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Tavenier AH, de Boer FJ, Moshaver B, van der Leur SJCM, Stegeman CA, Groeneveld PHP. Flow cytometric analysis of viable bacteria in urine samples of febrile patients at the emergency department. CYTOMETRY PART B-CLINICAL CYTOMETRY 2017; 94:689-695. [PMID: 28815948 DOI: 10.1002/cyto.b.21548] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 06/21/2017] [Accepted: 08/03/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Fast and reliable diagnostics are important in febrile patients admitted to the emergency department. Current urine diagnostics are fast but moderately reliable or reliable but time consuming. Flow cytometry (FC) is a new promising technique in the diagnostics of complicated urinary tract infections by counting bacteria in urine samples. The aim of this study is to improve the FC method by counting only viable bacteria. METHODS Urine was obtained from 135 consecutive febrile patients at the emergency department. According to protocol regular diagnostic urine tests were performed. In addition, FC counting of viable and non-viable bacteria was executed after staining with thiazole orange and propidium iodide. All test results were compared to the results of urine culture (≥ 105 colony forming units/mL). RESULTS At a cut-off value of 2.01 × 105 viable bacteria/mL the sensitivity was 100% and specificity was 78.4% (AUC-value 0.955 on ROC-curve). Spearman correlation test exhibited a higher correlation for flow cytometric counting of only viable bacteria than counting of all bacteria (0.59 vs. 0.37). Using ROC-curves, the AUC-values for FC counting of all bacteria, only viable bacteria and Gram staining were respectively 0.935, 0.955, and 0.968 (P > 0.05). CONCLUSION FC counting of only viable bacteria can predict quickly and reliably positive and negative urine cultures in febrile patients admitted to the emergency department. It can help to improve the speed and accuracy of the diagnostic procedure at the emergency department. © 2017 Clinical Cytometry Society.
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Affiliation(s)
- Anne H Tavenier
- Department of Internal Medicine/Infectious diseases, Isala Zwolle, The Netherlands
| | - Foppie J de Boer
- Department of Internal Medicine/Infectious diseases, Isala Zwolle, The Netherlands
| | - Bijan Moshaver
- Department of Clinical Chemistry, Isala Zwolle, The Netherlands
| | | | - Coen A Stegeman
- Department of Nephrology, University Medical Centre Groningen and University of Groningen, The Netherlands
| | - Paul H P Groeneveld
- Department of Internal Medicine/Infectious diseases, Isala Zwolle, The Netherlands
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Drozdov D, Schwarz S, Kutz A, Grolimund E, Rast AC, Steiner D, Regez K, Schild U, Guglielmetti M, Conca A, Reutlinger B, Ottiger C, Buchkremer F, Haubitz S, Blum C, Huber A, Buergi U, Schuetz P, Bock A, Fux CA, Mueller B, Albrich WC. Procalcitonin and pyuria-based algorithm reduces antibiotic use in urinary tract infections: a randomized controlled trial. BMC Med 2015; 13:104. [PMID: 25934044 PMCID: PMC4427918 DOI: 10.1186/s12916-015-0347-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are common drivers of antibiotic use. The minimal effective duration of antibiotic therapy for UTIs is unknown, but any reduction is important to diminish selection pressure for antibiotic resistance, costs, and drug-related side-effects. The aim of this study was to investigate whether an algorithm based on procalcitonin (PCT) and quantitative pyuria reduces antibiotic exposure. METHODS From April 2012 to March 2014, we conducted a factorial design randomized controlled open-label trial. Immunocompetent adults with community-acquired non-catheter-related UTI were enrolled in the emergency department of a tertiary-care 600-bed hospital in northwestern Switzerland. Clinical presentation was used to guide initiation and duration of antibiotic therapy according to current guidelines (control group) or with a PCT-pyuria-based algorithm (PCT-pyuria group). The primary endpoint was overall antibiotic exposure within 90 days. Secondary endpoints included duration of the initial antibiotic therapy, persistent infection 7 days after end of therapy and 30 days after enrollment, recurrence and rehospitalizations within 90 days. RESULTS Overall, 394 patients were screened, 228 met predefined exclusion criteria, 30 declined to participate, and 11 were not eligible. Of these, 125 (76% women) were enrolled in the intention-to-treat (ITT) analysis and 96 patients with microbiologically confirmed UTI constituted the per protocol group; 84 of 125 (67%) patients had a febrile UTI, 28 (22%) had bacteremia, 5 (4%) died, and 3 (2%) were lost to follow-up. Overall antibiotic exposure within 90 days was shorter in the PCT-pyuria group than in the control group (median 7.0 [IQR, 5.0-14.0] vs. 10.0 [IQR, 7.0-16.0] days, P = 0.011) in the ITT analysis. Mortality, rates of persistent infections, recurrences, and rehospitalizations were not different. CONCLUSIONS A PCT-pyuria-based algorithm reduced antibiotic exposure by 30% when compared to current guidelines without apparent negative effects on clinical outcomes.
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Affiliation(s)
- Daniel Drozdov
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. .,Division of Infectious Diseases, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Stefanie Schwarz
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Alexander Kutz
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Eva Grolimund
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Anna Christina Rast
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Deborah Steiner
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Katharina Regez
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Ursula Schild
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Merih Guglielmetti
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Antoinette Conca
- Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Barbara Reutlinger
- Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Cornelia Ottiger
- Department of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Florian Buchkremer
- Division of Nephrology, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Sebastian Haubitz
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Claudine Blum
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Ulrich Buergi
- Department of Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Philipp Schuetz
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Andreas Bock
- Division of Nephrology, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Christoph Andreas Fux
- Division of Infectious Diseases, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Beat Mueller
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland.
| | - Werner Christian Albrich
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. .,Division of Infectious Diseases, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. .,Department of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland.
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Abel zur Wiesch P, Kouyos R, Abel S, Viechtbauer W, Bonhoeffer S. Cycling empirical antibiotic therapy in hospitals: meta-analysis and models. PLoS Pathog 2014; 10:e1004225. [PMID: 24968123 PMCID: PMC4072793 DOI: 10.1371/journal.ppat.1004225] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 05/13/2014] [Indexed: 01/12/2023] Open
Abstract
The rise of resistance together with the shortage of new broad-spectrum antibiotics underlines the urgency of optimizing the use of available drugs to minimize disease burden. Theoretical studies suggest that coordinating empirical usage of antibiotics in a hospital ward can contain the spread of resistance. However, theoretical and clinical studies came to different conclusions regarding the usefulness of rotating first-line therapy (cycling). Here, we performed a quantitative pathogen-specific meta-analysis of clinical studies comparing cycling to standard practice. We searched PubMed and Google Scholar and identified 46 clinical studies addressing the effect of cycling on nosocomial infections, of which 11 met our selection criteria. We employed a method for multivariate meta-analysis using incidence rates as endpoints and find that cycling reduced the incidence rate/1000 patient days of both total infections by 4.95 [9.43–0.48] and resistant infections by 7.2 [14.00–0.44]. This positive effect was observed in most pathogens despite a large variance between individual species. Our findings remain robust in uni- and multivariate metaregressions. We used theoretical models that reflect various infections and hospital settings to compare cycling to random assignment to different drugs (mixing). We make the realistic assumption that therapy is changed when first line treatment is ineffective, which we call “adjustable cycling/mixing”. In concordance with earlier theoretical studies, we find that in strict regimens, cycling is detrimental. However, in adjustable regimens single resistance is suppressed and cycling is successful in most settings. Both a meta-regression and our theoretical model indicate that “adjustable cycling” is especially useful to suppress emergence of multiple resistance. While our model predicts that cycling periods of one month perform well, we expect that too long cycling periods are detrimental. Our results suggest that “adjustable cycling” suppresses multiple resistance and warrants further investigations that allow comparing various diseases and hospital settings. The rise of antibiotic resistance is a major concern for public health. In hospitals, frequent usage of antibiotics leads to high resistance levels; at the same time the patients are especially vulnerable. We therefore urgently need treatment strategies that limit resistance without compromising patient care. Here, we investigate two strategies that coordinate the usage of different antibiotics in a hospital ward: “cycling”, i.e. scheduled changes in antibiotic treatment for all patients, and “mixing”, i.e. random assignment of patients to antibiotics. Previously, theoretical and clinical studies came to different conclusions regarding the usefulness of these strategies. We combine meta-analyses of clinical studies and epidemiological modeling to address this question. Our meta-analyses suggest that cycling is beneficial in reducing the total incidence rate of hospital-acquired infections as well as the incidence rate of resistant infections, and that this is most pronounced at low baseline levels of resistance. We corroborate our findings with theoretical epidemiological models. When incorporating treatment adjustment upon deterioration of a patient's condition (“adjustable cycling”), we find that our theoretical model is in excellent accordance with the clinical data. With this combined approach we present substantial evidence that adjustable cycling can be beneficial for suppressing the emergence of multiple resistance.
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Affiliation(s)
- Pia Abel zur Wiesch
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
- Division of Global Health Equity, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Roger Kouyos
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Sören Abel
- Division of Infectious Diseases, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Wolfgang Viechtbauer
- Department of Psychiatry and Psychology, School for Mental Health and Neuroscience, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Drozdov D, Thomer A, Meili M, Schwarz S, Kouegbe RB, Regez K, Guglielmetti M, Schild U, Conca A, Schäfer P, Reutlinger B, Ottiger C, Buchkremer F, Litke A, Schuetz P, Huber A, Bürgi U, Fux CA, Bock A, Müller B, Albrich WC. Procalcitonin, pyuria and proadrenomedullin in the management of urinary tract infections--'triple p in uti': study protocol for a randomized controlled trial. Trials 2013; 14:84. [PMID: 23522152 PMCID: PMC3614534 DOI: 10.1186/1745-6215-14-84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/28/2013] [Indexed: 11/30/2022] Open
Abstract
Background Urinary tract infections (UTIs) are among the most common infectious diseases and drivers of antibiotic use and in-hospital days. A reduction of antibiotic use potentially lowers the risk of antibiotic resistance. An early and adequate risk assessment combining medical, biopsychosocial and functional risk scores has the potential to optimize site-of-care decisions and thus allocation of limited health-care resources. The aim of this factorial design study is twofold: first, for Intervention A, it investigates antibiotic exposure of patients treated with a protocol based on the type of UTI, procalcitonin (PCT) and pyuria. Second, for Intervention B, it investigates the usefulness of the prognostic biomarker proadrenomedullin (ProADM) integrated into an interdisciplinary assessment bundle for site-of-care decisions. Methods and design This randomized controlled open-label trial has a factorial design (2 × 2). Randomization of patients will be based on a pre-specified computer-generated randomization list and independent for the two interventions. Adults with UTI presenting to the emergency department (ED) will be screened and enrolled after providing informed consent. For our first Intervention (A), we developed a protocol based on previous observational research to recommend initiation and duration of antibiotic use based on the clinical presentation of UTI, pyuria and PCT levels. For our second intervention (B), an algorithm was developed to support site-of care decisions based on the prognostic marker ProADM and distinct nursing factors on days 1 and 3. Both interventions will be compared with a control group conforming to the guidelines. The primary endpoints for the two interventions will be: (A) overall exposure to antibiotics and (B) length of physician-led hospitalization within a follow-up of 30 days. Endpoints are assessed at discharge from hospital, and 30 and 90 days after admission. We plan to screen 300 patients and enroll 250 for an anticipated estimated loss of follow-up of 20%. This will provide adequate power for the two interventions. Discussion This trial investigates two strategies for improved individualized medical care in patients with UTI. The minimally effective duration of antibiotic therapy is not known for UTIs, which is important for reducing the selection pressure for antibiotic resistance, costs and drug-related side effects. Triage decisions must be improved to reflect the true medical, biopsychosocial and functional risks in order to allocate patients to the most appropriate care setting and reduce hospital-acquired disability. Trial registration Trial registration number:
ISRCTN13663741
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Affiliation(s)
- Daniel Drozdov
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland
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