Diagnosis and management of urinary tract infection in older adults

Diagnosis of urinary tract infections in the hospitalized older adult population in Alberta

BACKGROUND

Urinary tract infections (UTIs) are one of the most common infections reported in older adults, across all settings. Although a diagnosis of a UTI requires specific clinical and microbiological criteria, many older adults are diagnosed with a UTI without meeting the diagnostic criteria, resulting in unnecessary antibiotic treatment and their potential side effects, and a failure to find the true cause of their presentation to hospital.

OBJECTIVE

The aim of this study was to evaluate the accuracy of UTI diagnoses amongst hospitalized older adults based on clinical and microbiological findings, and their corresponding antibiotic treatment (including complications), in addition to identifying possible factors associated with a confirmed UTI diagnosis.

METHODS

A single-center retrospective cross-sectional study of older adult patients (n = 238) hospitalized at the University of Alberta Hospital with an admission diagnosis of UTI over a one-year period was performed.

RESULTS

44.6% (n = 106) of patients had a diagnosis of UTI which was supported by documents clinical and microbiological findings while 43.3% (n = 103) of patients had bacteriuria without documented symptoms. 54.2% (n = 129) of all patients were treated with antibiotics, despite not having evidence to support a diagnosis of a UTI, with 15.9% (n = 37) of those patients experiencing complications including diarrhea, Clostridioides difficile infection, and thrush. History of major neurocognitive disorder was significantly associated with diagnosis of UTI (p = 0.003).

CONCLUSION

UTIs are commonly misdiagnosed in hospitalized older adults by healthcare providers, resulting in the majority of such patients receiving unnecessary antibiotics, increasing the risk of complications. These findings will allow for initiatives to educate clinicians on the importance of UTI diagnosis in an older adult population and appropriately prescribing antibiotics to prevent unwanted complications.

Distinct patterns of postoperative fever in paediatric neurosurgery patients

PURPOSE

Postoperative fever is a common problem following neurosurgery but data on the causes among paediatric patients is sparse. In this report, we determined the incidence, causes, and outcomes of postoperative fever in paediatric neurosurgical patients (< 18 years), and contrasted the findings with an adult cohort published recently from our unit.

METHODS

We recruited 61 patients who underwent 73 surgeries for non-traumatic neurosurgical indications over 12 months. A standard protocol was followed for the evaluation and management of postoperative fever. We prospectively collected data pertaining to operative details, daily maximal temperature, clinical features, and use of surgical drains, urinary catheters, and other adjuncts. Elevated body temperature of > 99.9 °F or 37.7 °C for > 48 h or associated with clinical deterioration or localising features was considered as "fever"; elevated temperature not meeting these criteria was classified as transient elevation in temperature (TET).

RESULTS

Twenty-six patients (35.6%) had postoperative fever, more frequent than in adult patients. TET occurred in 12 patients (16.4%). The most common causes of fever were aseptic meningitis (34.6%), followed by urinary tract infections (15.4%), pyogenic meningitis, COVID-19, and wound infections. Postoperative fever was associated with significantly longer duration of hospital admission and was the commonest cause of readmission.

CONCLUSION

In contrast to adults, early temperature elevations in paediatric patients may portend infectious and serious non-infectious causes of fever, including delayed presentation with aseptic meningitis, a novel association among paediatric patients. Investigation guided by clinical assessment and conservative antibiotic policy in keeping with the institutional microbiological profile provides the most appropriate strategy in managing paediatric postoperative fever.

Laboratory Tests, Bacterial Resistance, and Treatment Options in Adult Patients Hospitalized with a Suspected Urinary Tract Infection

Patients treated for systemic urinary tract infections commonly have nonspecific presentations, and the specificity of the results of the urinalysis and urine cultures is low. In the following narrative review, we will describe the widespread misuse of urine testing, and consider how to limit testing, the disutility of urine cultures, and the use of antibiotics in hospitalized adult patients. Automated dipstick testing is more precise and sensitive than the microscopic urinalysis which will result in false negative test results if ordered to confirm a positive dipstick test result. There is evidence that canceling urine cultures if the dipstick is negative (negative leukocyte esterase, and nitrite) is safe and helps prevent the overuse of urine cultures. Because of the side effects of introducing a urine catheter, for patients who cannot provide a urine sample, empiric antibiotic treatment should be considered as an alternative to culturing the urine if a trial of withholding antibiotic therapy is not an option. Treatment options that will decrease both narrower and wider spectrum antibiotic use include a period of watching and waiting before antibiotic therapy and empiric treatment with antibiotics that have resistance rates > 10%. Further studies are warranted to show the option that maximizes patient comfort and safety.

A Case of Bacteremia Caused by Raoultella planticola Direct Identification from Blood Culture by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry

Background: Raoultella planticola is an uncommon gram-negative organism found in the environment. Patients and Methods: The patient, an 81-year-old female who had undergone total cystectomy and bilateral ureteral stoma surgery, presented to the hospital with a fever. It was determined that Raoultella planticola was responsible for the bacteremia. Results: Rapid identification of bacteria using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) in blood culture samples and appropriate antibacterial treatment was begun and the patient was discharged three days later. Conclusions: This case emphasizes the presence of a rare pathogen as the cause of bacteremia and underscores the importance of utilizing rapid methods for bacterial identification to establish an accurate diagnosis.

Proposing the "Continuum of UTI" for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections

PURPOSE

Patients with suspected UTIs are categorized into 3 clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach.

MATERIALS AND METHODS

This was a retrospective cohort study of a random sample of adult noncatheterized inpatient and emergency department encounters with paired urinalysis and urine cultures from 5 hospitals in 3 states between January 01, 2017, and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the continuum of UTI, a 5-level classification scheme that includes 2 new categories: lower urinary tract symptoms/other urologic symptoms and bacteriuria of unclear significance. The newly defined continuum of UTI categories were compared to the current UTI classification scheme.

RESULTS

Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the continuum of UTI categories, 68% of patients (n = 478) with ASB were reclassified as bacteriuria of unclear significance and 29% of patients (n = 467) with "no UTI" were reclassified to lower urinary tract symptoms/other urologic symptoms.

CONCLUSIONS

Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by frontline clinicians, and promote a nuanced approach to diagnosis and management of UTIs.

The Clinical Profile of Patients With Culture-Positive Urinary Tract Infections Admitting to a Tertiary Hospital in Sri Lanka

Introduction Urinary tract infections (UTIs) are globally prevalent. This study explores the clinical and pathological profile of culture-positive UTI patients at Sri Jayewardenepura General Hospital. Method In this descriptive cross-sectional study conducted at Sri Jayewardenepura General Hospital from December 2020 to May 2021, we evaluated patients over 14 years with positive urine culture reports. Excluding those with HIV, undergoing chemotherapy, or pregnant, we used consecutive sampling. Data were collected via interviewer-administered questionnaires and analyzed using SPSS version 21.0 (IBM Inc., Armonk, New York), employing descriptive statistics and Fisher's exact tests to identify factors associated with urinary tract infections. Results The study involved approximately 278 participants. The mean age remained 60 ± 20.279 years, with over half of the participants being female. Common symptoms like fever and lower abdominal pain were observed in 22.30% of cases. The incidence of acute kidney injury was 30.58%. Escherichia coli (36%) and Klebsiella pneumoniae (26%) were the predominant organisms found. Indwelling catheters and other urinary tract conditions were considered risk factors. Patients with at least one risk factor were more likely to receive antibiotics before the urine culture. Similarly, males exhibited a higher prevalence of at least a risk factor than females. Conclusion UTIs are a significant clinical issue in older populations, with females being more susceptible. Fever and abdominal pain were common symptoms. Escherichia coli and Klebsiella pneumoniae were the most frequent causative agents. Further research is necessary to identify risk factors and predictors of antimicrobial resistance in UTI patients.

Prevalence, antibiotic resistance pattern for bacteriuria from patients with urinary tract infections

Background and Aims

Antibiotic resistance presents a significant global public health challenge, particularly for urinary tract infections (UTIs), and is notably severe in developing countries. Surveillance of the antimicrobial susceptibility patterns of UTI-causing bacteria is crucial for effective treatment selection. This study aimed to analyze these patterns in bacteria isolated from the urine samples of patients at Mughda Medical College Hospital, Dhaka, Bangladesh.

Methods

A retrospective study (January 2019 to December 2020) at Mugdha Medical College and Hospital, Dhaka, examined clinical and laboratory data from patients with positive urine cultures (≥105 CFU/mL). The study classified patients into four age groups: children (1-<18 years), young adults (18-<33 years), middle-aged adults (33-50 years), and old adults (>50 years). The standard Kirby-Bauer method was used to assess antibiotic sensitivity to 28 common antibiotics.

Results

Among 243 positive urine cultures in both community- and hospital-acquired UTIs, Escherichia coli was the most common uropathogen (65.84%), followed by Klebsiella spp. (12.34%), Enterococcus spp. (8.23%), and other types of bacteria.

Conclusion

Old adults are particularly vulnerable to UTIs, with E. coli being the predominant causative agent in the study region. The observed antimicrobial resistance patterns underscore the necessity of judicious antibiotic selection to effectively treat UTIs across different age groups.

Case report: Long-term follow-up of patients who received a FimCH vaccine for prevention of recurrent urinary tract infections caused by antibiotic resistant Enterobacteriaceae: a case report series

Urinary tract infections (UTI) caused by carbapenem-resistant Enterobacteriaceae (CRE) are considered one of the most urgent health threats to humans according to the Centers for Disease Control (CDC), and the World Health Organization (WHO). A FimCH Vaccine expanded access study is being conducted in patients with a history of antibiotic resistant UTIs who are considered to be at risk for development of CRE UTI. This case series describes the clinical, safety and immunogenicity findings for four participants who received a FimCH four-vaccine series. Participants were followed for 12 months after administration of the fourth vaccine for safety, general health status and UTI occurrence. The study was later amended to allow additional follow-up of up to five years post vaccine administration to assess long-term health status, UTI occurrences and to obtain blood samples for anti-FimH antibody testing. In our population of 4 study participants, the number of symptomatic UTI occurrences caused by gram-negative bacteria in the 12-month period following peak anti-FimH antibody response were approximately 75% lower than the 12-month period preceding study enrollment. These results are consistent with the 30-patient cohort of a Phase 1 study with the same FimCH Vaccine. UTI occurrences increased during the long-term follow-up period for all 4 participants but did not reach the rate observed pre-vaccination. No new safety concerns related to the FimCH Vaccine were identified during long-term follow-up. This case series has clinical importance and public health relevance since it examines and reports on UTI frequency and recurrence following vaccination with the FimCH Vaccine in a high-risk population of patients with recurrent UTI. Additionally, participants described improved well-being following vaccination which was maintained in the long-term follow-up period.

Antibiotics prophylaxis at the time of catheter removal after radical prostatectomy: a systematic review of the literature and meta-analysis

PURPOSE

To conduct a systematic literature review with meta-analysis to identify whether antibiotic prophylaxis after removal of the indwelling urinary catheter reduces posterior infections.

METHODS

A systematic literature review was conducted in the databases PubMed, Embase, Cochrane, Google Scholar, and Latin American and Caribbean Health Sciences Literature, using the keywords "antibiotics" AND "prostatectomy" AND "urinary catheter."

RESULTS

Three articles were identified having the scope of our review, with 1,040 patients, which were subjected to our meta-analysis revealing a marginally significant decrease in the risk of urinary infection after indwelling urinary catheter removal (odds ratio-OR = 0.51; 95% confidence interval-95%CI 0.27-0.98; p = 0.04; I2 = 0%). No difference was found regarding the presence of bacteriuria (OR = 0.39; 95%CI 0.12-1.24; p = 0.11; I2 = 73%).

CONCLUSIONS

In our meta-analysis, there was a significant decrease in urinary tract infection with antibiotic prophylaxis after indwelling urinary catheter removal following radical prostatectomy.

Methenamine for urinary tract infection prophylaxis: A systematic review

Urinary tract infections (UTIs) commonly affect many patient populations. Recurrent UTIs (rUTIs) can be particularly problematic and lead to potential hospitalizations, multiple antibiotic courses, and have a potential negative impact on quality of life. To prevent UTIs, antibiotics are frequently used for prophylaxis; however, antibiotic prophylaxis has notable untoward consequences including but not limited to potential adverse effects and development of antibiotic resistance. Methenamine, an antiseptic agent initially available in 1967, has re-emerged as a potential option for UTI prophylaxis in various populations, including older adults and renal transplant recipients. The objective of this systematic review was to evaluate the clinical effectiveness and safety of methenamine for UTI prophylaxis. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance was performed. A PubMed, Embase, and Cochrane library search was conducted to identify relevant English-language studies evaluating methenamine for UTI prophylaxis including randomized controlled trials, case-control studies, and meta-analyses through June 2023. Articles were excluded if the studies did not primarily describe or evaluate methenamine for UTI prophylaxis, were commentaries/viewpoints articles, point prevalence studies, review articles, studies that evaluated methenamine used with another agent, and any duplicate publications from searched databases. A total of 11 articles were identified for inclusion. This systematic review suggests methenamine generally appears to be an effective and well-tolerated antibiotic-sparing option for UTI prophylaxis. Furthermore, the pharmacology, dosage and formulation, warnings, precautions, and safety considerations of methenamine that provide potential clinical considerations regarding its use for UTI prophylaxis are described. Further studies are needed to evaluate the clinical utility of methenamine for UTI prophylaxis.

Delayed and Non-Antibiotic Therapy for Urinary Tract Infections: A Literature Review

Urinary tract infections are among the most common infections encountered in the clinic and remain a top indication for women to receive antibiotics. Delayed antibiotic prescribing and non-antibiotic symptomatic therapies are treatment paradigms common to other uncomplicated infectious diseases, such as upper respiratory infections. We aimed to review the literature on delayed antibiotics and non-antibiotic treatments as alternatives to immediate antibiotic prescriptions for uncomplicated cystitis. A literature search was performed in PubMed, Google Scholar, and Web of Science to identify relevant clinical trials and reference lists of included articles were examined to find additional studies. All published trials where same day treatment with antibiotics was compared to scenarios where antibiotics were intentionally delayed or withheld or where antibiotics were compared to non-antimicrobial agents or placebo were analyzed. A total of 13 articles were included. Trials were grouped into categories based on their comparator groups: placebo (n = 5), delayed antibiotic therapy (n = 3), and symptomatic treatment (n = 5). Antibiotic delay and ibuprofen, while less effective than antibiotics in early microbiologic and clinical cure, may still be considered plausible alternatives to immediate antibiotic treatment in non-pregnant women with cystitis. Day 7 and later symptomatic resolution ranges from 26-75% with delayed or placebo therapy and 70-83% with nonsteroidal anti-inflammatory drugs. Symptom improvement, however, may be delayed compared to immediate antibiotics. These approaches have shown to decrease antibiotic use in primary care settings with low rates of pyelonephritis. Methodology included in these studies may be considered in stewardship interventions for outpatient clinics.

D-Mannose reduces cellular senescence and NLRP3/GasderminD/IL-1β-driven pyroptotic uroepithelial cell shedding in the murine bladder

Aging is a risk factor for disease via increased susceptibility to infection, decreased ability to maintain homeostasis, inefficiency in combating stress, and decreased regenerative capacity. Multiple diseases, including urinary tract infection (UTI), are more prevalent with age; however, the mechanisms underlying the impact of aging on the urinary tract mucosa and the correlation between aging and disease remain poorly understood. Here, we show that, relative to young (8-12 weeks) mice, the urothelium of aged (18-24 months) female mice accumulates large lysosomes with reduced acid phosphatase activity and decreased overall autophagic flux in the aged urothelium, indicative of compromised cellular homeostasis. Aged bladders also exhibit basal accumulation of reactive oxygen species (ROS) and a dampened redox response, implying heightened oxidative stress. Furthermore, we identify a canonical senescence-associated secretory phenotype (SASP) in the aged urothelium, along with continuous NLRP3-inflammasome- and Gasdermin-D-dependent pyroptotic cell death. Consequently, aged mice chronically exfoliate urothelial cells, further exacerbating age-related urothelial dysfunction. Upon infection with uropathogenic E. coli, aged mice harbor increased bacterial reservoirs and are more prone to spontaneous recurrent UTI. Finally, we discover that treatment with D-mannose, a natural bioactive monosaccharide, rescues autophagy flux, reverses the SASP, and mitigates ROS and NLRP3/Gasdermin/interleukin (IL)-1β-driven pyroptotic epithelial cell shedding in aged mice. Collectively, our results demonstrate that normal aging affects bladder physiology, with aging alone increasing baseline cellular stress and susceptibility to infection, and suggest that mannose supplementation could serve as a senotherapeutic to counter age-associated urothelial dysfunction.

Diagnostic validation study of rapid urinary tract infection diagnosis kit at peripheral health facilities of West Bengal, India

Patients reporting to the outpatient departments of peripheral health care settings in India with symptoms of urinary tract infection (UTI) receive one or the other antibiotic before culture confirmation and out of the total culture confirmed UTI cases, in less than one third cases the prescribed antibiotics matches to the antibiotic sensitivity test result. Hence, in this study, an indigenous point-of-care (POCT) rapid diagnostic kit (Rapidogram) for UTI was validated against conventional urine culture and sensitivity to understand its possible applicability at peripheral health care settings. This cross-sectional study was conducted during November 2021 to June 2022 in OPDs of two peripheral hospitals. A sample size of 300 was calculated using prevalence of urinary tract infection (UTI) as 33% for sensitivity and specificity using Buderer's formula. Urine specimens were collected following standard aseptic procedures from the recruited suspected UTI cases and transferred to laboratory maintaining the cold chain. The validation work up was done in two sections: lab validation and field validation. Out of 300 urine samples, 29 were found positive for the growth of UTI pathogen by both methods and 267 were found negative by both methods. Thus, the kit shows very high specificity (99.6%; 97.9-99.9%) and considerably high sensitivity (90.6%; 74.9-98.0%). We also observed higher PPV, NPV, test accuracy (> 96%). Diagnostic Odds Ratio and Youden index were respectively 2581 and 0.89. Clinical data showed that 44% of the suspected UTI cases were prescribed at least one antibiotic before urine test. Mostly they received Norfloxacin whereas the mostly identified organism E.coli was sensitive to Nitrofurantoin. In the context of absence of microbiology facility at peripheral setting and rampant empirical use of antibiotics in UTI, this highly specific and sensitive POCT for UTI may be used as it not only identifies the organism, also shows the antibiotic sensitivity pattern.

Benefits of a digital health technology for older nursing home residents. A de-novo cost-effectiveness model for digital health technologies to aid in the assessment of toileting and containment care needs

The aim of this study was first, to introduce a comprehensive, de-novo health economic (HE) model incorporating the full range of activities involved in toileting and containment care (T&CC) for people with incontinence, capturing all the potential benefits and costs of existing and future Digital Health Technologies (DHT) aimed at improving continence care, for both residential care and home care. Second, to use this novel model to evaluate the cost-effectiveness of the DHT TENA SmartCare Identifi in the implementation of person-centred continence care (PCCC), compared with conventional continence care for Canadian nursing home residents. The de-novo HE model was designed to evaluate technologies across different care settings from the perspective of several stakeholders. Health states were based on six care need profiles with increasing need for toileting assistance, three care stages with varying degrees of toileting success, and five levels of skin health. The main outcomes were incremental costs and quality-adjusted life years. The effectiveness of the TENA SmartCare Identifi was based primarily on trial data combined with literature and expert opinion where necessary. Costs were reported in CAD 2020. After 2 years, 21% of residents in the DHT group received mainly toileting as their continence care strategy compared with 12% in the conventional care group. Conversely, with the DHT 15% of residents rely mainly on absorbent products for incontinence care, compared with 40% with conventional care. On average, residents lived for 2.34 years, during which the DHT resulted in a small gain in quality-adjusted life years of 0.015 and overall cost-savings of $1,467 per resident compared with conventional care. Most cost-savings were achieved through reduced costs for absorbent products. Since most, if not all, stakeholders gain from use of the DHT-assisted PCCC, widespread use in Canadian residential care facilities should be considered, and similar assessments for other countries encouraged.

Incidence of complications associated with deep brain stimulation surgery in patients with Parkinson's disease: An 8-year retrospective study

Background

Various complications occur in patients undergoing deep brain stimulation (DBS) surgery. The objective of this study was to determine the incidence of complications in patients with Parkinson's disease who underwent DBS surgery and identify the risk factors, especially anesthetic factors.

Methods

A retrospective cohort study was performed between May 2015 and December 2022. Based on a review of medical charts, patients aged 18 years or older who underwent DBS surgery at a tertiary neurological center in Thailand were recruited. Univariate analysis using the Chi-square test or Fisher's exact test was performed to compare patients with and without complications. Multivariate logistic regression analysis was performed to identify the predictive factors for complications.

Results

The study included 46 patients. The most common complication during DBS electrode placement was hypertension (30/46, 65.2%), and 19 patients (41.3%) who developed hypertension did not receive antihypertensive treatment. The most common complication during battery placement was clinical hypotension (14/46, 30.4%). The most common postoperative complication was delirium (6/46, 13.0%). In the multivariate analysis, no significant independent risk factors for overall complications after DBS surgery were identified.

Conclusions

Hypertension during DBS electrode insertion was the most common perioperative complication. Hemodynamic instability is preventable and manageable, and vigilant and prompt treatment should be provided during DBS surgery.

Patterns of Drug Resistance and Bacterial Pathogen Distribution in Patients with Urinary Tract Infections in the Jiaxing Region from 2020 to 2022

Background

Urinary tract infections (UTIs) and the antibiotic resistance of pathogenic bacteria pose severe threats to public health in the current healthcare environment.

Objective

The purpose of this study was to assess the frequency distribution of bacterial pathogens causing UTIs as well as the characteristics of antibiotic susceptibility and resistance.

Methods

The retrospective study was conducted on 32,391 samples of midstream urine culture from January 1, 2020, to December 31, 2022, in Jiaxing. Bacteria were cultivated on blood agar and identified using MALDI-TOF, and their susceptibility to different antibiotics was assessed using the Kirby-Bauer disk diffusion method and drug sensitivity reaction cards. The SPSS 22 software was used for data analysis. Bivariate logistic regression was used to analyze the risk factors for multidrug resistance.

Results

The total number of positive growth samples was 5378 (16.6%), including 3206 females (59.6%) and 2172 males (40.4%). The four most common urinary pathogens were Escherichia coli (39.2%), Enterococcus faecalis (12.4%), Klebsiella pneumoniae (7.6%), and Enterococcus faecium (7.6%). As far as antibiotic resistance was concerned, Escherichia coli had a greater than 50% resistance rate to ampicillin (76.1%), ciprofloxacin (58.6%), and levofloxacin (51.2%). The multidrug resistance rate was high (41.8%). Low levels of resistance were seen to ertapenem (0.1%), imipenem (0.7%), meropenem (0.7%), piperacillin/tazobactam (0.7%), and nitrofurantoin (1.8%). Klebsiella pneumoniae was highly sensitive to ertapenem (100%). The resistance rates to nitrofurantoin, ceftriaxone, and ciprofloxacin were 37.4%, 37.1%, and 35.1%, respectively. Up to 41% of Escherichia coli strains and 26% of Klebsiella pneumoniae strains produced extended-spectrum lactamases (ESBL). Two species of enterococci were highly sensitive to tigecycline and linezolid (100%), and a small number of norvancomycin-resistant strains (0.2%/two strains) were found.

Conclusion

Escherichia coli and Enterococcus faecium were the most common urinary pathogens in this study. The isolated pathogens showed different sensitivity patterns. Antibiotics should be selected reasonably according to the sensitivity mode of pathogenic bacteria to effectively treat and prevent urinary tract infections.

Prevalence and antimicrobial susceptibility pattern of bacterial uropathogens among adult patients in Madinah, Saudi Arabia

BACKGROUND

Urinary tract infection (UTI) is considered one of the most prevalent infections that may lead to many renal complications. They account for almost 10% of all infections in Saudi Arabia, making them the second most common cause of emergency department admissions. Bacterial pathogens, primarily Escherichia coli, Klebsiella spp., Enterococcus spp., Proteus spp., and Staphylococcus spp. are the most causative agents of UTI. This study aims to evaluate the prevalence and antimicrobial susceptibility patterns of uropathogens in adult patients from Madinah, Saudi Arabia.

METHODS

A retrospective cross-sectional study was performed using data collected from patients who visited King Fahad General Hospital in Madinah, Saudi Arabia. Data included 16,803 urine bacterial cultures and their antimicrobial susceptibility profiles collected between January 2019 and October 2021.

RESULTS

Among the 16,803 tested samples, 3937 (23.4%) showed positive results for urine bacterial cultures. UTI prevalence was slightly higher in women (52.1%) than men (47.9%). Escherichia coli (29.8%) was the most prevalent, followed by Klebsiella spp. (23.2%) and Pseudomonas spp. (8.4%). As for Gram-positive bacteria, Enterococcus spp. (10.8%) were most common, followed by Streptococcus spp. (8%) and Staphylococcus spp. (3.3%). Gram-negative bacteria exhibited high resistance rates toward aztreonam (> 83.3%), ampicillin (78.8%), and cephalexin (68.5%). Enterococcus spp. displayed elevated resistance rates (> 62.3%) against ciprofloxacin, gentamicin, and tetracycline. Conversely, Streptococcus spp. showed substantial resistance rates (> 76.6%) toward colistin and trimethoprim/sulfamethoxazole.

CONCLUSION

To optimize therapy and minimize the risk of multidrug-resistant uropathogenic infections, physicians should consider the local epidemiological trends and antimicrobial resistance patterns of prevalent uropathogens prior to initiating any empirical antibacterial therapy.

Are Antibiotics Helpful for Older Adults with Delirium and Pyuria or Bacteriuria?

Antibiotics for Delirium and Pyuria or BacteriuriaDelirium is common among hospitalized older adults, frequently leading to initiation of antibiotics when pyuria or bacteriuria is detected. However, it is difficult to determine if pyuria or bacteriuria is the cause of delirium or incidentally identified. This article proposes a trial to assess if treatment with antibiotics hastens delirium resolution.

The effect of urinary tract infection on overall mortality in elderly male patients

INTRODUCTION

Urinary tract infections are the most common bacterial infections in the older population.

Literature Review of Ascorbic Acid, Cranberry, and D-mannose for Urinary Tract Infection Prophylaxis in Older People

Background Urinary tract infections (UTIs) are the most prevalent infections in older patients with the potential for morbidity and mortality. Antibiotics are not generally recommended for UTI prophylaxis in this population. There is interest among the public and health providers to try over-the-counter products, such as cranberry, D-mannose, and vitamin C. The objective of this analysis was to review the literature for the efficacy and tolerability of these supplements in older individuals. Methods A literature review was conducted on PubMed using the search terms urinary tract infection or UTI, prevention/prophylaxis, cranberry, D-mannose, vitamin C/ascorbic acid. Few studies were conducted among older people; therefore, the authors included studies of all adults who had recurrent UTIs or were at increased risk of UTIs. Level (quality) of evidence were determined using the ACC/AHA Clinical Practice Guideline Recommendation Classification System. Results A total of 24 studies were included. This review captured all studies in previous reviews as well as recent publications. The authors determined that there were limited data for D-mannose and vitamin C, and randomized data for cranberry as defined by the classification system. Conclusions The three supplements reviewed appear not to be strongly supported by clinical data. For those who are interested in trying these products despite the lack of robust evidence for clinical efficacy, it may be helpful to know that the studies included in this review did not identify any clinically important signs of harm, to the extent that safety data were documented and reported.

Flow cytometric detection of vancomycin-resistant Enterococcus faecium in urine using fluorescently labelled enterocin K1

A urinary tract infection (UTI) occurs when bacteria enter and multiply in the urinary system. The infection is most often caused by enteric bacteria that normally live in the gut, which include Enterococcus faecium. Without antibiotic treatment, UTIs can progress to life-threatening septic shock. Early diagnosis and identification of the pathogen will reduce antibiotic use and improve patient outcomes. In this work, we develop and optimize a cost-effective and rapid (< 40 min) method for detecting E. faecium in urine. The method uses a fluorescently labelled bacteriocin enterocin K1 (FITC-EntK1) that binds specifically to E. faecium and is then detected using a conventional flow cytometer. Using this detection assay, urine containing E. faecium was identified by an increase in the fluorescent signals by 25-73-fold (median fluorescence intensity) compared to control samples containing Escherichia coli or Staphylococcus aureus. The method presented in this work is a proof of concept showing the potential of bacteriocins to act as specific probes for the detection of specific bacteria, such as pathogens, in biological samples.

Determinants of urinary tract infection in hospitalized patients with acute ischemic stroke

BACKGROUND

Stroke is a major cause of morbidity and mortality worldwide. Urinary tract infection (UTI) is a common post-acute ischemic stroke (AIS) complication. We assessed the incidence, determinant factors, infection characteristics, post-stroke complications, and outcomes of hospitalized AIS patients with UTI.

METHODS

This retrospective cohort study included AIS patients admitted within 7 days of stroke onset. The patients were divided into the UTI group and the non-UTI (control) group. Clinical data were collected and compared between the groups.

RESULTS

There were 342 AIS patients (31 with UTIs and 311 controls). The multivariate analysis showed that an initial National Institutes of Health Stroke Scale (NIHSS) score of ≥ 15 (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.33-18.72) and Foley catheter retention (OR 14.10, 95% CI 3.25-61.28) were risk factors for UTI, whereas smoking (OR 0.08, 95% CI 0.01-0.50), an initial systolic blood pressure (SBP) of > 120 mmHg (OR 0.06, 95% CI 0.01-0.31), and statin use (OR 0.02, 95% CI 0.0006-0.42) were protective factors. Twenty cases (64.5%) were community-acquired and 11 cases (35.3%) were hospital-acquired. Ten patients (32.3%) had catheter-associated UTIs. The most common pathogen was Escherichia coli (13 patients, 41.9%). Post-stroke complications were significantly more common in the UTI group, including pneumonia, respiratory failure, sepsis, brain edema, seizure, symptomatic hemorrhagic transformation, congestive heart failure, atrial fibrillation with a rapid ventricular response, acute kidney injury, and hyponatremia. The median length of stay (LOS) in the UTI group was 12 days versus 3 days in the control group (p < 0.001). The median 3-month modified Rankin Scale score was higher (5 in UTI and 2 in control; p < 0.001) and the median 3-month Barthel Index was lower (0 in UTI and 100 in control; p < 0.001) in the UTI group than in the control group.

CONCLUSIONS

The risk factors for post-AIS UTI included severe stroke (NIHSS score ≥ 15) and urethral catheter indwelling. An initial SBP of > 120 mmHg and statin use were protective factors. The UTI group had significantly worse post-stroke complications, a longer LOS, and worse 3-month outcomes. Smoking was protective, which requires further investigation.

Red Blood Cell Transfusions Are Not Associated With Incident Complications or Poor Outcomes in Patients With Intracerebral Hemorrhage

Background Anemia is associated with poor intracerebral hemorrhage (ICH) outcomes, yet the relationship of red blood cell (RBC) transfusions to ICH complications and functional outcomes remains unclear. We investigated the impact of RBC transfusion on hospital thromboembolic and infectious complications and outcomes in patients with ICH. Methods and Results Consecutive patients with spontaneous ICH enrolled in a single-center, prospective cohort study from 2009 to 2018 were assessed. Primary analyses assessed relationships of RBC transfusions on incident thromboembolic and infectious complications occurring after the transfusion. Secondary analyses assessed relationships of RBC transfusions with mortality and poor discharge modified Rankin Scale score 4 to 6. Multivariable logistic regression models adjusted for baseline demographics and medical disease severity (Acute Physiology and Chronic Health Evaluation II), and ICH severity (ICH score).Of 587 patients with ICH analyzed, 88 (15%) received at least one RBC transfusion. Patients receiving RBC transfusions had worse medical and ICH severity. Though patients receiving RBC transfusions had more complications at any point during the hospitalization (64.8% versus 35.9%), we found no association between RBC transfusion and incident complications in our regression models (adjusted odds ratio [aOR], 0.71 [95% CI, 0.42-1.20]). After adjusting for disease severity and other relevant covariates, we found no significant association between RBC transfusion and mortality (aOR, 0.87 [95% CI, 0.45-1.66]) or poor discharge modified Rankin Scale score (aOR, 2.45 [95% CI, 0.80-7.61]). Conclusions In our cohort with ICH, RBC transfusions were expectedly given to patients with higher medical and ICH severity. Taking disease severity and timing of transfusions into account, RBC transfusion was not associated with incident hospital complications or poor clinical ICH outcomes.

Emerging Technologies in Diagnosing Periprosthetic Joint Infections

Periprosthetic joint infection (PJI) is a well-known serious complication following joint replacement surgeries and is responsible for high failure rates of implanted devices. Any delay in the diagnosis can compromise treatment success, putting a huge burden on the patients' wellness and healthcare systems. Diagnosing PJIs is quite complex as there is still no gold standard test to reach the definitive diagnosis in a timely manner. A number of laboratory tests and radiological imaging inventions have evolved in the past few years, requiring consistent updates of the available guidelines to keep up with the latest advances in the field. This article highlights the recent advances in diagnosing PJIs and discusses their validity for use in clinical practice.

First Case of Raoultella planticola Urinary Tract Infection Reported in Western Romania

Raoultella planticola is a Gram-negative bacterium rarely involved in urinary tract infections. The patient was an 80-year-old woman with several associated diseases who presented to the hospital with fever and dysuria. Raoultella planticola was identified to be the causative agent of the urinary tract infection. Antibacterial treatment led to a full recovery within 7 days. This report highlights the presence of a rare pathogen as a causative agent in the case of a urinary tract infection and also the importance of using multiple methods in order to identify bacteria and to establish the diagnosis.

Antibiotic resistance in elderly patients: Comparison of Enterobacterales causing urinary tract infections between community, nursing homes and hospital settings

OBJECTIVE

The objective was to compare the prevalence of antibiotic resistance of, Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae in elderly patients in, three sectors: community, nursing homes, and hospital settings.

MATERIAL AND METHODS

This study was a retrospective observational study conducted in, Bourgogne Franche-Comté (France). We collected positive urine samples from, patients over 75 years of age from six private laboratories.

RESULTS

Antibiotic resistance rate for E. coli in nursing homes was close to that of the, ommunity setting. Conversely, resistance of K. pneumoniae in nursing homes was, close to hospital settings. No difference in resistance of P. mirabilis was observed, between the three healthcare sectors.

CONCLUSIONS

Patients living in nursing homes should not be considered more at risk of, infection by multi-drug resistant E. coli than patients living in community setting. Screening of multi-drug resistant K. pneumoniae could be of interest for nursing home, patients.

Cultureless enumeration of live bacteria in urinary tract infection by single-cell Raman spectroscopy

Urinary tract infections (UTIs) are the most common outpatient infections. Obtaining the concentration of live pathogens in the sample is crucial for the treatment. Still, the enumeration depends on urine culture and plate counting, which requires days of turn-around time (TAT). Single-cell Raman spectra combined with deuterium isotope probing (Raman-DIP) has been proven to identify the metabolic-active bacteria with high accuracy but is not able to reveal the number of live pathogens due to bacteria replication during the Raman-DIP process. In this study, we established a new approach of using sodium acetate to inhibit the replication of the pathogen and applying Raman-DIP to identify the active single cells. By combining microscopic image stitching and recognition, we could further improve the efficiency of the new method. Validation of the new method on nine artificial urine samples indicated that the exact number of live pathogens obtained with Raman-DIP is consistent with plate-counting while shortening the TAT from 18 h to within 3 h, and the potential of applying Raman-DIP for pathogen enumeration in clinics is promising.

Prospective Evaluation of Infections in Geriatric Patients in Intensive Care Units

Objective

Nosocomial infections (NIs) are major health problems with morbidity and mortality. Geriatric patients require intensive care unit (ICU) admission more frequently, and serious challenges occur during treatment. We aimed to evaluate the risk factors of NI and mortality in geriatric patients admitted to the ICU.

Materials and Methods

The study was conducted between April 2018 and April 2019 in two hospitals. We prospectively recorded the data on the forms prepared according to daily ICU visits.

Results

During the study period, 600 patients were hospitalized in the ICUs. Geriatric patients constituted 446 (74.3%) of the total number. The NI rate was 59% in adult patients and 80% in geriatric patients. The most frequent NI in geriatric patients was pneumonia (42%). Furthermore, the need for mechanical ventilation support, prolongation of hospital stay, total parenteral nutrition, and tracheostomy were statistically higher in geriatric patients with NI. The mortality rate in geriatric patients was statistically higher than in non-geriatric. We found the rates of prolonged hospitalization, NI development, malignancy, and cerebrovascular disease diagnosis significantly higher in geriatric patients than in non-geriatric patients.

Conclusion

NI and mortality rate are higher in geriatrics than in adult patients. Pneumonia is the most common type of NI in the ICU. Identification of risk factors regarding NI and mortality in geriatric patients in ICU will contribute to developing strategies for prevention.

Effect of Transcutaneous Acupoint Electrical Stimulation on Urinary Retention and Urinary ATP in Elderly Patients After Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled Clinical Trial

PURPOSE

To investigate the effect of transcutaneous electrical acupoint stimulation (TEAS) on urinary retention after laparoscopic cholecystectomy in elderly patients, and to explore the relationship between TEAS and urinary ATP.

PATIENTS AND METHODS

The TEAS group was administered active TEAS at specific acupuncture points prior to induction of anesthesia and continued for 45 mins after surgery. In the control group, participants received sham stimulus at the same acupoints and no output current was delivered by disconnecting the device's output line. Urine samples were collected and evaluated in the first spontaneous voiding after surgery. In this study, postoperative urinary retention (POUR) was the primary outcome, which was diagnosed based on clinical symptoms, ultrasound assessments, and the need for bladder catheterization. Secondary outcomes include urinary ATP, postoperative spontaneous urination, urination symptoms, catheter-related bladder discomfort (CRBD), delirium, duration and hospitalization costs.

RESULTS

The study involved 598 patients recruited and randomized between August 2018 and June 2020. Among these patients, 547 (91.5%) completed the study and were analyzed. There were 64 cases of POUR, including 23 (8.4%, 95% confidence interval [CI]: 6.4-9.9%) in the TEAS group and 41 (15.0%, 95% CI: 9.3-13.4%) in the control group (p = 0.017). A significant difference was observed between the TEAS and control groups for urinary ATP concentration in the first spontaneous urine postoperatively (344 nmol/L versus 233 nmol/L, p=0.001). There was a shorter spontaneous voiding recovery time, smaller voiding threshold, less postoperative catheterization, less CRBD, and lower hospitalization costs in TEAS group compared with control group.

CONCLUSION

TEAS reduces the incidence of POUR in elderly patients undergoing laparoscopic cholecystectomy, which may be related to an increase in bladder ATP release.

The role of Dutch guidelines in the diagnostic outcomes and treatment decisions of hospitalised older adults with a suspected urinary tract infection: a retrospective cohort study

PURPOSE

Urinary tract infections (UTIs) are highly prevalent and difficult to diagnose in older adults. We aimed to evaluate the applicability of Dutch Association of Urology (NVU) and Dutch Association of Elderly Care Physicians (Verenso) guidelines in terms of diagnostic outcomes and treatment decisions in hospitalised older adults with suspected UTIs.

METHODS

A retrospective cohort study was conducted on 225 geriatric patients with a urine culture taken in 2019, to determine conformity of the studied population to NVU and Verenso.

RESULTS

Of 225 patients with suspected UTI (mean age 86 years; 56.4% female), 67.6% had urinary tract-related symptoms, of whom 96 received antibiotics, including those with a negative urine dipstick (n = 12) or urine culture (n = 28). Hundred seventy-seven and 147 patients were assessed and treated conforming to the NVU and Verenso guidelines, respectively. The 38 patients who were assessed and treated non-conforming to NVU, including patients with negative urine diagnostics, received antibiotics more often compared with 177 patients treated conforming to NVU (p < 0.001). A large number of patients with negative urine tests were treated conforming to Verenso and antibiotics were withheld in 75.5% of the patients. The non-conforming Verenso-treated patients with prescribed antibiotics had significantly more negative dipstick results (p = 0.05), fewer urinary tract-related symptoms (p < 0.001) and more often a different infectious focus (p < 0.001).

CONCLUSION

The common practice performed on the studied geriatric population was more in accordance with the NVU guideline than Verenso. The results indicated that compliance with the guidelines might lead to fewer antibiotic prescriptions in the study population.

Recurrent E. coli Urinary Tract Infections in Nursing Homes: Insight in Sequence Types and Antibiotic Resistance Patterns

Introduction: Recurrent urinary tract infections (rUTI) largely contribute to antibiotic use in older adults. Understanding the genetic characteristics of Escherichia coli (E.coli) is needed to identify patients at risk for recurrence. The aim of this study was to obtain a greater understanding of the genetics of E. coli rUTI in nursing home residents. Methods: This is a secondary analysis of a multicenter Dutch nursing home study (PROGRESS). E. coli strains from residents with a suspected UTI and positive urine culture were analyzed using antimicrobial susceptibility testing and whole-genome sequencing (WGS). Same-strain recurrences were identified by single-nucleotide polymorphism (SNP) analysis. Result: In total, 121 E. coli strains were analyzed using WGS, of which 54 belonged to a rUTI episode. One third of E. coli rUTI episodes were caused by the same strain (n = 18, 33.3%). Same-strain recurrence occurred anywhere between 30 and 434 days after the index UTI, caused by sequence types (ST): ST12, ST23, ST73, ST131, ST453, ST538 and ST2522, in seven nursing home residents. In both single UTI and rUTI, antimicrobial resistance rates were low. Conclusion: Recurrent UTI in nursing home residents are caused by same-strain E. coli as well as due to different E. coli strains or other uropathogens. Same-strain recurrence can occur over 400 days after the index UTI, suggesting that some strains have the ability to colonize the bladder or gut for longer periods.

Association of Vitamin B12 deficiency with long-term PPIs use: A cohort study

Background

Proton Pump inhibitors are widely used among the majority of the world's population as acid-suppressing medications. Proton Pump Inhibitors have been reported to cause intestinal damage and adverse gut microbiota changes affecting several mechanisms, including malabsorption, etc.

Aim

In order to gain a deeper understanding, we conducted a cohort analysis to assess the prevalence & association of Vitamin B12 deficiency in patients on long-term use of PPIs.

Methods

This single-center cohort study was conducted at the Department of Internal Medicine, KRL hospital in Islamabad, Pakistan from May 2021 to May 2022. Rao soft calculator with a 95% confidence interval and 5% error margin was used to find the estimated sample size. Vitamin B₁₂ levels were analyzed using the Cobas e411 analyzer. Chi-square test, odds ratio, and t-tests were used for analysis.

Results

Among the 1225 participants, more than half of the men (55.10%) had low levels of vitamin B12. Vit B12 levels were observed to be significantly lower in Omeprazole patients than in Pantoprazole patients. A vitamin B12 deficiency is 0.5 times more likely in patients taking PPIs. There is a substantial difference between the early and final levels of B12 indicated by the t-test.

Conclusion

According to our findings, long-term usage of PPIs is linked to an increased risk of vitamin B12 insufficiency specifically in men falling under the ages of 18 and 40.

•

Increased focus and precision have been achieved by single-centered approach.

•

Over 1200 people were enrolled during the course of the year-long data collection period, which have contributed to the study's overall authenticity.

•

It is possible that this large-scale investigation may serve to clarify the link between PPIs and VIT B12 deficiency during this period of uncertainty.

A review of recent advances in the treatment of adults with complicated urinary tract infection

INTRODUCTION

Complicated urinary tract infections (cUTIs) entail diverse clinical conditions that could be managed differently and not necessarily with premature empiric therapy. Since multidrug-resistant organisms (MDROs) are widely spreading worldwide, the possibility of encountering these resistant bacteria is inevitably part of the daily life of physicians who manage cUTIs.

AREAS COVERED

The advances in the management of cUTIs are explored, illustrating: 1) a proposed therapeutical approach to cUTIs within the antimicrobial stewardship context; 2) evidence regarding novel antibiotics targeting MDROs. Evidence research has been performed through MEDLINE/PubMed using appropriate keywords and terms regarding cUTIs published before June 2022.

EXPERT OPINION

Novel antimicrobial drugs are available in the clinicians' armamentarium. Selecting the optimal therapy for suitable patients may be challenging given the multifaceted group of cUTIs. Carbapenems use is widely increasing, the role of old β-lactam/β-lactamase inhibitors is constantly revised, and novel drugs lack real-life studies. Understanding the different ranges of the complexity of patients affected by cUTIs may help select the most suitable antibiotic for every single case. More multicentric observational studies targeting cUTIs are needed to elucidate the appropriate drug based on patient characteristics and presentations, providing stronger recommendations for cases encountered in everyday clinical practice.

A prospective evaluation of postoperative fever in adult neurosurgery patients in the COVID-19 era

Postoperative fever is mostly transient and inconsequential but may portend a serious postoperative infection requiring a thorough evaluation, especially during the recent COVID-19 pandemic. We aimed to determine the incidence, causes and outcomes of postoperative fever in neurosurgical patients, as well as to evaluate a protocol for management of postoperative fever. We conducted a prospective study over 12 months, recruiting 425 adult patients operated for non-traumatic neurosurgical indications. We followed a standard protocol for the evaluation and management of postoperative fever collecting data regarding operative details, daily maximal temperature, clinical features, as well as use of surgical drains, urinary catheters, and other invasive adjuncts. Elevated body temperature of > 99.9°F or 37.7 °C for over 48 h or associated with clinical deterioration or localising features was considered as “fever” and was evaluated according to our protocol. We classified elevated temperature not meeting this criterion as a transient elevation in temperature (TET). Sixty-five patients (13.5%) had postoperative fever. Transient elevation of temperature, occurring in 40 patients (8.8%) was most common in the first 48 h after surgery. The most common causes of fever were urinary tract infections (13.7%), followed by aseptic meningitis (10.8%), wound infections and pneumonia. Various aetiologies of fever followed distinct patterns, with COVID-19 and meningitis causing high-grade, prolonged fever. Multivariate analysis revealed cranial surgery, prolonged duration of surgery, urinary catheters and wound drains retained beyond POD 3 to predict fever. Postoperative fever was associated with significantly longer duration of hospital admission. COVID-19 had a high mortality rate in the early postoperative period.

Isolation and drug susceptibility pattern of uropathogens in Saudi diabetic and non-diabetic patients with urinary tract infection

Urinary tract infection (UTI), contribute substantially to healthcare burden. Diabetes predispose to UTI with high glycosuria being fertile medium for bacterial growth. With changing bacterial drug resistance patterns; the problem needs to be studied periodically to ensure a rational therapy, minimize adverse effects, and cost. Therefore, it is of interest to compare the profile and susceptibility pattern of uropathogens isolated from diabetic and non-diabetic patients with UTI. Mid-stream urine samples of 1100 patients (diabetic and non-diabetic), presenting with UTI symptoms were aseptically collected and inoculated into CLED medium. Colony counts of 105cfu/ml or 104cfu/ml and >5 pus cells per high power microscopic field were regarded as significant bacteriuria. Colonies from CLED were sub-cultured onto sheep blood agar and MacConkey agar. Bacterial identification was performed on the basis of colony morphology, gram staining, and series of biochemical tests though Analytical Profile Index (API) test strips. Drug susceptibility was done by standard Kirby-Bauer disk diffusion. Data was analyzed by SPSS ver. 25.Clinically significant bacteriuria was 32.8% and 19.2% in diabetics and non-diabetics respectively. The frequency of male and female patients was 153 and 208 in diabetic group; and 69 and 142 respectively in non-diabetic group. Diabetics were twice at risk of UTI; [Odds ratio; 2.04 (CI: 1.68-2.48, p<0.05)]. .Escherichia coli and klebsiella were most common gram-negative, while Staphylococcus aureus and Coagulase-negative staphylococci (CoNS) were most common gram-positive bacteria in both the groups. Most effective antibiotics against gram-negative bacteria were carbapenems, amikacin, colistin, and piperacillin/tazobactam; while ampicillin/amoxicillin, fluoroquinolones and cephalexin were least effective. For gram-positives, vancomycin, linezolid and tigecycline were most effective. No significant difference in bacterial profile and susceptibility pattern was found between diabetics and non-diabetics. However, diabetics were twice at risk of UTI compared to non-diabetics.

D-mannose for preventing and treating urinary tract infections

BACKGROUND

Urinary tract infections (UTIs) are very common, affecting more than 7 million people worldwide. Whilst many people may only experience a single episode in their lifetime and are generally responsive to standard antibiotics, a significant proportion of adults and children (approximately 15% to 25%) are chronic symptomatic UTI sufferers. Certain population groups are at greater risk than others, such as immunosuppressed and people with chronic kidney disease. D-mannose is a sugar part of normal human metabolism found within most diets. The mechanism of action is to prevent bacterial adherence to the uroepithelial cells. The D-mannose-based inhibitors can block uropathogenic Escherichia coli adhesion and invasion of the uroepithelial cells. The bacteria are then understood to essentially be eliminated by urination. Early pilot studies on animals and humans have trialled concentrated forms of D-mannose (tablets or sachets) in doses ranging from 200 mg up to 2 to 3 g and found possible efficacy in reducing UTI symptoms or recurrence. Although the anti-adhesive effects of D-mannose have been well-established, only recently have we seen a small number of pilot studies and small clinical trials conducted.

OBJECTIVES

To assess the benefits and harms of D-mannose for preventing and treating UTIs in adults and children.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 22 February 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included RCTs measuring and reporting the effect of D-mannose, in any combination and any formulation, to prevent or treat UTIs in adults and children, females and males, in any setting (including perioperative). Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Data extraction was independently carried out by two authors using a standard data extraction form. Methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another author. The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included seven RCTs (719 participants) in adult females and males who had either acute cystitis or a history of recurrent (at least two episodes in six months or three episodes in 12 months) UTIs (symptomatic or asymptomatic). Two were prevention studies, four were prevention and treatment studies (two perioperative and one in people with multiple sclerosis), and one was a treatment study. Time periods ranged from 15 days to six months. No two studies were comparable (by dose or treatments), and we could not undertake meta-analyses. Individual studies reported no clear evidence to determine whether D-mannose is more or less effective in preventing or treating UTIs. D-mannose (2 g) had uncertain effects on symptomatic and bacteriuria-confirmed UTIs when compared to no treatment (1 study, 205 participants; very low certainty evidence) and antibiotics (nitrofurantoin 50 mg) (1 study, 206 participants; very low certainty evidence). D-mannose, in combination with herbal supplements, had uncertain effects on symptomatic and bacteria-confirmed UTI and pain when compared to no treatment (1 study, 40 participants; very low certainty evidence). D-mannose 500 mg plus supplements (N-acetylcysteine and Morinda citrifolia fruit extract) had uncertain effects on symptomatic and bacteriuria-confirmed UTIs when compared to an antibiotic (prulifloxacin 400 mg) (1 study, 75 participants; very low certainty evidence). Adverse events were very few and poorly reported; none were serious (mostly diarrhoea and vaginal burning). Overall, the quality of the evidence is poor. Most studies were judged to have unclear or high risk of bias across most domains. Data was sparse and addressed very few outcomes. The GRADE evaluation was rated as very low certainty evidence due to very serious limitations in the study design or execution (high risk of bias across all studies) and sparse data (single study data and small sample sizes).

AUTHORS' CONCLUSIONS

There is currently little to no evidence to support or refute the use of D-mannose to prevent or treat UTIs in all populations. This review highlights the severe lack of high-quality RCTs testing the efficacy of D-mannose for UTIs in any population. Despite UTIs being one of the most common adult infections (affecting 50% of women at least once in their lifetime) and the growing global antimicrobial resistance, we found very few studies that adequately test this alternative treatment. Future research in this field requires, in the first instance, a single adequately powered RCT comparing D-mannose with placebo.

The Urinary Microbiome of Older Adults Residing in a Nursing Home Varies With Duration of Residence and Shows Increases in Potential Pathogens

The community of bacteria that colonize the urinary tract, the urinary microbiome, is hypothesized to influence a wide variety of urinary tract conditions. Older adults who reside in nursing homes are frequently diagnosed and treated for urinary tract conditions such as urinary tract infection. We investigated the urinary microbiome of older adults residing in a nursing home to determine if there are features of the urinary microbiome that are associated with specific conditions and exposure in this population. We were also interested in the stability of urinary microbiome over time and in similarities between the urinary and gastrointestinal microbiome. Urine samples were prospectively collected over a period of 10 months from a cohort of 26 older adults (aged >65 years) residing in a single nursing home located in Central Massachusetts. Serial samples were obtained from 6 individuals over 10 months and 5 participants were concurrently enrolled in a study of the gastrointestinal microbiome. Information collected on participants included demographics, medical history, duration of residence in the nursing home, frailty, dementia symptoms, urinary symptoms, antibiotic treatment, urinary catheterization, and hospitalizations over a 10-month period. Clean catch, midstream urine samples were collected and stored at -80°C. DNA was extracted and 16S rRNA gene sequencing was performed. The length of stay in the nursing facility and the Clinical Frailty Scale correlated with significant changes in microbiome composition. An increase in the relative abundance of a putative urinary pathogen, Aerococcus urinae, was the largest factor influencing change that occurred over the duration of residence.

Revisiting the Frequency and Antimicrobial Resistance Patterns of Bacteria Implicated in Community Urinary Tract Infections

Urinary tract infections (UTIs) are one of the most common infectious diseases at the community level. The continue misuse of antimicrobials is leading to an increase in bacterial resistance, which is a worldwide problem. The objective of this work was to study the incidence and pattern of antimicrobial resistance of the main bacteria responsible for UTI in the community of central and northern Portugal, and establish an appropriate empirical treatment. The urine samples were collected in Avelab—Laboratório Médico de Análises Clínicas over a period of 5 years (2015−2019). The urine cultures were classified as positive when bacterial growth was equal to or higher than 105 CFU/mL, and only for these cases, an antimicrobial susceptibility test was performed. Of the 106,019 samples analyzed, 15,439 had a urinary infection. Urinary infections were more frequent in females (79.6%) than in males (20.4%), affecting more elderly patients (56.9%). Escherichia coli (70.1%) was the most frequent uropathogen, followed by Klebsiella pneumoniae (8.9%). The bacteria responsible for UTI varied according to the patient’s sex, with the greatest differences being observed for Enterococcus faecalis and Pseudomonas aeruginosa, these being more prevalent in men. In general, there was a growth in bacterial resistance as the age of the patients increased. The resistance of bacteria in male patients was, in most cases, statistically different (Chi-Square test, p < 0.05) from that observed for bacteria isolated from female patients, showing, in general, higher resistance in male patients. Although E. coli was the most responsible uropathogen for UTI, it was among the bacteria most susceptible to antibiotics. The isolates of K. pneumoniae, Proteus vulgaris and Enterobacter showed high resistance to the tested antimicrobials. The most common multidrug-resistant (MDR) bacteria implicated in UTI were K. pneumoniae (40.4%) and P. aeruginosa (34.7%), but E. coli, the most responsible bacteria for UTI, showed a MDR of 23.3%. When we compared our results with the results from 10 years ago for the same region, in general, an increase in bacterial resistance was observed. The results of this study confirmed that urinary tract infections are a very common illness, caused frequently by resistant uropathogens, for which the antibiotic resistance profile has varied over a short time, even within a specific region. This indicates that periodically monitoring the microbial resistance of each region is essential in order to select the best empirical antibiotic therapy against these infections, and prevent or decrease the resistance among uropathogenic strains.

Bacteriospermia and Male Infertility: Role of Oxidative Stress

Male infertility is one of the major challenging and prevalent diseases having diverse etiologies of which bacteriospermia play a significant role. It has been estimated that approximately 15% of all infertility cases are due to infections caused by uropathogens and in most of the cases bacteria are involved in infection and inflammation leading to the development of bacteriospermia. In response to bacterial load, excess infiltration of leukocytes in the urogenital tract occurs and concomitantly generates oxidative stress (OS). Bacteria may induce infertility either by directly interacting with sperm or by generating reactive oxygen species (ROS) and impair sperm parameters such as motility, volume, capacitation, hyperactivation. They may also induce apoptosis leading to sperm death. Acute bacteriospermia is related with another clinical condition called leukocytospermia and both compromise male fertility potential by OS-mediated damage to sperm leading to male infertility. However, bacteriospermia as a clinical condition as well as the mechanism of action remains poorly understood, necessitating further research in order to understand the role of individual bacterial species and their impact in male infertility.

Knowledge and Risk Perceptions of Chronic Kidney Disease Risk Factors among Women of Childbearing Age in Lagos State, Nigeria: From a Health Demography Approach

Background. Kidney disease (KD), also known as chronic kidney disease (CKD), is a long-term underrecognized public health concern and one of the eight leading causes of death in women. Despite that, little is known about women’s knowledge, perceived risk, and perceptions of CKD risk factors. In this study, we assessed knowledge, perceived risk, and perceptions of CKD risk factors among women of childbearing age in Lagos State, Nigeria. Methods. Administering a pretested and structured questionnaire among 825 women aged 15–49 years, we conducted a cross-sectional descriptive study to evaluate knowledge, self-reported CKD risk factors, and risk perception among women of childbearing age in urban and semiurban communities in Lagos State, Nigeria. We used descriptive (mean, frequencies, and percentages) and bivariate statistics (chi-square) to assess sociodemographic factors influencing knowledge and perceptions of CKD risk factors. Binary and multinomial logistic regressions were further employed to assess risk perceptions of CKD factors associated with knowledge. Results. Five hundred and forty (65.5%) out of 825 women reported being knowledgeable of CKD risk factors with majority of the younger adult women (15–29 years) having good knowledge than other age cohorts, with a mean age of 33.5 ± 11.5 years. The women’s knowledge of CKD was found to be significantly associated with independent and dependent risk factors ( $p$  < 0.05). The major self-reported independent CKD risk factors were misuse of analgesics (NSAIDs) (OR = 1.20; $p$  < 0.05), herbal drinks (OR = 2.30; $p$  < 0.05), and herbal supplements (OR = 1.37; $p$  < 0.05), while self-reported dependent CKD risk factors were hypertension (OR = 2.14; $p$  < 0.05), family history of KD ailments (OR = 1.30; $p$  < 0.05), and high cholesterol (OR = 1.44; $p$  < 0.05). Similarly, majority of the women had low perceived CKD risk (54.8%), while women with CKD risk factors (independent and dependent) view themselves at decreased perceived risk for the disease compared to those who are not associated with CKD risk factors ( $p$  < 0.05). Also, findings revealed that women had poor perception of risk factors associated with CKD. The multivariate analysis of perceived risk showed that demographic factors (younger aged adults, high education, and high income), independent risk factors of CKD (misuse of NASAIDs and excessive use of herbal drink and herbal supplement), and dependent risk factors (hypertension and family history of KD ailments) were significantly associated with knowledge of CKD ( $p$  < 0.05). Conclusion. Our study reveals high knowledge of CKD risk factors but low perceived risk and poor perception of the link between CKD risk factors and its ailments. Given this, there is a call for urgent measures to create sensitization and provide public CKD behavioural health interventions as well as easy communication strategies for women to secure better access to awareness intervention programmes and healthcare services.

Bacteriological and systemic immunity study of patients with urinary tract infection in Babylon province

One hundred mid stream urine specimens and  blood sample and fifty healthy specimen[urine and blood ]as control for detection TLR-2 in serum have been collected From October to March 2021, urine specimen  from urinary tract infection patients in Hospital Hilla were cultivated for isolation and identification in Uropathogenic bacteria can be found in a variety of places. The automated VITEK-2 compact system was used to perform the final identification, which was based on colony positive identification. morphology, microscopic examination, and biochemical tests, while final identification was done with the automated VITEK-2 compact system using Gram positive-identification morphology, microscopic examination, and biochemical tests [GP-ID]and Gram negative-identification [GP-ID] [GN-ID]. The current study's findings revealed that samples grew bacteria, which were classified into Gram negative bacteria [51.48%] and Gram positive bacteria [51.48%]. [48.52 percent ]. E. coli was the culprit. 80 [21.5%] followed by Klebsiella pneumoniae40 [10.75%], and then Staphylococcus aureus 36[9.6%], 35[9.4%] for each Staphylococcus epidermidis, and Staphylococcus saprophytics 16[4.3%] while Enterococcus faecalis50[13.44%], while Enterococcus facium 40[10.75%] Streptococcus agalactiae 2[0.5%]and Enterobacter cloacae at a rate of 2[0.5%] and finally each of Morganella morganii 10[2.68%], Pseudomonas aeruginosa 40[10.75], Proteus mirabilis 20[5.3%].Candida albicans 46 . 

Clinical Characteristics of Patients with Pyogenic Vertebral Osteomyelitis and Concurrent Infections and Their Clinical Outcomes

Patients with pyogenic vertebral osteomyelitis (PVO) often develop concurrent infections, and a significant number of these patients show rapid deterioration in their medical condition, leading to mortality without PVO-related structural instability or neurological deficits. To improve clinical outcomes, we investigated the clinical presentation and treatment outcomes of patients with PVO and concurrent infections. This study included 695 patients with PVO, of which 175 (25%) had concurrent infections and 520 (75%) did not. The clinical characteristics of the two groups were compared, and multivariable analysis was performed to identify the association between concurrent infections and clinical outcomes. Patients with concurrent infections were older and had more comorbidities than those without. Moreover, there were significant intergroup differences in the anatomical involvement of PVO, and patients with concurrent infections had a higher number of regions involved more frequently than those without concurrent infections (15% vs. 6%). In contrast, patients with concurrent infections showed a lower degree of focal invasiveness, including a lower incidence of posterior abscess (47% vs. 59%; p = 0.008) and fewer neurological impairments according to the American Spinal Injury Association grade (p < 0.001) than those without concurrent infections. The causative organisms also differed significantly between the two groups, and patients with concurrent infections had a greater proportion of Gram-negative infections (31% vs. 16%, respectively) and a smaller proportion of methicillin-resistant S. aureus infections than those without concurrent infections (6% vs. 24%). Consequently, their clinical outcomes were significantly different, and patients with concurrent infections showed lower recurrence and higher mortality rates. We investigated the 1-year recurrence and mortality rates and their 95% confidence intervals according to the types of concurrent infections and their time of diagnosis and found variations in these parameters. Our results, based on a large number of patients, can be practically used as a reasonable reference to warn clinicians of the clinical risks of concurrent infections in patients with PVO and to help predict their clinical outcomes.

Potential Value of Presepsin Guidance in Shortening Antibiotic Therapy in Septic Patients: a Multicenter, Prospective Cohort Trial

INTRODUCTION

Long-term use of antibiotics for septic patients leads to bacterial resistance, increased mortality, and hospital stay. In this study, we investigated an emerging biomarker presepsin-guided strategy, which can be used to evaluate the shortening of antibiotic treatment in patients with sepsis without risking a worse outcome.

METHODS

In this multicenter prospective cohort trial, patients were assigned to the presepsin or control groups. In the presepsin group, antibiotics were ceased based on predefined cut-off ranges of presepsin concentrations. The control group stopped antibiotics according to international guidelines. The primary endpoints were the number of days without antibiotics within 28 days and mortality at 28 and 90 days. Secondary endpoints were the percentage of patients with a recurrent infection, length of stay in ICU and hospital, hospitalization costs, days of first episode of antibiotic treatment, percentage of antibiotic administration and multidrug-resistant bacteria, and SOFA score.

RESULTS

Overall, 656 out of an initial 708 patients were eligible and assigned to the presepsin group (n = 327) or the control group (n = 329). Patients in the presepsin group had significantly more days without antibiotics than those in the control group (14.54 days [SD 9.01] vs. 11.01 days [SD 7.73]; P < 0.001). Mortality in the presepsin group showed no difference to that in the control group at days 28 (17.7% vs. 18.2%; P = 0.868) and 90 (19.9% vs. 19.5%; P = 0.891). Patients in the presepsin group had a significantly shorter mean length of stay in the hospital and lower hospitalization costs than control subjects. There were no differences in the rate of recurrent infection and multidrug-resistant bacteria and the SOFA score tendency between the two groups.

CONCLUSIONS

Presepsin guidance has potential to shorten the duration of antibiotic treatment in patients with sepsis without risking worse outcomes of death, recurrent infection, and aggravation of organ failure.

TRIAL REGISTRATION

ChiCTR, ChiCTR1900024391. Registered 9 July 2019-Retrospectively registered, http://www.chictr.org.cn.

Urinary Tract Infection Investigation and Treatment in Older Adults Presenting to the Emergency Department with Confusion: a Health Record Review of Local Practice Patterns

BACKGROUND

The rate of urinary tract infection (UTI) investigation and treatment in confused older emergency department (ED) patients has not been described in the literature. We aim to describe the pattern of practice in an academic tertiary care ED for this common presentation.

METHODS

A health record review was conducted on 499 adults aged ≥65 presenting to academic EDs with confusion. Exclusion criteria: Glasgow Coma Scale < 13, current treatment for UTI, indwelling catheters, nephrostomy tubes, transfer from another hospital. Outcomes were the prevalence of UTI investigation, diagnosis and antibiotic treatment.

RESULTS

64.9% received urine tests, 11.4% were diagnosed with UTI, and 35.2% were prescribed antibiotics. In the subgroup with no urinary symptoms, fever, or other obvious indication for antibiotics, these numbers were 58.2%, 7.6%, and 18.1%, respectively. Patients who had urine tests or received antibiotics were older than those who did not (p values < .01). Patients receiving antibiotics had higher admission rates and 30-day and six-month mortality (OR of 2.9 [2.0-4.3], 4.0 [1.6-11], and 2.8 [1.4-5.8], respectively).

CONCLUSION

Older patients presenting to ED with confusion were frequently investigated and treated for UTI, even in the absence of urinary symptoms. Antibiotic treatment was associated with higher hospitalization and mortality.

A retrospective comparison of guidelines to assess hospital-diagnosed urinary tract infection in nursing home residents

BACKGROUND

Inappropriate antibiotic treatments for urinary tract infection (UTI) in nursing home (NH) residents are common and contribute to antibiotic resistance. Published guidelines aim to improve accurate assessment, diagnosis, and treatment of UTIs. This study assessed whether records from hospitalized NH residents diagnosed with UTI, while comparing the Cooper Tool and Stone criteria, supported appropriate treatment.

METHODS

A retrospective chart review was conducted using electronic medical record (EMR) data from residents of 3 NHs who were diagnosed with UTI when hospitalized over a 3-year period. The Cooper Tool and Stone criteria were used to assess treatment appropriateness.

RESULTS

Of 79 hospitalized residents treated for UTI, 11 (13.9%) were appropriately treated according to the Cooper Tool and 9 (11.4%) according to Stone. The 2 criteria agreed in 9 of the cases including 100% of those with catheters. Urinalysis was documented in 72% of residents and 24% had documentation of culture and sensitivity.

CONCLUSIONS

Appropriate UTI treatment rates using both tools were low but much higher in those with catheters. Future research is necessary to validate the use of these tools in the hospital setting which have the potential to improve treatment accuracy and reduce unnecessary antibiotics use.

Trends in urinary tract infection hospitalization in older adults in Spain from 2000-2015

Objective

To analyze trends in urinary tract infection hospitalization (cystitis, pyelonephritis, prostatitis and non-specified UTI) among patients over 65 years in Spain from 2000–2015.

Methods

We conducted a retrospective observational study using the Spanish Hospitalization Minimum Data Set (CMBD), with codifications by the International Classification of Diseases (ICD-9). We collected data on sex, age, type of discharge, main diagnosis, comorbid diagnosis, length of stay, and global cost. All the hospitalizations were grouped by age into three categories: 65–74 years old, 75–84 years old, and 85 years old and above. In the descriptive statistical analysis, crude rates were defined as hospitalizations per 1,000 inhabitants aged ≥65. To identify trends over time, we performed a Joinpoint regression.

Results

From 2000–2015, we found 387,010 hospitalizations coded as UTIs (54,427 pyelonephritis, 15,869 prostatitis, 2643 cystitis and 314,071 non-specified UTI). The crude rate of hospitalization for UTIs between 2000 and 2015 ranged from 2.09 in 2000 to 4.33 in 2015 Rates of hospitalization were higher in men than in women, except with pyelonephritis. By age group, higher rates were observed in patients aged 85 years or older, barring prostatitis-related hospitalizations. Joinpoint analyses showed an average annual percentage increase (AAPC) in incidence rates of 4.9% (95% CI 3.2;6.1) in UTI hospitalizations. We observed two joinpoints, in 2010 and 2013, that found trends of 5.5% between 2000 and 2010 (95% CI 4.7;6.4), 1.5% between 2010 and 2013 (95% CI -6.0;9.6) and 6.8% between 2013 and 2015 (95% CI -0.3;14.4).

Conclusions

The urinary infection-related hospitalization rate in Spain doubled during the period 2000–2015. The highest hospitalization rates occurred in men, in the ≥85 years old age group, and in non-specified UTIs. There were increases in all types of urinary tract infection, with non-specified UTIs having the greatest growth. Understanding these changing trends can be useful for health planning.

Improved diagnostics of infectious diseases in emergency departments: a protocol of a multifaceted multicentre diagnostic study

BACKGROUND

The major obstacle in prescribing an appropriate and targeted antibiotic treatment is insufficient knowledge concerning whether the patient has a bacterial infection, where the focus of infection is and which bacteria are the agents of the infection. A prerequisite for the appropriate use of antibiotics is timely access to accurate diagnostics such as point-of-care (POC) testing.The study aims to evaluate diagnostic tools and working methods that support a prompt and accurate diagnosis of hospitalised patients suspected of an acute infection. We will focus on the most common acute infections: community-acquired pneumonia (CAP) and acute pyelonephritis (APN). The objectives are to investigate (1) patient characteristics and treatment trajectory of the different acute infections, (2) diagnostic and prognostic accuracy of infection markers, (3) diagnostic accuracy of POC urine flow cytometry on diagnosing and excluding bacteriuria, (4) how effective the addition of POC analysis of sputum to the diagnostic set-up for CAP is on antibiotic prescriptions, (5) diagnostic accuracy of POC ultrasound and ultralow dose (ULD) computerized tomography (CT) on diagnosing CAP, (6) diagnostic accuracy of specialist ultrasound on diagnosing APN, (7) diagnostic accuracy of POC ultrasound in diagnosing hydronephrosis in patients suspected of APN.

METHODS AND ANALYSIS

It is a multifaceted multicentre diagnostic study, including 1000 adults admitted with suspicion of an acute infection. Participants will, within the first 24 hours of admission, undergo additional diagnostic tests including infection markers, POC urine flow cytometry, POC analysis of sputum, POC and specialist ultrasound, and ULDCT. The primary reference standard is an assigned diagnosis determined by a panel of experts.

ETHICS, DISSEMINATION AND REGISTRATION

Approved by Regional Committees on Health Research Ethics for Southern Denmark, Danish Data Protection Agency and clinicaltrials.gov. Results will be presented in peer-reviewed journals, and positive, negative and inconclusive results will be published.

TRIAL REGISTRATION NUMBERS

NCT04661085, NCT04681963, NCT04667195, NCT04652167, NCT04686318, NCT04686292, NCT04651712, NCT04645030, NCT04651244.