients beyond two months post-transplant: A multicenter, prospective, cross-sectional study

BACKGROUND

During routine post-kidney transplant care, most European transplant physicians screen patients for asymptomatic bacteriuria. The usefulness of this strategy is debated. To make screening cost-effective, asymptomatic bacteriuria should be prevalent enough to justify the expense, and antibiotics should improve patient outcomes significantly if asymptomatic bacteriuria is detected. Regrettably, the prevalence of asymptomatic bacteriuria among kidney transplant recipients is not well defined.

METHODS

To determine the prevalence of asymptomatic bacteriuria among kidney transplant recipients, we did a cross-sectional study among kidney transplant recipients undergoing routine surveillance in three outpatient transplant clinics in Belgium and France. We excluded patients who were in the first two months post-transplantation and/or had a urinary catheter. Asymptomatic participants who had a urine culture with one organism isolated at ≥ 105 CFU/mL were asked to provide a confirmatory urine specimen. Asymptomatic bacteriuria was defined per Infectious Diseases Society of America guidelines.

RESULTS

We screened 500 consecutive kidney transplant recipients. Overall, the prevalence of asymptomatic bacteriuria was 3.4% (17/500 patients). It was similarly low among kidney transplant recipients who were between 2 and 12 months after transplantation (1.3%, 1/76 patients) and those who were farther after transplantation (3.8%, 16/424 patients: p = 0.49). Asymptomatic bacteriuria was significantly associated with female gender (risk ratio 3.7, 95% CI 1.3-10.3, p = 0.007) and older age (mean age: 61 ± 12 years [bacteriuric participants], versus 53 ± 15 years [non-bacteriuric participants], p = 0.03). One participant's colistin-resistant Escherichia coli isolate carried the globally disseminated mcr-1 gene.

CONCLUSIONS

Among kidney transplant recipients who are beyond the second month post-transplant, the prevalence of asymptomatic bacteriuria is low. Further studies are needed to ascertain the cost-effectiveness of a screen-and-treat strategy for asymptomatic bacteriuria in this population.

Evaluation of functional outcomes in traumatic spinal cord injury with rehabilitation-acquired urinary tract infections: A retrospective study

OBJECTIVE

The objective of this study was to evaluate the impact of urinary tract infections (UTIs) acquired during acute inpatient traumatic Spinal Cord Injury (tSCI) rehabilitation on Functional Independence Measure (FIM) gains.

DESIGN

Retrospective chart review of consecutive patients with tSCI admitted to an acute rehabilitation facility from 2007-2012. The primary outcome was FIM scores and the association with UTI.

RESULTS

The sample included 110 patients and 70 acquired UTIs. No demographic differences were observed between groups with and without UTI. Those with UTIs had significantly lower FIM motor scores, on admission, discharge, and gain, as well as lower FIM efficiency and longer lengths of stay compared to those without a UTI. Recurrence of UTI was associated with increased length of stay, but did not impact FIM motor gains.

CONCLUSIONS

There was a statistically significant correlation between acquired UTIs and lower FIM motor scores on admission, gain, and discharge in tSCI rehabilitation. The correlation of UTI and decreased FIM gains are similar to other neurorehabilitation populations with UTI occurrence. UTIs are an important negative variable when measuring functional outcomes in rehabilitation. Further prospective studies should be performed to investigate this correlation.

A cell-free DNA metagenomic sequencing assay that integrates the host injury response to infection

High-throughput metagenomic sequencing offers an unbiased approach to identify pathogens in clinical samples. Conventional metagenomic sequencing, however, does not integrate information about the host, which is often critical to distinguish infection from infectious disease, and to assess the severity of disease. Here, we explore the utility of high-throughput sequencing of cell-free DNA (cfDNA) after bisulfite conversion to map the tissue and cell types of origin of host-derived cfDNA, and to profile the bacterial and viral metagenome. We applied this assay to 51 urinary cfDNA isolates collected from a cohort of kidney transplant recipients with and without bacterial and viral infection of the urinary tract. We find that the cell and tissue types of origin of urinary cfDNA can be derived from its genome-wide profile of methylation marks, and strongly depend on infection status. We find evidence of kidney and bladder tissue damage due to viral and bacterial infection, respectively, and of the recruitment of neutrophils to the urinary tract during infection. Through direct comparison to conventional metagenomic sequencing as well as clinical tests of infection, we find this assay accurately captures the bacterial and viral composition of the sample. The assay presented here is straightforward to implement, offers a systems view into bacterial and viral infections of the urinary tract, and can find future use as a tool for the differential diagnosis of infection.

Evaluation and Management of Urinary Tract Infection in the Emergency Department

Urinary tract infection (UTI) affects patients of all ages and is a diagnosis that emergency physicians might make multiple times per shift. This article reviews the evaluation and management of patients with infections of the urinary tract. Definitions of asymptomatic bacteriuria, uncomplicated UTI, and complicated UTI are presented, as well as techniques for distinguishing them. The pathophysiology and clinical and laboratory diagnoses of UTI are described. Treatment of UTI is reviewed, with attention to bacteriuria and special populations, including pregnant, elderly/geriatric, and spinal cord injury patients.

Impact of syndrome-specific antimicrobial stewardship interventions on use of and resistance to fluoroquinolones: An interrupted time series analysis

BACKGROUND

Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile.

METHODS

We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care-associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis.

RESULTS

The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days -15.3, P < .01). The health care-associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P < .01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile.

CONCLUSIONS

Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.

Antibiotic stewardship targets in the outpatient setting

BACKGROUND

Outpatient prescriptions comprise 60% of antibiotic use. This study prospectively identified inappropriate antibiotic use enabling a focused approach to outpatient antimicrobial stewardship.

METHODS

Outpatients at the Veterans Affairs Western New York Healthcare System were identified via an electronic antibiotic alert from June 2017 to September 2017. Descriptive statistics and multivariable logistic regression identified stewardship targets.

RESULTS

Of the 1,063 patients, 40% of antibiotic prescriptions were not indicated. Urinary tract infections (21%), bronchitis (20%), skin structure infections (17%), and sinusitis (10%) were common causes of inappropriate antibiotic use. Azithromycin (37%) was prescribed unnecessarily most often, followed by ciprofloxacin (16%), amoxicillin/clavulanate (13%), and cephalexin (12%). The correct drug was chosen in 52%, dose in 81%, and duration in 75% of patients. When the antibiotic was indicated, the correct drug was 2.9 times more likely to be prescribed and 2 times more likely to have the correct duration and receive care in the emergency room.

DISCUSSION

Focusing on 4 drugs; amoxicillin/clavulanate, azithromycin, ciprofloxacin, and cephalexin accounted for 80% of unnecessary drug use. This study provides a guide to concentrate efforts during implementation of an outpatient stewardship program.

CONCLUSIONS

Poor antibiotic prescribing was found in the outpatient setting. This study identifies areas for improvement via stewardship.

Bacterial urinary tract infection among adult renal transplant recipients at St. Paul's hospital millennium medical college, Addis Ababa, Ethiopia

BACKGROUND

Despite significant advances in surgical techniques, immunosuppression protocols, follow up periods and antimicrobial stewardship in modern medicine; post-renal transplantation urinary tract infection remained a major public health problem globally. This multiple serious squeals includes asymptomatic bacteriuria, cystitis and pyelonephritis. Among these, the bacterial origin of infection complications accounts for the most significant clinical, socio-economic impacts in many countries of the world. Therefore, the aim of the study was to investigate the prevalence of bacterial isolates that cause urinary tract infections, assess antibiotic susceptibility pattern among symptomatic and asymptomatic renal transplant recipients attending at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted from December 2017 to August 2018 among 74 renal transplant recipients St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. A first morning voided clean-catch mid-stream urine specimens were collected and 0.001 ml inoculated onto blood and MacConkey agar plates following the standard bacteriological protocols. It was incubated aerobically at 35-37 °C for 24-48 h. Cultural characteristics and series of biochemical tests were used for the identification of isolates to species level based on the standard bacteriological protocols.

RESULTS

A hospital-based cross-sectional study has shown that significant bacteriuria was found in 11/74 (14.9, 95% CI =8.2-24.7) patients. The prevalence among females 6/32 (18.75%) was higher among males 5/42 (11.9%) without significant association (COR = 2.09, 95% CI = 1.04-8.45, P = 0.253). Urinary tract infection was higher in the age group of 35-49 years old (19.3%). Age was statistically significant and stronger independent associated risk factor with crude odds ratio = 3.67, 95% CI = 2.89-20.07 and P = 0.003, respectively. The most prevalent bacteria isolates were Escherichia coli 2(18.2%), Staphylococcus aureus 2(18.2%), Acinetobacter spp. 2(18.2%), Enterococcus spp. 2(18.2%), Coagulase-negative Staphylococci 2(18.2%) followed by Porteus mirabilis 1(9.1%). The majority (80%) of Gram-negative bacteria were resistant to ciprofloxacin, chloramphenicol, and trimethoprim/sulfamethoxazole. Simultaneously, the multidrug-resistant bacterial isolates accounts for 82% among tested kidney allograft recipients.

CONCLUSIONS

In conclusion, the overall prevalence of urinary tract infection in the study participants was relatively low with a prevalence of 14.9%. Majority of the study participants were asymptomatic and a higher percentage of females were involved. The multidrug-resistant bacterial isolates in the present study account for 82%.

Asymptomatic bacteriuria among hospitalized diabetic patients: Should they be treated?

Diabetes Mellitus is a significant health care challenge in the United States. The Center for Disease Control and Prevention estimates approximately 9.4% of patients in the United States are afflicted by diabetes. The Infectious Disease Society of America asymptomatic bacteriuria in women as two consecutive clean-catch voided urine specimens with isolation of the same bacterial strain in counts ≥ 10⁵ cfu/mL It is understood that diabetic patients tend to be at higher risk for infections than non-diabetics. Urinary tract infections (UTIs) tend to be the most common infection contracted by this population. UTIs are not only a significant cause of morbidity and mortality, they are also a significant financial burden. The data are conflicting, in regard to treating asymptomatic bacteriuria in diabetic patients to avoid hospital complications and ultimately decrease healthcare costs associated with these complications. However, clinicians continue to prescribe antibiotics empirically. Further randomized controlled study looking into the specific population as immunocompromised diabetic patients, patient with diabetic ketoacidosis and patient in intensive care unit needs to be undertaken.

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.

Postoperative urinary tract infection after urogynecologic surgery: timing and uropathogens

INTRODUCTION AND HYPOTHESIS

Although postoperative urinary tract infections (UTIs) after urogynecologic surgery are a common adverse event, there is no standardized postoperative time period used to assess this outcome, and the uropathogens unique to this sub-population of patients have not been well described. Our objective is to describe the timing and uropathogens of postoperative UTI after urogynecologic surgery.

METHODS

This retrospective study analyzed postoperative UTI occurring within 90 days following urogynecologic procedures from November 2013 to January 2018 at a single academic institution. Postoperative UTI was defined as any uropathogen growth from standard urine culture. Continuous variables were compared with independent samples t-test and categorical variables with chi-square with Bonferonni corrections as appropriate.

RESULTS

One hundred and two of 1085 (9.4%) patients experienced UTI; 63.7% occurred within 6 weeks and 78.4% within 8 weeks; 36.3% of UTIs occurred at a time period of 6 weeks to 90 days. Most commonly isolated uropathogens were Escherichia coli (47.8%) with an additional 11.2% extended-spectrum beta-lactamase (ESBL) Escherichia coli. Other bacteria included Enterococcus faecalis (10.4%), Klebsiella pneumoniae (9%), and one culture each for ESBL Klebsiella pneumoniae and vancomycin-resistant (VRE) Enterococcus faecium.

CONCLUSIONS

More than one third of UTIs after urogynecologic surgery occur between 6 weeks and 90 days postoperatively. A plateau of UTI incidence occurs at 8 weeks, a time period at which 78.4% of all UTIs were captured. Escherichia coli was the most commonly isolated uropathogen, and multi-drug-resistant bacteria were implicated in 12.8% of UTIs.

Implementing a Ureteric Magnetic Stent in the Kidney Transplant Setting: Report of 100 Consecutive Cases

BACKGROUND

Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease. The double-J-stent has been used to prevent urological complications (UCs), but it requires cystoscopy extraction. The novel magnetic black star (MBS) stent provided with a customized retrieval device (9 or 15 Fr) has been developed to spare cystoscopy. Scope of the paper is to analyze MBS in 100 consecutive KTs.

METHODS

We report a retrospective analysis of 100 consecutive KT performed between April 2015 and September 2018 using MBS (4.8 Fr, 15 cm) to protect Lich-Gregoir ureteroneocystotomy. MBS was removed 4 weeks after KT by either the 9 Fr (61 cases) or the 15 Fr (39 cases) retrieval device.

RESULTS

Intraoperative MBS insertion was straightforward in all cases, and its extraction was carried out in the outpatient setting in 93 patients. Extraction time was <30 seconds in 45 out of 61 patients (73.8%) and in 38 out of 39 patients (97.4%) using the 9 Fr and the 15 Fr retrieval device, respectively. In 15 patients, MBS removal took between 30 seconds and 3 minutes. Only 2 cases required extraction by cystoscopy. We observed 2 UC (ureteric leak and stenosis), 8 urinary tract infections, and 9 stent-related symptoms. 7 patients experienced distressing pain according to Visual Analog Scale for Pain.

CONCLUSIONS

In our cohort, MBS appeared to be safe and cost-effective. We advocate its routine implementation in KT because of an easy and comfortable extraction in the outpatient setting even by nondedicated staff, without detrimental impact on UC and urinary tract infection rates.

Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines

Background

A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters.

Methods

We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines.

Results

On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by “pan-culturing” rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures.

Conclusions

Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.

Electronic Health Record-Assisted Reflex Urine Culture Testing Improves Emergency Department Diagnostic Efficiency

The authors evaluated the effectiveness of an electronic health record (EHR)-based reflex urine culture testing algorithm on urine test utilization and diagnostic yield in the emergency department (ED). The study implemented a reflex urine culture order with EHR decision support. The primary outcome was the number of urine culture orders per 100 ED visits. The secondary outcome was the diagnostic yield of urine cultures. After the intervention, the mean number of urine cultures ordered was 5.95 fewer per 100 ED visits (9.3 vs 15.2), and there was a decrease in normal, or negative, cultures by 2.42 per 100 ED visits. There also was a statistically significant decrease in urine culture utilization and an increase in the positive proportion of cultures. Simple EHR clinical decision-support tools along with reflex urine culture testing can significantly reduce the number of urine cultures performed while improving diagnostic yield in the ED.

Community acquired urinary tract infections among adults in Accra, Ghana

Background: Urinary tract infection (UTI) is one of the most common bacterial infectious diseases encountered in clinical practice, and accounts for significant morbidity and high medical costs. To reduce its public health burden, there is the need for local research data to address aspects of prevention and management of UTI. The aim of this study was to investigate community-acquired UTI among adults in Accra, Ghana, including the risk factors, etiological agents, and antibiotic resistance. Methods: This was a cross-sectional study involving 307 patients clinically diagnosed with UTI at the Korle Bu and Mamprobi polyclinics in Accra. Urine specimens were collected from the study participants and analyzed by culture, microscopy, and dipstick. The bacterial isolates were identified using standard microbiological methods and tested against a spectrum of antibiotics by the Kirby Bauer method. Multidrug resistant Enterobacteriaceae isolates were screened for Extended Spectrum β-lactamase (ESBL) production by the double disc method, and isolates that tested positive were analyzed by Polymerase Chain Reaction for ESBL genes. Demographic information and clinical history of study participants were collected. Results: Based on the criteria for laboratory confirmed UTI, 31 (10.1%) of the 307 specimens were positive and the main risk factor of UTI among the study participants was pregnancy (P=0.02, OR=2.43). The most common uropathogen isolated was Escherichia coli (48.9%), followed by Klebseilla sp. (16.1%). Prevalence of resistance was highest for Piperacillin (87.1%) and Amoxicillin+Clavulanic Acid (87.1%) and lowest for Amikacin (12.9%). Prevalence of multidrug resistance among the uropathogens was 80.1% (25) and the most common ESBL gene detected was CTX-M-15. Conclusion: Pregnant women constitute the key risk population of UTI in Accra, while Amikacin remains a suitable drug for the treatment of febrile UTI. The high prevalence of multidrug resistance among the uropathogens highlights the need for surveillance of antimicrobial resistance among these pathogens.

Determination of leucocyte extracellular traps (ETs) in seminal fluid (ex vivo) in infertile patients-A pilot study

Leucocytospermia has been associated with loss of sperm function. Extracellular traps (ETs) of leucocytes are produced during innate immune response. ETs can be activated by spermatozoa in contact with polymorphonuclear (in vitro), inducing sperm entrapment and decrease motility. In this pilot study, we describe the results of ETosis ex vivo, in seminal fluid (SF) smear of infertile patients, associating ETs with leucocytospermia and bacteriospermia. In 21 infertile patients, semen parameters (WHO, 2010), microbiological study, leucocytospermia and presence of ETs in SF were determined. Leucocytes (CD45, CD15 and CD68) were evaluated by immunostaining in SF smears. Indirect immunofluorescence (global histone and H4-citrullinated 3) and scanning electron microscopy (SEM) were used to determine ETs morphology. In 28.6% of patients presented leucocytospermia without bacteriospermia, all of them presented a large number of ETs in the SF smears examined. About 76.6% of the patients without leucocytospermia were positive for ETs. Samples with leucocytospermia have a higher number of ETs and would be related to the amount of leucocytes in the SF. The morphological predominant ETs were diffuse (diffETs) and spread (sprETs). The formation of ETs indicates leucocyte activation in semen, and it was observed that ETosis does not depend exclusively on the presence of bacterial contamination.

National Patterns of Urine Testing During Inpatient Admission

Background

Overuse of urine testing is a driver of inappropriate antimicrobial use. Limiting wasteful testing is important for patient safety. We examined the national prevalence and patterns of urine testing during adult inpatient admission in the United States.

Methods

We performed a retrospective cohort study using a national dataset of inpatient admissions from 263 hospitals in the United States from 2009 to 2014. We included all adult inpatient admissions, excluding those related to pregnancy, urology procedures, and with lengths of stay >30 days. A facility-level fixed-effects quasi-Poisson regression model was used to examine the incidence of urinalysis and urine culture testing for select diagnoses and patient factors.

Results

The cohort included 4473655 admissions. Charges for urinalysis were present for 2086697 (47%) admissions, with 584438 (13%) including >1 urinalysis. Charges for urine culture were present for 1197242 (27%) admissions, with 246211 (6%) having >1 culture. Urine culture testing varied by principal diagnosis. Heart failure and acute myocardial infarction had 29% and 35% fewer cultures sent on the first day of admission compared to all other admissions (P < .001). Female sex and receipt of antibiotics during the hospital admission consistently predicted increased culture testing, regardless of principal diagnosis or age.

Conclusions

Urine testing was common and frequently repeated during inpatient admission, suggesting large-scale overuse. The variation in testing by diagnosis suggests that clinical presentation modifies test use. The sex bias in urine testing is not clinically supported and must be addressed in interventions aimed at reducing excess urine testing.

Is Routine Urinary Screening Indicated Prior To Elective Total Joint Arthroplasty? A Systematic Review and Meta-Analysis

BACKGROUND

Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty, and prevention is of great importance. The genitourinary tract is a potential source of bacterial seeding and one that can be easily managed. Despite little supportive evidence, routine urine screening and subsequent treatment before elective surgery in patients without symptoms has found its way into clinical practice in many countries. This systematic review and meta-analysis aims to ascertain whether asymptomatic bacteriuria (ASB) is a risk factor for PJI and if so, whether preoperative antibiotic treatment is effective in reducing its risk.

METHODS

PubMed, Ovid Medline, and Cochrane databases were searched using a systematic strategy. Selection of papers was exclusive to include only those which offered information about PJI rate specifically in patients with or without asymptomatic abnormal urinalysis or bacteriuria and/or information on whether ASB patients were preoperatively treated with antibiotics or not to be included in the analysis.

RESULTS

Six-hundred sixty-three papers were screened, and 10 papers were ultimately included (28,588 patients). Results show an increased risk of developing PJI among ASB patients (odds ratio = 3.64, 95% confidence interval = 1.40-9.42). However, most PJI microorganisms are unrelated to those previously found in the urine and preoperative antibiotic therapy does not influence PJI risk (odds ratio = 0.98, 95% confidence interval = 0.39-2.44).

CONCLUSION

Routine urinary screening prior to elective total joint arthroplasty and treatment of asymptomatic patients is not recommended.

Asymptomatic bacteriuria in older adults: the most fragile women are prone to long-term colonization

Background

The diagnosis of urinary tract infections (UTIs) in institutionalized older adults is often based on vague symptoms and a positive culture. The high prevalence of asymptomatic bacteriuria (ABU), which cannot be easily discriminated from an acute infection in this population, is frequently neglected, leading to a vast over-prescription of antibiotics. This study aimed to identify subpopulations predisposed to transient or long-term ABU.

Methods

Residents in a long-term care facility were screened for ABU. Mid-stream urine samples were collected during two sampling rounds, separated by 10 weeks, each consisting of an initial and a confirmative follow-up sample.

Results

ABU occurred in approximately 40% of the participants and was mostly caused by Escherichia coli. Long-term ABU (> 3 months) was found in 30% of the subjects. The frailest women with urinary incontinence and dementia had drastically increased rates of ABU and especially long-term ABU. ABU was best predicted by a scale describing the functional independence of older adults.

Conclusions

Institutionalized women with incontinence have ABU prevalence rates of about 80% and are often persistent carriers. Such prevalence rates should be considered in clinical decision making as they devalue the meaning of a positive urine culture as a criterion to diagnose UTIs. Diagnostic strategies are urgently needed to avoid antibiotic overuse and to identify patients at risk to develop upper UTI.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1181-4) contains supplementary material, which is available to authorized users.

Evidence-Informed Practice: Diagnostic Questions in Urinary Tract Infections in the Elderly

Introduction

Routine interventions in the practice of medicine often lack definitive evidence or are based on evidence that is either not high quality or of only modest-to-marginal effect sizes. An abnormal urinalysis in an elderly patient presenting to the emergency department (ED) with non-specific symptoms represents one condition that requires an evidence-informed approach to diagnosis and management of either asymptomatic bacteriuria or urinary tract infection (UTI). The emergency provider often will not have access to urine cultures, and the risks associated with antibiotic use in the elderly are not without potentially significant side effects.

Methods

We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin.

Results

Serum procalcitonin, a peptide that undergoes proteolysis into calcitonin, has been demonstrated to quickly and reliably rise in patients with severe bacterial infections, and may serve as a potentially sensitive and specific marker for identification of bacterial illness.

Conclusion

In the absence of validated risk scores for diagnosing UTI in elderly patients presenting to the ED, there may be a role for the use of procalcitonin in this patient population.

The etiology and management of recurrent urinary tract infections in postmenopausal women

Urinary tract infections (UTIs) are one of the most common infections and affect up to 50% of women in their lifetime, with almost half of these women experiencing a recurrence in 6-12 months. Menopause predisposes women to recurrent UTI (rUTI), as normally lower levels of estrogen lead to changes in the urogenital epithelium and subsequently urogenital microbiome. The recently discovered urobiome is now known to have different compositions in both healthy and unhealthy bladders, including a role in the pathophysiology of rUTI, and may be a therapeutic target for prevention and treatment options for rUTI. In postmenopausal women with frequent UTI, the diagnosis of acute UTI should be made using a combination of the symptom assessment and urine diagnostic studies. The choice of UTI antibiotic should include consideration of efficacy, collateral effects, and side-effects. Some women may be candidates for self-start therapy, in which the patient accurately recognizes her UTI symptoms and then starts previously prescribed antibiotics. A large component of the management of women with rUTI is prevention. Urobiome research for bladder health and disease is a young field of investigation with significant potential to improve care for postmenopausal women affected by rUTI through novel, evidence-based prevention and treatment strategies.

The Slow-Motion Catastrophe of Antimicrobial Resistance and Practical Interventions for All Prescribers

All medical and surgical specialties depend on the pool of effective antibiotics that continues to evaporate because of the increasing prevalence of drug-resistant bacteria. Antimicrobial-resistant infections kill 700,000 patients every year. By 2050, they are projected to cause 10 million deaths per year at a cumulative global cost of $100 trillion. Professional societies and international health agencies, including the United Nations, have declared escalating antimicrobial resistance as one of the gravest and most urgent threats to global public health and issued calls for action. The propensity of bacteria to mobilize and share genetic resistance determinants across species and genera, record levels of conflict-driven human population displacement, and the dearth of new antibiotics and rapid diagnostic tests, along with climate change and the epidemic of opioid addiction, exacerbate the antimicrobial resistance crisis. The predominant cause of antibiotic resistance is exposure to antibiotics through appropriate and inappropriate use. Mindfulness, nudging by peers, and adjuncts and alternatives to antibiotics, such as phage therapies, microbiome-based therapies, and novel medical informatics applications, could help reduce antibiotic use. This article describes the antimicrobial resistance crisis and highlights points in the continuum of care in which clinicians can readily implement practical, no-cost changes to minimize antibiotic exposure.

Asymptomatic bacteriuria in pediatric kidney transplant recipients: to treat or not to treat? A retrospective study

BACKGROUND

Urinary tract infections (UTI) are common infectious complications in kidney transplant recipients (KTR); asymptomatic bacteriuria (AB) is also frequent. It is unclear whether treatment of AB reduces subsequent UTI in KTR; no guideline is available in pediatric KTR. In this retrospective study, we analyzed the incidence of AB in pediatric KTR and the impact of screening and treating AB on the onset of subsequent UTI.

METHODS

Thirty-seven pediatric patients were included. Inclusion criteria were the occurrence of one or more episodes of AB between 2 and 24 months post-renal transplantation. Primary outcome was the cumulative incidence of acute pyelonephritis (APN) or lower urinary tract infections (LUTI) occurring between 2 and 24 months post-renal transplantation.

RESULTS

Thirty-seven patients presented 171 AB episodes. One hundred sixty-four AB episodes were untreated (95.9%); among them, 150 episodes (91.5%) were not followed by a clinical infection. Ten episodes (6.1%) led to APN, and 4 (2.4%) to LUTI. There were 53 episodes of APN: 10 (18.9%) after untreated AB and 43 (81.1%) de novo. There were 11 episodes of LUTI: 4 (36.4%) after untreated AB and 7 (63.6%) de novo. Multi-drug resistant bacteria were present in 27% of the patients and in 20% of patients with pre-existing uropathy.

CONCLUSIONS

Our results are not in favor of systematic treatment of AB in pediatric KTR. Notably, limitation of antibiotic treatment is an urgent and important health issue in this population, in order to reduce multi-drug resistant bacteria emergence.

Impact of asymptomatic bacteriuria incidence and management post-kidney transplantation

OBJECTIVE

Urinary tract infections (UTIs) are the most commonly occurring infectious complication following kidney transplantation. Questions remain regarding whether asymptomatic bacteriuria (ASB) should be treated. The aim was to evaluate the incidence and management of ASB in kidney transplant recipients at a large academic medical center.

METHODS

All subjects receiving an isolated kidney transplant between September 2012 and October 2016, and with at least one ASB episode were included. Demographics, symptomatology, and urine culture data were collected on subjects with bacteriuria in the first year post-transplant. Cultures were classified by symptoms, ASB treatment trends were analyzed, and ASB-to-UTI progression was compared between ASB treatment and non-treatment.

RESULTS

A total of 527 subjects were transplanted with 64 developing at least one ASB episode. The incidence of ASB was 12.1% and treated 74.6% of the time. Neither lack of ASB treatment (P = 0.463) nor ASB within the first month post-transplant (P = 0.303) were associated with ASB-to-UTI progression.

CONCLUSION

Despite high ASB treatment rate, this was not found to be protective against ASB-to-UTI progression. ASB within the first month post-transplant also did not correlate with increased progression risk. These results suggest minimization of ASB treatment in kidney transplant recipients remains an important antimicrobial stewardship target.

Resuscitating the Critically Ill Geriatric Emergency Department Patient

The emergency department resuscitation of the critically ill geriatric patient is challenging and can be fraught with peril. The anatomic and physiologic changes that occur with aging can significantly influence the recognition of critical illness and the logistics of resuscitation itself. This article discusses the relevant physiologic changes with aging, the effect of these changes on clinical manifestations of critical illness in older adults, and the core principles of resuscitation in this population, with specific attention to sepsis and trauma care. In addition, end-of-life care is also discussed.

Antibiotic Treatment Versus No Treatment for Asymptomatic Bacteriuria in Kidney Transplant Recipients: A Multicenter Randomized Trial

Background

Whether antibiotic treatment of asymptomatic bacteriuria (AB) can prevent acute graft pyelonephritis (AGP) in kidney transplant (KT) recipients has not been elucidated.

Methods

In this multicenter, open-label, nonblinded, prospective, noninferiority, randomized controlled trial, we compared antibiotic treatment with no treatment for AB in KT recipients in the first year after transplantation when urinary catheters had been removed. The primary endpoint was the occurrence of AGP. Secondary endpoints included bacteremic AGP, cystitis, susceptibility of urine isolates, graft rejection, graft function, graft loss, opportunistic infections, need for hospitalization, and mortality.

Results

We enrolled 205 KT recipients between 2013 and 2015. AB occurred in 41 (42.3%) and 46 (50.5%) patients in the treatment and no treatment groups, respectively. There were no differences in the primary endpoint in the intention-to-treat population (12.2% [5 of 41] in the treatment group vs 8.7% [4 of 46] in the no treatment group; risk ratio, 1.40; 95% confidence interval, 0.40–4.87) or the per-protocol population (13.8% [4 of 29] in the treatment group vs 6.7% [3 of 45] in the no treatment group; risk ratio, 2.07, 95% confidence interval, 0.50–8.58). No differences were found in secondary endpoints, except for antibiotic susceptibility. Fosfomycin (P = .030), amoxicillin-clavulanic (P < .001) resistance, and extended-spectrum β-lactamase production (P = .044) were more common in KT recipients receiving antibiotic treatment for AB.

Conclusions

Antibiotic treatment of AB was not useful to prevent AGP in KT recipients and may increase antibiotic resistance. However, our findings should be regarded with caution, due to the small sample size analyzed.

An introduction to the epidemiology and burden of urinary tract infections

Urinary tract infections (UTIs) are the most common outpatient infections, with a lifetime incidence of 50−60% in adult women. This is a narrative review aimed at acting as an introduction to the epidemiology and burden of UTIs. This review is based on relevant literature according to the experience and expertise of the authors. The prevalence of UTI increases with age, and in women aged over 65 is approximately double the rate seen in the female population overall. Etiology in this age group varies by health status with factors such as catheterization affecting the likelihood of infection and the pathogens most likely to be responsible. In younger women, increased sexual activity is a major risk factor for UTIs and recurrence within 6 months is common. In the female population overall, more serious infections such as pyelonephritis are less frequent but are associated with a significant burden of care due to the risk of hospitalization. Healthcare-associated UTIs (HAUTIs) are the most common form of healthcare-acquired infection. Large global surveys indicate that the nature of pathogens varies between the community and hospital setting. In addition, the pathogens responsible for HAUTIs vary according to region making adequate local data key to infection control. UTIs create a significant societal and personal burden, with a substantial number of medical visits in the United States every year being related to UTIs. European data indicate that recurrent infections are related to increased absenteeism and physician visits. In addition, quality of life measures are significantly impacted in women suffering from recurrent UTIs. Data suggest that nonantimicrobial prophylactic strategies offer an opportunity to reduce both the rate of UTIs and the personal burden experience by patients.