Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections

Fever and infections in surgical intensive care: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.

Impact of Urine Culture Reflex Policy Implementation in a Large County Hospital Inpatient Rehabilitation Unit-A Pilot Study

OBJECTIVE

To promote antimicrobial stewardship, many institutions have implemented a policy of reflexing to a urine culture based on a positive urinalysis result. The rehabilitation patient population, including individuals with brain and spinal cord injuries, may have atypical presentations of urinary tract infections. The study objective is to determine the effects of implementing a urine culture reflex policy in this specific patient population.

DESIGN

In an inpatient rehabilitation unit, 348 urinalyses were analyzed from August 2019 to June 2021. Urinalysis with greater than or equal to 10 white blood cells per high power field was automatically reflexed to a urine culture in this prospective study. Primary outcome was return to acute care related to urinary tract infection. Secondary outcomes included adherence to reflex protocol, antibiotic utilization and appropriateness, adverse outcomes related to antibiotic use, and reduction in urine cultures processed and the associated reduction in healthcare costs.

RESULTS

There was no statistically significant difference before and after intervention related to the primary outcome. Urine cultures processed were reduced by 58% after intervention.

CONCLUSIONS

Urine culture reflex policy is likely an effective intervention to reduce the frequency of urine cultures without significantly affecting the need to transfer patients from inpatient rehabilitation back to the acute care setting.

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.

How to disagree better: utilizing advocacy-inquiry techniques to improve communication and spur behavior change

The ability to provide feedback to a colleague is a key skill required for professional growth and patient safety. However, these conversations are limited by time constraints, differences in values, and a culture of "noninterference." This advocacy-inquiry-identify-teach framework creates an organized approach to initiating successful "challenging" conversations with peers.

An Initiative to Stop Antibiotics Prescribed for Urinary Symptoms When Urine Culture Is Negative

ABSTRACT

Urinary symptoms pose frequent diagnostic and management challenges in the emergency department (ED). In our regional health system, we identified the problem of patients started on antibiotics for urinary symptoms in the ED without a process for eventual review or discontinuation if urine culture (UC) later resulted as negative. To address this gap, we implemented a pharmacist-driven follow-up process to discontinue antibiotics after a negative UC. After project implementation, cases reviewed by a pharmacist increased from 0% to 96.7%. Patients contacted to discontinue antibiotics increased from 0% to 40% postintervention. This process improvement is now shared across five rural departments. Our results have broad applicability in any ED environment.

Why Are We Frequently Ordering Urinalyses in Patients without Symptoms of Urinary Tract Infections in the Emergency Department?

(1) Background: In the emergency department (ED), ordering urine tests in patients without symptoms of a urinary tract infection can lead to inappropriate antimicrobial treatment. We aimed to identify factors contributing to the unnecessary ordering of urinalyses in the ED. (2) Methods: An online survey study among nurses and physicians working in the EDs of five hospitals in the Netherlands was conducted. (3) Results: The overall response rate was 26% (221/850; 85 nurses and 136 physicians). The vast majority of the respondents reported knowing when to order urine tests (197/221; 90%). Almost two-thirds of the respondents (145/221; 66%) agreed that they ordered urinalyses because it is rapid and non-invasive to patients. Most nurses (66/86; 78%) said they informed the doctor if they thought the urine test would not contribute to the patient's diagnosis, but only one-third of the physicians agreed with this statement (44/136; 32%). Most respondents (160/221; 72%) thought guidelines or protocols about urinalyses in the ED would be functional. (4) Conclusions: These results suggest urinalyses were frequently ordered in the ED to achieve a fast work process. Nurses and physicians could improve their communication about the indications for urine tests. Developing diagnostic guidelines for urine testing may be convenient.

Top Myths of Diagnosis and Management of Infectious Diseases in Hospital Medicine

Antimicrobial agents are among the most frequently prescribed medications during hospitalization. However, approximately 30% to 50% or more of inpatient antimicrobial use is unnecessary or suboptimal. Herein, we describe 10 common myths of diagnosis and management that often occur in the hospital setting. Further, we discuss supporting data to dispel each of these myths. This analysis will provide hospitalists and other clinicians with a foundation for rational decision-making about antimicrobial use and support antimicrobial stewardship efforts at both the patient and institutional levels.

Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI.

OBJECTIVE

The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI.

METHODS

A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis.

RESULTS

Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without.

CONCLUSIONS

Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI.

Antioxidant-rich Clove Extract, A Strong Antimicrobial Agent against Urinary Tract Infections-causing Bacteria in vitro

Clove (Syzygium aromaticum) is an exotic culinary spice that has been used for centuries due to its known antimicrobial and antioxidant properties. The main aim of this study is to compare the antimicrobial activity and antioxidant capacity of clove ethanolic extract (CEE) and commercial clove essential oil (CEO) at a standardised eugenol content. Disk diffusion assay showed that CEE (2000 μg) was able to exhibit broad-spectrum inhibition against both Gram negative and Gram positive Urinary Tract Infections (UTIs)-causing pathogens: Proteus mirabilis (19.7 ± 0.6 mm) > Staphylococcus epidermidis (18 mm) > Staphylococcus aureus (14.7 ± 0.6 mm) > Escherichia coli (12.7 ± 0.6 mm) > Klebsiella pneumoniae (12.3 ± 0.6 mm) (according to the size of inhibition zone). Interestingly, the comparison between CEE and commercial CEO revealed that the former demonstrated stronger antimicrobial and antioxidative properties at similar eugenol concentration. The EC₅₀ of DPPH (1,1-diphenyl-2-picrylhydrazyl), ABTS (2,2′-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) and reducing power assay for CEE were determined as 0.037 mg/mL, 0.68 mg/mL and 0.44 mg/mL, respectively. Besides eugenol, High Performance Liquid Chromatography (HPLC) analyses identified the presence of kaempferol, gallic acid and catechin in CEE. As a conclusion, we concluded that there was a possible synergistic effect between eugenol and the others active compounds especially kaempferol which led to the observed bioactivities in CEE.

Influence of gender on the performance of urine dipstick and automated urinalysis in the diagnosis of urinary tract infections at the emergency department

BACKGROUND

Urinary tract infections (UTIs) are frequently encountered at the Emergency Department (ED). Given the anatomical differences between men and women, we aimed to clarify differences in the diagnostic performance of urinary parameters at the ED.

METHODS

A cohort study of adults presenting at the ED with fever and/or clinical suspected UTI. Performance of urine dipstick (UD) and automated urinalysis (UF-1000i) were analysed for the total study population and men and women separately. We focused on 1) UTI diagnosis and 2) positive urine culture (UC, ≥10⁵ CFU/ml) as outcome.

RESULTS

In 360 of 917 cases (39.3%) UTI was established (men/women 35.1%/43.6%). Diagnostic accuracy of UD was around 10% lower in women compared to men. Median automated leucocyte and bacterial count were higher in women compared to men. Diagnostic performance by receiver operating analysis was 0.851 for leucocytes (men/women 0.879/0.817) and 0.850 for bacteria (men/women 0.898/0.791). At 90% sensitivity, cut-off values of leucocyte count (men 60/µL, women 43/µL), and bacterial count (men 75/µL, women 139/µL) showed performance differences in favour of men. In both men and women, diagnostic performance using specified cut-off values was not different between normal and non-normal bladder evacuation. UC was positive in 327 cases (men/women 149/178), as with UTI diagnosis, diagnostic values in men outperformed women.

CONCLUSIONS

Overall diagnostic accuracy of urinary parameters for diagnosing UTI is higher in men. The described differences in cut-off values for leukocyte and bacterial counts for diagnosing UTI necessitates gender-specific cut-off values, probably reflecting the influence of anatomical and urogenital differences.

A retrospective study on the microbial spectrum and antibiogram of uropathogens in children in a secondary care hospital in Rural Vellore, South India

Background:

Urinary tract infection (UTI) is common among children. Empiric antibiotics have to be started as early as possible or it may lead to an irreversible renal parenchymal damage and renal scarring in children. The objectives were to determine the prevalence and microbial profile of paediatric UTI and to determine the antimicrobial susceptibility pattern.

Methodology:

This is a retrospective study which looked at urine cultures of children below 15 years that were sent during the study period.

Results:

Among the total urine cultures sent only 21.2% showed significant growth of organisms. The most common organism isolated was E. coli (75.5%). E. coli was least sensitive to cefpodoxime and co-trimoxazole, whereas highly sensitive to nitrofurantoin. Of the total children who had significant growth, 46% had ESBL.

Discussion:

The prevalence of culture-proven UTI among children was found to be 21.2%. The most common organism isolated among the study population was E. coli (75.5%) followed by Enterococcus species (19.0%) and Klebsiella species (14.5%). It was also found that E. coli was least sensitive to cefpodoxime (31.6%) and co-trimoxazole (26.3%), moderately to amoxicillin-clavulanate (52.4%), whereas highly sensitive to nitrofurantoin (82.9%). This was similar with the studies done at other secondary care hospitals, in Oman and Oddanchathram, South India.

Conclusions:

With the increasing resistance, cephalosporins should not be used in treating paediatric UTI, whereas nitrofurantoin can be started as an empiric antibiotic, which can later be changed according to the susceptibility pattern.

Exploring the Experiences and Information Needs of Parents Caring for a Child With a Urinary Tract Infection: A Qualitative Study

Urinary tract infections (UTIs) are common in children, however, clinical practice variations can leave parents unsure how to care for their child. We aim to develop knowledge tools that provide evidence-based information about pediatric UTIs. To inform tool development, we asked parents to share their experiences and information needs in caring for a child with a UTI. Using qualitative description methods, 16 semistructured interviews were conducted with 18 parents. Parents were recruited through the emergency department (ED) of a major Canadian urban pediatric hospital. Five major themes emerged: (1) parent descriptions of their child’s symptoms and behaviors; (2) UTIs have an effect on the entire family; (3) reasons for going to the ED; (4) parent experiences with UTI treatment, management, and follow-up strategies for their child; and (5) parent information needs and preferred information sources for UTIs. Our findings highlight the diversity of UTI symptoms children experience, which causes uncertainty and confusion for parents. This diversity suggests the development of knowledge tools for parents about UTIs is needed.

Antibiotic prescribing for adult bacteriuria and pyuria in community hospital emergency departments

OBJECTIVE

To describe emergency department (ED) antibiotic prescribing for urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) and to identify improvement opportunities.

METHODS

Patients treated for UTI in 16 community hospital EDs were reviewed to identify prescribing that was unnecessary (any treatment for ASB, duration >7 days for cystitis or >14 days for pyelonephritis) or suboptimal [ineffective antibiotics (nitrofurantoin/fosfomycin) or duration <7 days for pyelonephritis]. Duration criteria were based on recommendations for complicated UTI since criteria for uncomplicated UTI were not reviewed. 14-day repeat ED visits were evaluated.

RESULTS

Of 250,788 ED visits, UTI was diagnosed in 13,466 patients (5%), and 1427 of these (11%) were manually reviewed. 286/1427 [20%, 95% CI: 18-22%] met criteria for ASB and received 2068 unnecessary antibiotic days [mean (±SD) 7 (2) days]. Mean treatment duration was 7 (2) days for cystitis and 9 (2) days for pyelonephritis. Of 446 patients with cystitis, 128 (29%) were prescribed >7 days (total 396 unnecessary). Of 422 pyelonephritis patients, 0 (0%) were prescribed >14 days, 20 (5%) were prescribed <7 days, and 9 (2%) were given ineffective antibiotics. Overall, prescribing was unnecessary or suboptimal in 443/1427 [31%, 95% CI: 29-33%] resulting in 2464/11,192 (22%) unnecessary antibiotic days and 8 (0.5%) preventable ED visits.

CONCLUSIONS

Among reviewed patients, poor UTI prescribing in 16 EDs resulted in unnecessary antibiotic days and preventable readmissions. Key areas for improvement include non-treatment of ASB and shorter durations for cystitis.

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

Background

Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes.

Methods

We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018-February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes.

Results

Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02).

Conclusions

Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

A diagnostic algorithm for detection of urinary tract infections in hospitalized patients with bacteriuria: The "Triple F" approach supported by Procalcitonin and paired blood and urine cultures

For acute medicine physicians, distinguishing between asymptomatic bacteriuria (ABU) and clinically relevant urinary tract infections (UTI) is challenging, resulting in overtreatment of ABU and under-recognition of urinary-source bacteraemia without genitourinary symptoms (USB). We conducted a retrospective analysis of ED encounters in a university hospital between October 2013 and September 2018 who met the following inclusion criteria: Suspected UTI with simultaneous collection of paired urinary cultures and blood cultures (PUB) and determination of Procalcitonin (PCT). We sought to develop a simple algorithm based on clinical signs and PCT for the management of suspected UTI. Individual patient presentations were retrospectively evaluated by a clinical "triple F" algorithm (F1 ="fever", F2 ="failure", F3 ="focus") supported by PCT and PUB. We identified 183 ED patients meeting the inclusion criteria. We introduced the term UTI with systemic involvement (SUTI) with three degrees of diagnostic certainty: bacteremic UTI (24.0%; 44/183), probable SUTI (14.2%; 26/183) and possible SUTI (27.9%; 51/183). In bacteremic UTI, half of patients (54.5%; 24/44) presented without genitourinary symptoms. Discordant bacteraemia was diagnosed in 16 patients (24.6% of all bacteremic patients). An alternative focus was identified in 67 patients, five patients presented with S. aureus bacteremia. 62 patients were diagnosed with possible UTI (n = 20) or ABU (n = 42). Using the proposed "triple F" algorithm, dichotomised PCT of < 0.25 pg/ml had a negative predictive value of 88.7% and 96.2% for bacteraemia und accordant bacteraemia respectively. The application of the algorithm to our cohort could have resulted in 33.3% reduction of BCs. Using the diagnostic categories "possible" or "probable" SUTI as a trigger for initiation of antimicrobial treatment would have reduced or streamlined antimicrobial use in 30.6% and 58.5% of cases, respectively. In conclusion, the "3F" algorithm supported by PCT and PUB is a promising diagnostic and antimicrobial stewardship tool.

A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections

BACKGROUND

Uncomplicated urinary tract infections (UTIs) can often be diagnosed based solely on symptoms and should be treated with a short course of narrow spectrum antibiotics. However, clinicians often order urine analyses and prescribe long courses of broad spectrum antibiotics.

OBJECTIVE

The objectives of our study are: 1) Understand how primary care providers and residents clinically approach UTIs and 2) to understand specific opportunities, based on provider type, to target future antibiotic stewardship interventions.

DESIGN AND PARTICIPANTS

We conducted semi-structured qualitative interviews of community primary care providers (n = 15) and internal medicine residents (n = 15) in St. Louis, Missouri from 2018-2019. A 5-point Likert scale was used to evaluate participant preferences for possible interventions. Interviews were transcribed, de-identified, and coded by two independent researchers using a combination inductive and deductive approach.

KEY RESULTS

Several common themes emerged. Both providers and residents ordered urine tests to "confirm" presence of urinary tract infections. Antibiotic prescription decisions were often based on historical practice and anecdotal experience rather than local susceptibility data or clinical practice guidelines. Community providers were more comfortable treating patients over the phone than residents and tended to prescribe longer courses of antibiotics. Both community providers and residents voiced frustrations with guidelines being difficult to easily incorporate due to length and extraneous information. Preferences for receiving and incorporating guidelines into practice varied. Both groups felt benchmarking would improve prescribing practices but had reservations about implementation. Community providers preferred pragmatic clinical decision support systems and nurse triage algorithms. Residents preferred order sets.

CONCLUSIONS

Significant opportunities exist to optimize urinary tract infection management among residents and community providers. Multifaceted interventions that include provider education, synthesis of guidelines, and pragmatic clinical decision support systems are needed to improve antibiotic prescribing and diagnostic testing; optimal interventions to improve UTI management may vary based on provider training level.

Which patient should start empirical antibiotic treatment in urinary tract infection in emergency departments?

OBJECTIVES:

This study aims to determine the factors that would lead the doctors in EDs to a more the accurate diagnosis of urinary tract infection (UTI) and the correct initiation of empirical antibiotherapy in the emergency room and reduce the use of unnecessary antibiotherapy.

METHODS:

This study is a prospective observational study from a single-center, investigating patients with an age of 18 years and older who presented to the emergency department (ED) with the symptoms of UTI between January and May 2018. The guiding parameters to establish a UTI diagnosis and start an empirical antibiotherapy were investigated between the negative (Group 1) and positive (>10³ colonies) (Group 2) groups, as a result of urine culture in terms of urine culture.

RESULTS:

Our study included a total of 108 patients (59 women and 49 men). The average age was 47.11 ± 14.97. Age and gender were similar among the groups and not a discriminating factor in the diagnosis of UTI. High Charlson Comorbidity Index score, history of chronic kidney failure and cerebrovascular disease, leukocyte esterase, nitrite positivity, and leukocyte cluster presence were higher in Group 2. We suggest that these parameters might be predictive values to detect bacterial growth in urine culture. Empirical antibiotherapy was started in 48.4% of the patients in Group 1 and 95.7% of the patients in Group 2.

CONCLUSIONS:

In EDs, admission complaints of the patients and physical examination findings do not always result in the diagnosis of UTI. Our study showed that UTI diagnosis could be made more accurately using leukocyte esterase, nitrite positivity, the presence of leukocyte clusters, and the Charlson Comorbidity Index score. We also suggest that regional antibiotic resistance should be considered before starting empirical antibiotherapy.

Evaluating and prioritizing antimicrobial stewardship programs for nursing homes: A modified Delphi panel

BACKGROUND

Antibiotic use in nursing homes is often inappropriate, in terms of overuse and misuse, and it can be linked to adverse events and antimicrobial resistance. Antimicrobial stewardship programs (ASPs) can optimize antibiotic use by minimizing unnecessary prescriptions, treatment cost, and the overall spread of antimicrobial resistance. Nursing home providers and residents are candidates for ASP implementation, yet guidelines for implementation are limited.

OBJECTIVE

To support nursing home providers with the selection and adoption of ASP interventions.

DESIGN AND SETTING

A multiphase modified Delphi method to assess 15 ASP interventions across criteria addressing scientific merit, feasibility, impact, accountability, and importance. This study included surveys supplemented with a 1-day consensus meeting.

PARTICIPANTS

A 16-member multidisciplinary panel of experts and resident representatives.

RESULTS

From highest to lowest, 6 interventions were prioritized by the panel: (1) guidelines for empiric prescribing, (2) audit and feedback, (3) communication tools, (4) short-course antibiotic therapy, (5) scheduled antibiotic reassessment, and (6) clinical decision support systems. Several interventions were not endorsed: antibiograms, educational interventions, formulary review, and automatic substitution. A lack of nursing home resources was noted, which could impede multifaceted interventions.

CONCLUSIONS

Nursing home providers should consider 6 key interventions for ASPs. Such interventions may be feasible for nursing home settings and impactful for improving antibiotic use; however, scientific merit supporting each is variable. A multifaceted approach may be necessary for long-term improvement but difficult to implement.

Joint report of SBI (Brazilian Society of Infectious Diseases), FEBRASGO (Brazilian Federation of Gynecology and Obstetrics Associations), SBU (Brazilian Society of Urology) and SBPC/ML (Brazilian Society of Clinical Pathology/Laboratory Medicine): recommendations for the clinical management of lower urinary tract infections in pregnant and non-pregnant women

Urinary tract infection (UTI) is a common condition in women. There is an increased concern on reduction of bacterial susceptibility resulting from wrongly prescribing antimicrobials. This paper summarizes the recommendations of four Brazilian medical societies (SBI – Brazilian Society of Infectious Diseases, FEBRASGO – Brazilian Federation of Gynecology and Obstetrics Associations, SBU – Brazilian Society of Urology, and SBPC/ML – Brazilian Society of Clinical Pathology/Laboratory Medicine) on the management of urinary tract infection in women.

Asymptomatic bacteriuria should be screened at least twice during pregnancy (early and in the 3rd trimester). All cases of significant bacteriuria (≥10⁵ CFU/mL in middle stream sample) should be treated with antimicrobials considering safety and susceptibility profile. In women with typical symptoms of cystitis, dipsticks are not necessary for diagnosis. Urine cultures should be collected in pregnant women, recurrent UTI, atypical cases, and if there is suspicion of pyelonephritis. First line antimicrobials for cystitis are fosfomycin trometamol in a single dose and nitrofurantoin, 100 mg every 6 hours for five days. Second line drugs are cefuroxime or amoxicillin-clavulanate for seven days. During pregnancy, amoxicillin and other cephalosporins may be used, but with a higher chance of therapeutic failure.

In recurrent UTI, all episodes should be confirmed by urine culture. Treatment should be initiated only after urine sampling and with the same regimens indicated for isolated episodes. Prophylaxis options of recurrent UTI are behavioral measures, non-antimicrobial and antimicrobial prophylaxis. Vaginal estrogens may be recommended for postmenopausal women. Other non-antimicrobial prophylaxis, including cranberry and immunoprophylaxis, have weak evidence supporting their use. Antimicrobial prophylaxis may be offered as a continuous or postcoital scheme. In pregnant women, options are cephalexin, 250–500 mg and nitrofurantoin, 100 mg (contraindicated after 37 weeks of pregnancy). Nonpregnant women may use fosfomycin trometamol, 3 g every 10 days, or nitrofurantoin, 100 mg (continuous or postcoital).

Oncologic Emergencies: The Fever With Too Few Neutrophils

BACKGROUND

Cancer is associated with a variety of complications, including neutropenic fever, which can result in severe morbidity and mortality. This oncologic emergency requires ED management.

OBJECTIVE

This narrative review provides focused updates for emergency clinicians regarding neutropenic fever.

DISCUSSION

Neutropenic fever is defined by fever with oral temperature >38.3°C or temperature >38.0°C for 1 hour with an absolute neutrophil count (ANC) < 1000 cells/microL. Patients who have received chemotherapy within 6 weeks of presentation are at high risk for neutropenia. While most patients with neutropenic fever do not have an identifiable bacterial source of fever, clinicians should treat patients for bacterial infection. Rapid assessment and management are vital to improving outcomes in patients with suspected or confirmed neutropenic fever. History and examination should focus on the most common sites of infection: the gastrointestinal tract, blood, skin, lung, and urinary tract. However, physical examination and laboratory or imaging assessment may not display classic signs of infection. Blood cultures should be obtained, and broad-spectrum antibiotics are recommended. Oncology consultation is an integral component in the care of these patients. Several risk scores can assist in stratifying patients who may be appropriate for discharge home and follow-up.

CONCLUSIONS

Neutropenic fever is an oncologic emergency. Rapid diagnosis and care of patients with neutropenic fever can improve outcomes, along with oncology consultation.

Diagnosis of urinary tract infection in older persons in the emergency department: To pee or not to pee, that is the question

Doreen is a 79-year-old woman referred by her general practitioner to the ED for intravenous antibiotics for a urinary tract infection (UTI). She lives in a residential aged care facility (RACF) and staff report malodourous and cloudy urine. She denies dysuria or frequency. On examination Doreen is frail with vital signs of: temperature 37.7°C, pulse 87 bpm, blood pressure 130/70; there is no suprapubic or flank tenderness. Do you perform a dipstick test on Doreen’s urine for a suspected UTI?

Evaluation and Management of Urinary Tract Infection in the Emergency Department

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

Does treatment of urinary tract infections reflect the antibiotic stewardship program guidelines?

Protocols are required for antibiotic use for treatment of urinary tract infections (UTIs) in long-term care facilities (LTCFs). This project assessed antibiotic prescribing practices for UTI in three LTCFs to elucidate practice and its relationship to protocols in these settings. A retrospective chart review of UTI cases occurring between February 1, 2017, and July 30, 2017, was conducted to describe provider management in three LTCFs. Sixty-three cases with compelling urinary symptoms potentially suggestive of UTI were included in the review. Urine culture findings indicated that a more than 100,000 CFU/ml colony count was present in 46% (n = 29) of the cases; however, 63.5% (n = 40) of the cases received antibiotics. Eleven cases (17.4%) received antibiotics based on symptoms without UTI diagnosis. Empirical treatment was initiated in 35% (n = 22) of the cases. When urine culture reports were available, previously untreated 28.57% (n = 18) cases received antibiotics for colony counts of >100,000 CFU/ml. Antibiotics were given for colony counts of <100,000 CFU/ml for 17.46% (n = 11) of the cases. Increased urinary frequency or burning on urination (95.23%) and change in behavior (88.9%) were the primary reasons for initiation of urinalysis and urine culture testing. Nurse practitioner implementation of protocols for antibiotic stewardship programs in LTCFs can prevent overprescription for UTI in these facilities.

Use of a subcutaneous ureteral bypass device for treatment of bilateral proximal ureteral injury in a 9-month-old cat

Case summary

A 9-month-old male domestic longhair cat presented following iatrogenic ureteral trauma after an attempted laparoscopic ovariectomy. Prior to identifying that the cat was male, both ureters were transected approximately 4 mm from the renal pelves. Initial management involved a left-sided Boari flap neoureterocystostomy, cystonephropexy and right ureteronephrectomy. Thirty-six hours later, the cat developed uroabdomen due to leakage from the neoureterocystostomy site. At a tertiary referral institution, the ureter was reconstructed via end-to-end anastomosis and a left-sided subcutaneous ureteral bypass (SUB) device was placed in the event the anastomosis failed. Five weeks after SUB placement, the cat was dysuric and stranguric. A urine culture was negative and clinical signs were attributed to sterile cystitis secondary to device placement. Blood urea nitrogen (BUN) was 22 mg/dl and creatinine was 1.2 mg/dl. Contrast pyelography confirmed device patency, but no contrast was identified through the ureteral anastomosis. At 12 months, BUN and creatinine were 1.5 mg/dl and 25 mg/dl, respectively, and a subclinical urinary tract infection was identified (Enterococcus faecalis). Antibiotic therapy was not prescribed in order to prevent multidrug resistance. At 42 months, BUN was 38 mg/dl and creatinine was 2.0 mg/dl. The cat had occasional and intermittent signs of pollakiuria and stranguria but was otherwise doing well.

Relevance and novel information

To our knowledge, this is the first case report to describe the use of a SUB device for management of traumatic proximal ureteral injury in a cat with one kidney. The case outcome provides valuable information about the direct effect of the SUB device and the presence of chronic Enterococcus species infection on long-term renal function.

Advances and Challenges in the Diagnosis and Treatment of Urinary Tract Infections: the Need for Diagnostic Stewardship

PURPOSE OF REVIEW

Urinary tract infections (UTIs), including catheter-associated UTIs, are among the most common bacterial infections in both inpatient and outpatient settings. Diagnosis of true UTI remains a clinical challenge, and excessive antimicrobial treatment of asymptomatic bacteriuria (ASB) or contaminated urine cultures is common.

RECENT FINDINGS

Challenges with the appropriate diagnosis of UTIs include the lack of specific signs and symptoms, no definitive diagnostic criteria, high incidence of ASB, contamination of samples, and frequent lack of indications for ordering urine cultures. Promising interventions include education and feedback, indication requirements when ordering cultures, and use of reflex culture policies that limit urine cultures. Antimicrobial and diagnostic stewardship interventions can work synergistically to decrease ordering of urine cultures without clear indication and prevent excessive antimicrobial administration in patients without clearly defined UTI.

Antimicrobial Stewardship in the Emergency Department

The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.

[Twenty-five myths in infectious diseases in primary care associated with overdiagnosis and overtreatment]

Overdiagnosis and overprescribing is common in current clinical practice of infectious diseases in primary care. On the basis of studies published in the medical literature we identify my means of a non-systematic review a total of 25 myths associated with the diagnosis and treatment and present the literature pertaining to each myth. These myths result in extraneous testing (overdiagnosis) and excessive antimicrobial treatment (overtreatment). Most of these myths are ingrained among general practitioners in our country. Not only should these myths be debunked from our clinical practice, but they should also be reversed, and we encourage our readers to critically appraise their practice when it comes down to the misconceptions treated in this manuscript. We attempt to give guidance to clinicians facing these frequent clinical scenarios.

Infectious Disease Emergencies in Oncology Patients

Oncology patients are a unique patient population in the emergency department (ED). Malignancy and associated surgical, chemotherapeutic, or radiation therapies put them at an increased risk for infection. The most ominous development is neutropenic fever, which happens often and may not present with signs or symptoms other than fever. A broad differential diagnosis is essential when considering infectious disease pathology in both neutropenic and non-neutropenic oncology patients in the ED.

The Emergency Department Diagnosis and Management of Urinary Tract Infection

Urinary tract infection (UTI) is a common infection seen in the emergency department. The spectrum of UTI includes simple versus complicated infection and lower versus upper UTI. No one history or examination finding is definitive for diagnosis. Testing often includes urinalysis and/or urine dipstick, and several pitfalls may occur in interpretation. Urine cultures should be obtained in complicated or upper UTIs but not simple and lower tract UTIs, unless a patient is pregnant. Imaging often is not required. Most patients with simple cystitis and pyelonephritis are treated as outpatients. A variety of potentially dangerous conditions may mimic UTI and pyelonephritis.

A systematic review of parents' experiences and information needs related to their child's urinary tract infection

OBJECTIVE

As a first step toward the development of an animated video and infographic to increase parents' knowledge of pediatric urinary tract infections (UTIs), we conducted a systematic review of their experiences and information needs.

METHODS

We searched Ovid Medline, Ovid PsycINFO, CINAHL, and ProQuest Dissertations and Theses Global for studies published in 2000 or thereafter. We appraised quality using the Mixed Methods Appraisal Tool. We summarised the quantitative data narratively and the qualitative data thematically.

RESULTS

We identified 1493 records and included four. Sample size ranged from 20 to 2726 parents. The children ranged from <1 to 12 years old and had experienced one to >10 UTIs. Parents were not always aware of UTI symptoms and generally received little information. Parents sought information online, and desired it via other means. Some parents were not confident in healthcare providers' (HCPs') knowledge of UTIs. Inadequate information about diagnostic tests sometimes resulted in fear and non-compliance.

CONCLUSIONS

From the limited literature, it appears that parents would like information about prevention, diagnosis, treatment, and prognosis, but do not always consider HCPs good information sources.

PRACTICE IMPLICATIONS

Care providers should communicate information in ways that suit parents' self-identified needs.

Reasons for home care clients' unplanned Hospital admissions and their associations with patient characteristics

BACKGROUND

Unplanned hospitalizations and emergency room visits occur frequently among home care clients The aim of this study was to identify typical discharge diagnoses and their associations with patient characteristics among a total of 6812 Finnish home care clients aged ≥63 years who were hospitalized within one year of their first home care assessment.

METHODS

A register-based study based on Resident Assessment Instrument-Home Care (RAI-HC) assessments and nationwide hospital discharge records. The RAI-HC assessments were linked to the hospital discharge records of the participants' first unplanned hospitalization. Univariate and multivariable regression analyses were used to evaluate the association of RAI-HC determinants with discharge diagnoses.

RESULTS

The most common reason for the first hospitalization was an infectious disease (21%; n = 1446). When hospitalizations were classified according to the main diagnosis, chronic skin ulcers, functional impairment and daily urinary incontinence were associated with hospitalization due to infectious diseases; impaired cognitive capacity, Alzheimer's disease or other dementia and polypharmacy (protective effect) were associated with hospitalizations due to dementia; age of ≥90 years, congestive heart failure, coronary artery disease and using ≥10 drugs with hospitalizations due to heart diseases; and moderate or strong pain with hospitalization due to musculoskeletal disorders. Previous falls, female sex and an earlier hip fracture were associated with injury-related hospitalizations. Feelings of loneliness increased the odds of hospitalization due to geriatric symptoms without a specific diagnosis.

CONCLUSION

Patient characteristics and geriatric syndromes identified using RAI-HC predict the reasons for future hospitalizations among new home care clients.

Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings

Background

Inappropriate ordering and acquisition of urine cultures leads to unnecessary treatment of asymptomatic bacteriuria (ASB). Treatment of ASB contributes to antimicrobial resistance particularly among hospital-acquired organisms. Our objective was to investigate urine culture ordering and collection practices among nurses to identify key system-level and human factor barriers and facilitators that affect optimal ordering and collection practices.

Methods

We conducted two focus groups, one with ED nurses and the other with ICU nurses. Questions were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We used iterative categorization (directed content analysis followed by summative content analysis) to code and analyze the data both deductively (using SEIPS domains) and inductively (emerging themes).

Results

Factors affecting optimal urine ordering and collection included barriers at the person, process, and task levels. For ED nurses, barriers included patient factors, physician communication, reflex culture protocols, the electronic health record, urinary symptoms, and ED throughput. For ICU nurses, barriers included physician notification of urinalysis results, personal protective equipment, collection technique, patient body habitus, and Foley catheter issues.

Conclusions

We identified multiple potential process barriers to nurse adherence with evidence-based recommendations for ordering and collecting urine cultures in the ICU and ED. A systems approach to identifying barriers and facilitators can be useful to design interventions for improving urine ordering and collection practices.

Cateter urinário: o tempo de exposição e calibre podem influenciar na formação de biofilme?

Resumo Objetivo: Avaliar a influência do tempo de exposição e calibre na formação de biofilme em cateteres urinários de Foley (CUFs). Método: Pesquisa in vitro com amostras de fragmentos de CUFs em látex siliconizado de diferentes calibres (n° 14 e n° 16 Frenchs). A urina artificial foi confeccionada, inoculada com bactérias-padrão Staphylococcus aureus (ATCC 25923) e Pseudomonas aeruginosa (ATCC 27853) e incubada a 37 °C por 24 horas e 72 horas. As análises foram realizadas por meio de cultura (carga bacteriana) e microscopia eletrônica de varredura. Resultados: Não houve diferença na carga bacteriana dos biofilmes formados nas superfícies dos CUFs com relação aos diferentes calibres (p > 0,05). Por outro lado, o tempo de exposição (24 horas e 72 horas) foi o fator determinante para formação do biofilme de P. aeruginosa nos CUFs (p < 0,05). Conclusão: O tempo de exposição influenciou a formação do biofilme de P. aeruginosa nos CUFs, independentemente dos calibres.

Bacteria on Urine Microscopy Is Not Associated with Systemic Infection in Patients with Obstructing Urolithiasis

INTRODUCTION

Determining whether bacterial presence in urine microscopy represents infection is important as ureteral stent placement is indicated in patients with obstructing urolithiasis and infection. We aim to investigate whether the presence of bacteria on urine microscopy is associated with other markers of infection in patients with obstructing urolithiasis presenting to the emergency room.

METHODS

We performed a cross-sectional study of 199 patients with obstructing urolithiasis and divided patients into two groups according to the presence of bacteria on urine microscopy. The primary outcome was serum white blood cell count and secondary outcomes were objective fever, subjective fever, tachycardia, pyuria, and final urine culture. Univariate and multivariate analysis were used to assess whether the presence of bacteria on microscopy was associated with other markers of infection.

RESULTS

The study included 72 patients in the bacteriuria group and 127 without bacteriuria. On univariate analysis, the presence of bacteria was not associated with leukocytosis, objective fever, or subjective fever, but it was associated with gender (p < 0.001), pyuria (p < 0.001), positive nitrites (p = 0.001), positive leukocyte esterase (p < 0.001), and squamous epithelial cells (p = 0.002). In a multilinear regression model including the presence of squamous cells, age, and sex, the presence of bacteriuria was not related to serum white blood cell count (coefficient -0.47; 95% confidence interval [CI] -1.1, 0.2; p = 0.17), heart rate (coefficient 0.85; 95% CI -2.5, 4.2; p = 0.62), presence of subjective or objective fever (odds ratio [OR] 1.5; 95% CI 0.8, 3.1; p = 0.18), or the presence of squamous epithelial cells (coefficient -4.4; 95% CI -10, 1.2; p = 0.12). However, the presence of bacteriuria was related to only the degree of pyuria (coefficient 16.4; 95% CI 9.6, 23.3; p < 0.001).

CONCLUSIONS

Bacteria on urine microscopy is not associated with other markers of systemic infection and may largely represent a contaminant. Renal colic may be a risk factor for providing a contaminated urine specimen.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Introduction

The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.

Methods

The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors.

Results

Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area.

Conclusion

The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

Optimizing Inpatient Urine Culture Ordering Practices Using the Electronic Medical Record: A Pilot Study

A prospective quasi-experimental before-and-after study of an electronic medical record-anchored intervention of embedded education on appropriate urine culture indications and indication selection reduced the number of urine cultures ordered for catheterized patients at an academic medical center. This intervention could be a component of CAUTI-reduction bundles. Infect Control Hosp Epidemiol 2017;38:486-488.