Current controversies in urinary tract infections: ICI-RS 2017

PREVALENCE OF ASYMPTOMATIC BACTERIURIA AND ITS DISTRIBUTION BY SEX AND AGE GROUPS IN CHILDREN COMING FOR ROUTINE IMMUNIZATION IN DISTRICT PESHAWAR, PAKISTAN

Background: Asymptomatic bacteriuria (ASB) in not an uncommon disease in children. It may lead to symptomatic infection and later on renal damage. The objectives of this study were to determine the prevalence of ASB and its distribution by sex and age groups in children coming for routine immunization in District Peshawar, Pakistan.Material and methods: This cross-sectional study was conducted in Department of Pediatrics, Khyber Girls Medical College, Peshawar, Pakistan form March 2017 to August 2017. 146 children presenting for routine immunization were selected. Sex, age groups, age in years and presence of ASB were variables. Sex, age groups and presence of ASB were analyzed by count and percentage with 80%CL. Age in years was analyzed by mean, SD and range with 95%CI.Results: Out of 146 children, 65 (44.52%) were males and 81 (55.48%) females, and 51 (34.93%) in age group ≤3 years, 52 (35.62%) in 3.0-6.50 years and 43 (29.45%) in 6.51-10 years. Mean age of sample was 4.82±2.81 (09-9.50, range 8.60) (95%CI 4.36-5.28) years. ASB was found in 16 (10.96%) cases. Prevalence of ASB was higher 4.11% in boys than 6.856% girls. It was highest 6.85% in age group 3.0-6.50 years, followed by 2.74% in 6.51-10 years and 1.37% in age group ≤3.0 years.Conclusion: Asymptomatic Bacteriuria is quite common in our children. It is a significant health risk especially among females, and we suggest more studies to find out the underlying factors and follow up studies on its complications.

Paper and thread as media for the frugal detection of urinary tract infections (UTIs)

Urinary tract infections (UTIs) make up a significant proportion of the global burden of disease in vulnerable groups and tend to substantially impair the quality of life of those affected, making timely detection of UTIs a priority for public health. However, economic and societal barriers drastically reduce accessibility of traditional lab-based testing methods for critical patient groups in low-resource areas, negatively affecting their overall healthcare outcomes. As a result, cellulose-based materials such as paper and thread have garnered significant interest among researchers as substrates for so-called frugal analytical devices which leverage the material's portability and adaptability for facile and reproducible diagnoses of UTIs. Although the field may be only in its infancy, strategies aimed at commercial penetration can appreciably increase access to more healthcare options for at-risk people. In this review, we catalogue recent advances in devices that use cellulose-based materials as the primary housing or medium for UTI detection and chart out trends in the field. We also explore different modalities employed for detection, with particular emphasis on their ability to be ported onto discreet casings such as sanitary products.

Investigation and treatment of asymptomatic bacteriuria in older patients with delirium: a cross-sectional survey of Canadian physicians

OBJECTIVES

Current guidelines suggest assessing non-infectious causes and careful observation before giving antibiotics to delirious patients with asymptomatic bacteriuria. Our study aims to describe the current practice of Canadian physicians regarding the investigation and treatment of asymptomatic bacteriuria in delirious older patients (aged ≥ 65 years).

METHODS

Our team of medical experts designed and reviewed a cross-sectional online survey. Study participants were physicians who conduct their clinical practice in Canada and care for older patients with delirium in their current practice. Potential study participants were reached through Canadian associations: Canadian Geriatrics Society, the Canadian Association of Emergency Physicians, the Association des Médecins d'Urgence du Québec and members of Choosing Wisely Canada.

RESULTS

297 physicians were included. The main results show 79.4% of our participants request a urine dipstick or urinalysis in delirious patients and 52.4% immediately order a urine culture with the urinalysis. If bacteriuria is found in delirious but afebrile patients without urinary symptoms, 38% of physicians immediately treat with antibiotics, 33.8% wait for culture before initiating treatment, 14.4% treat if no other cause is found for delirium and only 13.7% would refrain from giving antibiotics. Results from respondents were similar for delirious patients with known cognitive impairment. Participants were almost unanimous (92.5%) in saying they need clear guidelines regarding the treatment of bacteriuria in older delirious patients.

CONCLUSIONS

This survey highlights the heterogeneous clinical management of asymptomatic bacteriuria in delirious patients and the need for clear guidelines for patients.

Contemporary management considerations of urinary tract infections for women with spina bifida

INTRODUCTION AND HYPOTHESIS

Urinary tract infections (UTIs) are one of the leading health concerns and causes of hospitalization for adults with spina bifida (SB). The risk factors, evaluation, management, and prevention of UTIs in women with SB must take into consideration their unique pelvic anatomy and function as well as the desire for pregnancy or the occurrence UTI during pregnancy. This article reviews published literature regarding this topic and offers recommendations for UTI evaluation, management, and prevention in the context of the unique pelvic floor health needs of women with SB.

METHODS

A systematic review was conducted using the following keywords: spinal dysraphism, spina bifida, myelomeningocele, meningocele, urinary tract infections, females, and adults. Articles were included if they were in English, published during or after 2000, peer reviewed, included women with spina bifida aged 18 or greater, and included outcomes related to urinary tract infection.

RESULTS

No articles met inclusion criteria.

CONCLUSION

As no articles were found based on the initial search criteria, articles pertaining to neurogenic bladder UTI risks, evaluation, and management were discussed to develop consensus recommendations for the unique care of UTIs in women with SB.

Biomarkers in urinary tract infections - which ones are suitable for diagnostics and follow-up?

Introduction: Urinary tract infections (UTIs) are one of the most common infections worldwide. Under special circumstances, clinicians must rely on laboratory findings, which might have a weak predicting value, misguiding the practitioners and leading to incorrect diagnosis and overuse of antibiotics. Therefore, there is an urgent need for reliable biomarkers in UTIs. Methods: We performed a literature search for biomarkers used in UTIs from January 1999 until May 2020. We used "urinary tract infection" and "biomarker" as the main key words in the PubMed, Medline and Cochrane databases. After peer review, we excluded the duplicates and identified the suitable articles, from which we collected the data and divided the available biomarkers into 5 groups: i) conventional markers; ii) promising, thoroughly studied biomarkers; iii) promising biomarkers that need further studies; iv) biomarkers of unknown significance; v) controversial, not useful markers. Results: We found 131 articles, mostly from the paediatric population. Neutrophil gelatinase-associated lipocalin (NGAL) and interleukins (IL) have a leading role in diagnosing and differentiating UTIs based on a lot of observational, comparative trials. Heparin Binding Protein (HBP), Lactoferrin (LF), Heat-Shock Protein-70 (HSP-70), Human Defensin-5 (HD-5), Lipopolysaccharide Binding Protein (LBP) and mass spectrometry studies are promising, but confirming data are lacking. The measurable components of the innate immune system and local host cell response could be appropriate biomarkers, but their significance is currently unknown. Conclusions: Conventional biomarkers for UTIs have low specificity. The use of urinary NGAL and interleukins could improve the sensitivity and specificity of laboratory diagnosis of UTIs.

Management of Recurrent Urinary Tract Infections in Women: How Providers Can Improve the Patient Experience

OBJECTIVE

To provide guidance to providers on how to improve the patient experience for women with recurrent urinary tract infections (rUTIs).

METHODS

The recently updated 2019 American Urological Association (AUA) guidelines for recurrent uncomplicated acute cystitis and other contemporary publications pertaining to recurrent UTIs in women were reviewed. These data were used to summarize practice-based methodology to formulate recommendations with an emphasis on education to enhance the patient experience.

RESULTS

We summarize the guideline-based management of patients with rUTI and augment this with a patient-focused perspective to provide recommendations for how to best counsel patients regarding evaluation, treatment using antibiotic stewardship practices, and a comprehensive prevention plan. We focus on patient education as the foundation for successful provider-patient relationships as well as patient compliance with care pathways.

CONCLUSION

rUTIs are costly, time-consuming, and painful for patients. For providers, rUTIs represent a frustrating aspect of clinical care facing the balance of antibiotic stewardship with effective treatment and patient expectations with limited data supporting nonantibiotic therapies. Urologists have the skills and knowledge to provide this patient population with competent and compassionate care. By investing in these patients, being responsive to their concerns and offering education, patients will have a better overall experience with this chronic condition.

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.

Adult Neurogenic Lower Urinary Tract Dysfunction and Intermittent Catheterisation in a Community Setting: Risk Factors Model for Urinary Tract Infections

A risk factor model for urinary tract infections in patients with adult neurogenic lower urinary tract dysfunction performing clean intermittent catheterisation was developed; it consists of four domains, namely, (1) general (systemic) conditions in the patient, (2) individual urinary tract conditions in the patient, (3) routine aspects related to the patient, and (4) factors related to intermittent catheters per se. The conceptual model primarily concerns patients with spinal cord injury, spina bifida, multiple sclerosis, or cauda equina where intermittent catheterisation is a normal part of the bladder management. On basis of several literature searches and author consensus in case of lacking evidence, the model intends to provide an overview of the risk factors involved in urinary tract infections, with specific emphasis to describe those that in daily practice can be handled and modified by the clinician and so come to the benefit of the individual catheter user in terms of fewer urinary tract infections.

Identification of Urinary CD44 and Prosaposin as Specific Biomarkers of Urinary Tract Infections in Children With Neurogenic Bladders

PURPOSE

Distinguishing urinary tract infection (UTI) from urinary tract colonization (UTC) in children with neurogenic bladders who require clean intermittent catheterization (CIC) is challenging. Our objective was to identify urinary proteins to distinguish UTI from UTC in CIC-dependent children that have potential to serve as objective markers of UTI.

EXPERIMENTAL DESIGN

A total of 10 CIC-dependent children were included in the mass spectrometry analysis (UTI = 5, UTC = 5). Quantitative profiling of urine proteins with isobaric protein labeling was performed using tandem mass spectrometry. Candidate markers were normalized using a collective mixture of proteins from all samples. Relative quantitative abundance of proteins across all samples were compared. Proteins with >50% change in the average abundance were identified as proteins of interest, which were then measured using enzyme-linked immunosorbent assay (ELISA) in an additional 40 samples (no growth = 10, UTC = 15, UTI = 15).

RESULTS

Mass spectrometry revealed 8 differentially expressed proteins. Of these, apolipoprotein D, alpha-amylase 2B, non-secretory ribonuclease, CD44 antigen, and prosaposin were measurable by ELISA. Concentrations of both CD44 and prosaposin were significantly higher in UTI, with area under the curves (AUCs) of 0.72 and 0.78, respectively.

CONCLUSION

Urinary CD44 and prosaposin are candidate markers that may assist with the diagnosis of UTI in CIC-dependent children.