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Bex S, Leidi A, Marti C, Meyssonnier V, Huttner A. Which trial do we need? Three-day course of antibiotics for acute pyelonephritis in immunocompetent women. Clin Microbiol Infect 2024; 30:267-269. [PMID: 37690609 DOI: 10.1016/j.cmi.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Stijn Bex
- General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland
| | - Antonio Leidi
- General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland
| | - Christophe Marti
- General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland
| | - Vanina Meyssonnier
- General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland; Infectious Diseases Division, Geneva University Hospitals, Geneva, Switzerland
| | - Angela Huttner
- Infectious Diseases Division, Geneva University Hospitals, Geneva, Switzerland; Clinical Trials Unit, Center for Clinical Research, Geneva University Hospitals and School of Medicine, Geneva, Switzerland.
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Hojat LS, Bessesen MT, Huang M, Reid M, Knepper BC, Miller MA, Shihadeh KC, Fugit RV, Jenkins TC. Effectiveness of Shorter Versus Longer Durations of Therapy for Common Inpatient Infections Associated With Bacteremia: A Multicenter, Propensity-Weighted Cohort Study. Clin Infect Dis 2021; 71:3071-3078. [PMID: 31858136 DOI: 10.1093/cid/ciz1197] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND National guidelines for pneumonia (PNA), urinary tract infection (UTI), and acute bacterial skin and skin structure infection (ABSSSI) do not address treatment duration for infections associated with bacteremia. We evaluated clinical outcomes of patients receiving shorter (5-9 days) versus longer (10-15 days) duration of antibiotics. METHODS This was a multicenter retrospective cohort study of inpatients with uncomplicated PNA, UTI, or ABSSSI and associated bacteremia. The primary outcome was clinical failure, a composite of rehospitalization, reinitiation of antibiotics, or all-cause mortality within 30 days of antibiotic completion. Secondary outcomes included individual components of the primary outcome, Clostridioides difficile infection, and antibiotic-related adverse effects necessitating change in therapy. A propensity score-weighted logistic regression model was used to mitigate potential bias associated with nonrandom assignment of treatment duration. RESULTS Of 408 patients included, 123 received a shorter treatment duration (median 8 days) and 285 received a longer duration (median 13 days). In the propensity-weighted analysis, the probability of the primary outcome was 13.5% in the shorter group and 11.1% in the longer group (average treatment effect, 2.4%; odds ratio [OR], 1.25; 95% confidence interval [CI], .65-2.40; P = .505). However, shorter courses were associated with higher probability of restarting antibiotics (OR, 1.62; 95% CI, 1.01-2.61; P = .046) and C. difficile infection (OR, 4.01; 95% CI, 2.21-7.59; P < .0001). CONCLUSIONS Shorter courses of antibiotic treatment for PNA, UTI, and ABSSSI with bacteremia were not associated with increased overall risk of clinical failure; however, prospective studies are needed to further evaluate the effectiveness of shorter treatment durations.
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Affiliation(s)
- Leila S Hojat
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases and HIV Medicine, University Hospitals, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mary T Bessesen
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA.,Infectious Diseases Section, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Misha Huang
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, University of Colorado Hospital, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Hospital, Aurora, Colorado, USA.,Department of Patient Safety and Quality, University of Colorado Hospital, Aurora, Colorado, USA
| | - Margaret Reid
- Department of Biostatistics, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA
| | - Matthew A Miller
- Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA.,University of Colorado School of Pharmacy, Aurora, Colorado, USA
| | - Katherine C Shihadeh
- Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine, Denver Health, Denver, Colorado, USA.,Division of Infectious Diseases, Denver Health, Denver, Colorado, USA.,Department of Pharmacy, Denver Health, Denver, Colorado, USA
| | - Randolph V Fugit
- Department of Medicine, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA.,Infectious Diseases Section, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA.,Department of Pharmacy, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Timothy C Jenkins
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine, Denver Health, Denver, Colorado, USA.,Division of Infectious Diseases, Denver Health, Denver, Colorado, USA
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3
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Chan HTC, Leung LY, Law AKK, Cheng CH, Graham CA. Predictive factors for prolonged hospitalisation in acute pyelonephritis patients admitted to the emergency medicine ward. HONG KONG J EMERG ME 2021. [DOI: 10.1177/10249079211000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Acute pyelonephritis is a bacterial infection of the upper urinary tract. Patients can be admitted to a variety of wards for treatment. However, at the Prince of Wales Hospital in Hong Kong, they are managed initially in the emergency medicine ward. The aim of the study is to identify the risk factors that are associated with a prolonged hospital length of stay. Methods: This was a retrospective cohort study conducted in Prince of Wales Hospital. The study recruited patients who were admitted to the emergency medicine ward between 1 January 2014 and 31 December 2017. These patients presented with clinical features of pyelonephritis, received antibiotic treatment and had a discharge diagnosis of pyelonephritis. The length of stay was measured and any length of stay over 72 h was considered to be prolonged. Results: There were 271 patients admitted to the emergency medicine ward, and 118 (44%) had a prolonged hospital length of stay. Univariate and multivariate analyses showed that the only statistically significant predictor of prolonged length of stay was a raised C-reactive protein (odds ratio 1.01; 95% confidence 1.01–1.02; p < 0.0001). Out of 271 patients, 261 received antibiotics in the emergency department. All 10 patients (8.5%) who did not receive antibiotics in emergency department had a prolonged length of stay (p = 0.0002). Conclusion: In this series of acute pyelonephritis treated in the emergency medicine ward, raised C-reactive protein levels were predictive for prolonged length of stay. Patients who did not receive antibiotics in the emergency department prior to emergency medicine ward admission had prolonged length of stay.
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Affiliation(s)
- Howard Tat Chun Chan
- Accident and Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong SAR
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Alex Kwok Keung Law
- Accident and Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong SAR
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Chi Hung Cheng
- Accident and Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong SAR
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Colin A Graham
- Accident and Emergency Department, Prince of Wales Hospital, Shatin, Hong Kong SAR
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
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Jang YR, Ahn SJ, Choi SJ, Eom JS, Cho YK, Shim YS, Park SH, Kim JH, Kim HS. Clinical and computed tomography factors associated with sepsis in women with clinically uncomplicated pyelonephritis. Abdom Radiol (NY) 2021; 46:723-731. [PMID: 32857260 DOI: 10.1007/s00261-020-02711-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/28/2020] [Accepted: 08/18/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Sepsis is major determinants of prognosis in acute pyelonephritis (APN). This study aimed to assess factors associated with the development of sepsis among patients with clinically uncomplicated APN. SUBJECTS AND METHODS We examined 463 patients presenting to our hospital without complications. We assessed clinical factors including demographic and laboratory features. Renal and extrarenal features on computed tomography (CT) were also analyzed. Risk factors of sepsis are assessed. RESULTS The study included 361 patients without (78.0%) and 102 patients with sepsis (22.0%). Crude and attributable mortality rates were 3.9% and 2.0% versus 1.4% and 0.6%, respectively, among patients with and without sepsis. Clinical risk factors for sepsis were age >65 years (odds ratio [OR] 1.79, P = 0.02), absence of flank pain (OR 1.59, P = 0.04), absence of costovertebral tenderness (OR 1.89, P = 0.03), diabetes mellitus (OR 2.25, P = 0.02), bacteremia (OR 2.8, P = 0.01), C-reactive protein level >100 mg/L (OR 1.42, P = 0.02), and lack of previous APN history (OR 1.76, P = 0.04). APN grade IV (OR 3.16, P = 0.01), high grade hydronephrosis (OR 1.50, P = 0.03), diffuse peritoneal thickening (OR 4.12, P = 0.01), and acute interstitial pulmonary edema (OR 3.73, P = 0.01) were the CT features predictive of septic shock. CONCLUSIONS Although uncomplicated APN was largely non-fatal, several clinical and CT features could lead to sepsis. Our findings may be useful for predicting sepsis risk and deciding whether intravenous antibiotic treatment and intensive management should be initiated for uncomplicated APN.
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Affiliation(s)
- Young Rock Jang
- Division of Infectious Disease, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Su Joa Ahn
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 24, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea.
| | - Seung Joon Choi
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 24, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - Joong Sik Eom
- Division of Infectious Disease, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Yong Kyun Cho
- Division of Infectious Disease, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Young Sup Shim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 24, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - So Hyun Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 24, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - Jeong Ho Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 24, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - Hyung-Sik Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 24, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
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5
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Lee SH, Choi T, Choi J, Yoo KH. Differences between Risk Factors for Sepsis and Septic Shock in Obstructive Urolithiasis. J Korean Med Sci 2020; 35:e359. [PMID: 33169555 PMCID: PMC7653168 DOI: 10.3346/jkms.2020.35.e359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/24/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Complicated acute pyelonephritis (APN) is a life-threatening condition that requires immediate intervention. This study examined the characteristics of APN occurring as a complication of ureteral stone. METHODS We retrospectively reviewed 85 patients diagnosed with APN complicated by ureteral stone between December 2006 and July 2017 at our institution. Patients with concomitant renal stone, multiple ureteral stones, ureteral strictures, ureteral cancer, and urogenital anomalies, including vesicoureteral reflux were excluded. Clinical characteristics including age, sex, underlying disease, medical history, stone characteristics, initial laboratory data, and the procedure used to correct urinary obstruction were summarized, and the risk factors associated with sepsis and septic shock were analyzed. RESULTS Sepsis was diagnosed at initial presentation in 62 patients, 17 of whom suffered from septic shock. Disease-related death did not occur in any patient. Previous history of stone (P = 0.015), leukocytosis (P < 0.001), elevated C-reactive protein levels (P = 0.006), and low albumin (P = 0.038) were significant risk factors for progression to sepsis. The absence of hypertension (P = 0.047), thrombocytopenia (P = 0.006), decreased erythrocyte sedimentation rate (ESR) (P = 0.003), elevated blood urea nitrogen (P = 0.016), and positive blood culture (P = 0.018) were significant predictors for progression to septic shock. Multivariate analysis revealed that previous history of stone (P = 0.015) was an independent risk factor for sepsis, while the absence of hypertension (P = 0.047), thrombocytopenia (P = 0.013), and decreased ESR (P = 0.009) were risk factors for shock. CONCLUSION The risk factors associated with the progression from APN to sepsis differed from those associated with the progression from sepsis to septic shock. Various factors should be considered while selecting treatment options based on the severity of APN associated with ureteral stone. It should be managed with aggressive treatment and close observation, especially in the presence of risk factors.
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Affiliation(s)
- Sang Hyub Lee
- Department of Urology, School of Medicine, Kyung Hee University, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Taesoo Choi
- Department of Urology, School of Medicine, Kyung Hee University, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jeonghyouk Choi
- Department of Urology, School of Medicine, Kyung Hee University, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Koo Han Yoo
- Department of Urology, School of Medicine, Kyung Hee University, Kyung Hee University Hospital at Gangdong, Seoul, Korea.
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Rothrock SG, Cassidy DD, Guetschow B, Bienvenu D, Heine E, Briscoe J, Toselli N, Russin M, Young D, Premuroso C, Bailey D. Predicting outcome of patients with severe urinary tract infections admitted via the emergency department. J Am Coll Emerg Physicians Open 2020; 1:502-511. [PMID: 33000077 PMCID: PMC7493503 DOI: 10.1002/emp2.12133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To evaluate clinical prediction tools for making decisions in patients with severe urinary tract infections (UTIs). METHODS This was a retrospective study conducted at 2 hospitals (combined emergency department (ED) census 190,000). Study patients were admitted via the ED with acute pyelonephritis or severe sepsis-septic shock related UTI. Area under the receiver operating characteristic curve (AUROC) augmented by decision curve analysis and sensitivity of each rule for predicting mortality and ICU admission were compared. RESULTS The AUROC of PRACTICE was greater than that of BOMBARD (0.15 difference, 95% confidence interval [CI] = 0.09-0.22), SIRS (0.21 difference, 95% CI = 0.14-0.28) and qSOFA (0.06 difference, 95% CI = 0-0.11) for predicting mortality. PRACTICE had a greater net benefit compared to BOMBARD and SIRS at all thresholds and a greater net benefit compared to qSOFA between a 1% and 10% threshold probability level for predicting mortality. PRACTICE had a greater net benefit compared to all other scores for predicting ICU admission across all threshold probabilities. A PRACTICE score >75 was more sensitive than a qSOFA score >1 (90% versus 54.3%, 35.7 difference, 95% CI = 24.5-46.9), SIRS criteria >1 (18.6 difference, 95% CI = 9.5-27.7), and a BOMBARD score >2 (12.9 difference, 95% CI = 5-12.9) for predicting mortality. CONCLUSION PRACTICE was more accurate than BOMBARD, SIRS, and qSOFA for predicting mortality. PRACTICE had a superior net benefit at most thresholds compared to other scores for predicting mortality and ICU admissions.
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Affiliation(s)
- Steven G. Rothrock
- Department of Emergency MedicineOrlando HealthDr. P. Phillips HospitalOrlandoFloridaUSA
- Florida State University College of MedicineTallahasseeFloridaUSA
| | - David D. Cassidy
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Brian Guetschow
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Drew Bienvenu
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Erich Heine
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Joshua Briscoe
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Nicholas Toselli
- University of Central Florida College of MedicineOrlandoFloridaUSA
| | - Michelle Russin
- University of Central Florida College of MedicineOrlandoFloridaUSA
| | - Daniel Young
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Caitlin Premuroso
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - David Bailey
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - and ORMC Sepsis Study Group
- Department of Emergency MedicineOrlando HealthOrlando Regional Medical CenterOrlandoFloridaUSA
- Residency in Emergency MedicineOrlando HealthOrlandoFloridaUSA
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Khoo KSM, Lim ZY, Chai CY, Mahadevan M, Kuan WS. Management of acute pyelonephritis in the emergency department observation unit. Singapore Med J 2020; 62:287-295. [PMID: 32147739 DOI: 10.11622/smedj.2020020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre. METHODS We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes. RESULTS Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful. CONCLUSION EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.
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Affiliation(s)
| | - Zhen Yu Lim
- Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Chew Yian Chai
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Malcolm Mahadevan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Stalenhoef JE, van Nieuwkoop C, Wilson DC, van der Starre WE, Delfos NM, Leyten EMS, Koster T, Ablij HC, Van't Wout JJW, van Dissel JT. Biomarker guided triage can reduce hospitalization rate in community acquired febrile urinary tract infection. J Infect 2018; 77:18-24. [PMID: 29807091 DOI: 10.1016/j.jinf.2018.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 05/03/2018] [Accepted: 05/19/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Febrile urinary tract infections (fUTI) can often be treated safely with oral antimicrobials in an outpatient setting. However, a minority of patients develop complications that may progress into septic shock. An accurate assessment of disease severity upon emergency department (ED) presentation is therefore crucial in order to guide the most appropriate triage and treatment decisions. METHODS Consecutive patients were enrolled with presumptive fUTI across 7 EDs in the Netherlands. The biomarkers mid-regional proadrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and a clinical score (PRACTICE), were compared in their ability to predict a clinically severe course of fUTI, initial hospital admission and subsequent readmission using area under the receiver operating characteristic (AUROC) curves. RESULTS Biomarker concentrations were measured in 313 patients, with 259 (83%) hospitalized upon ED presentation, and 54 (17%) treated as outpatients. Of these outpatients, 12 (22%) were later hospitalized. MR-proADM had the highest diagnostic accuracy for predicting a complicated fUTI (AUROC [95% CI]: 0.86 [0.79-0.92]), followed by PCT (AUROC [95% CI]: 0.69 [0.58-0.80]). MR-proADM concentrations were unique in being significantly elevated in patients directly admitted and in outpatients requiring subsequent hospitalization, compared to those completing treatment at home. A virtual triage algorithm with an MR-proADM cut-off of 0.80 nmol/L resulted in a hospitalization rate of 66%, with only 2% secondary admissions. CONCLUSION MR-proADM could accurately predict a severe course in patients with fUTI, and identify greater patient numbers who could be safely managed as outpatients. An initial assessment on ED presentation may focus resources to patients with highest disease severities.
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Affiliation(s)
- Janneke Evelyne Stalenhoef
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Hospital, PO Box 40551, 2504 LN, The Hague, the Netherlands.
| | | | | | - Nathalie Manon Delfos
- Department of Internal Medicine, Alrijne Hospital, Postbus 4220, 2350 CC Leiderdorp, the Netherlands.
| | | | - Ted Koster
- Department of Internal Medicine, Groene Hart Hospital, PO Box 1098, 2800 BB Gouda, the Netherlands.
| | - Hans Christiaan Ablij
- Department of Internal Medicine, Alrijne Hospital, Postbus 4220, 2350 CC Leiderdorp, the Netherlands.
| | | | - Jaap Tamino van Dissel
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.
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9
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Karakonstantis S, Kalemaki D. Blood culture useful only in selected patients with urinary tract infections – a literature review. Infect Dis (Lond) 2018; 50:584-592. [DOI: 10.1080/23744235.2018.1447682] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Stamatis Karakonstantis
- 2nd Department of Internal Medicine, General Hospital of Heraklion ‘Venizeleio-Pananeio’, Heraklion, Greece
| | - Dimitra Kalemaki
- General Medicine, University Hospital of Heraklion, Heraklion, Greece
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10
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Chan TWT, Lam SK, Fung HT. Acute Pyelonephritis in Emergency Medicine Ward: A Four Years Retrospective Review. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To study the characteristics of patients with acute pyelonephritis (AP) admitted to the emergency medicine ward (EMW) and sensitivity pattern of bacteria cultured from urine as well as to find out which antibiotic should be the best empirical treatment. Methods This was a retrospective study. All patient diagnosed with AP admitted to the EMW in Tuen Mun Hospital from January 2007 to December 2010 were included in this study. Data on patients' demographics, length of stay, urine culture and antibiotic sensitivity results as well as the types of antibiotics administered to them were collected and analysed. Results Altogether 308 patients were admitted to the EMW during the study period, accounting for 58% of all hospital admissions with the same diagnosis. There were comparatively more female patients (p<0.001) and fewer patients with diabetes (p<0.001) admitted to the EMW compared with other departments. The mean length of stay in EMW (2.2 days) was significantly shorter than that in other departments (7.1 days) (p<0.001). E. Coli was the commonest cultured bacterium, accounting for 94% of all positive growths. Cefuroxime sodium had high sensitivity (84%) in treating AP, which was significantly higher than that of amoxicillin-clavulanate (75%) (p<0.001). Levofloxacin also had high sensitivity (86%) but the difference between cefuroxime sodium and levofloxacin was not statistically significant (p=0.67). Conclusions Patients with AP admitted to local EMWs should be given either cefuroxime sodium intravenously or levofloxacin orally (if they can tolerate oral intake) as empirical treatments. Oral levofloxacin can be continued upon discharge.
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11
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Ruiz-Mesa JD, Marquez-Gomez I, Sena G, Buonaiuto VA, Ordoñez JM, Salido M, Ciézar AP, Santis LVD, Mediavilla C, Colmenero JD. Factors associated with severe sepsis or septic shock in complicated pyelonephritis. Medicine (Baltimore) 2017; 96:e8371. [PMID: 29069028 PMCID: PMC5671861 DOI: 10.1097/md.0000000000008371] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Severe sepsis or septic shock are the main factors influencing the prognosis of acute pyelonephritis (APN). Our aim was to analyze factors associated with the development of severe sepsis or septic shock in a large sample of patients with acute complicated pyelonephritis (ACPN).This prospective observational study comprised 1507 consecutive patients aged 14 years or older who were admitted to a tertiary care hospital because of ACPN between 1997 and 2015. Covariates associated in univariate analysis with severe sepsis or septic shock were then analyzed by multivariate logistic regression.Of the 1507 patients, 423 (28.1%) fulfilled the criteria for severe sepsis or septic shock at the time of admission. Crude and attributable mortality at 30 days were 17.7% and 11.7% in patients with severe sepsis or septic shock versus 1.7% and 0.6% in patients without severe sepsis or septic shock, P < .0001 and P < .0005, respectively. An age > 65 years, urinary instrumentation in the previous 2 weeks, the lack of mictional syndrome or costovertebral tenderness, an ectasia ≥ grade II, and bacteremia were independent risk factors associated with severe sepsis or septic shock.The prevalence of severe sepsis and septic shock in patients with ACPN is high. Some factors associated with severe sepsis are easy to identify in any emergency department. The information provided here could be useful when deciding which patients should be admitted to receive immediate treatment.
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Affiliation(s)
- Juan D. Ruiz-Mesa
- Infectious Diseases Department
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | - Ignacio Marquez-Gomez
- Infectious Diseases Department
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | - Gabriel Sena
- Microbiology Department
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | - Veronica A. Buonaiuto
- Infectious Diseases Department
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | - Juan Mora Ordoñez
- Critical Care and Emergency Departments, Regional University Hospital
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | - Manuel Salido
- Critical Care and Emergency Departments, Regional University Hospital
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | - Antonio Plata Ciézar
- Infectious Diseases Department
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | | | - Concepción Mediavilla
- Microbiology Department
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
| | - Juan D. Colmenero
- Infectious Diseases Department
- Instituto de Investigación Biomedica de Málaga (IBIMA), Malaga, Spain
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12
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Abstract
Urinary tract infection (UTI) is one of the most common bacterial infections, and the incidence in women is much higher than in men. The diagnosis of a UTI can be made based on a combination of symptoms and a positive urine analysis or culture. Most UTIs are uncomplicated UTIs, defined as cystitis in a woman who is not pregnant, is not immunocompromised, has no anatomical and functional abnormalities of the urogenital tract, and does not exhibit signs of tissue invasion and systemic infection. All UTIs that are not uncomplicated are considered to be complicated UTIs. Differentiation between uncomplicated and complicated UTIs has implications for therapy because the risks of complications or treatment failure are increased for patients with a complicated UTI. Asymptomatic bacteriuria (ASB) is defined as the presence of a positive urine culture collected from a patient without symptoms of a UTI. Concerning the complicated UTI, it is possible to make a differentiation between UTI with systemic symptoms (febrile UTI) and UTI in a host, which carries an increased risk to develop complications of this UTI. Febrile UTIs are urosepsis, pyelonephritis, and prostatitis. A complicated host is defined as one that has an increased risk for complications, to which the following groups belong: men, pregnant women, immunocompromised patients, or those who have an anatomical or functional abnormality of the urogenital tract (e.g., spinal cord-injury patients, renal stones, urinary catheter).
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13
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Stalenhoef JE, van der Starre WE, Vollaard AM, Steyerberg EW, Delfos NM, Leyten EMS, Koster T, Ablij HC, Van't Wout JW, van Dissel JT, van Nieuwkoop C. Hospitalization for community-acquired febrile urinary tract infection: validation and impact assessment of a clinical prediction rule. BMC Infect Dis 2017; 17:400. [PMID: 28587665 PMCID: PMC5461732 DOI: 10.1186/s12879-017-2509-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 05/31/2017] [Indexed: 11/25/2022] Open
Abstract
Background There is a lack of severity assessment tools to identify adults presenting with febrile urinary tract infection (FUTI) at risk for complicated outcome and guide admission policy. We aimed to validate the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE), a modified form of the pneumonia severity index, and to subsequentially assess its use in clinical practice. Methods A prospective observational multicenter study for model validation (2004–2009), followed by a multicenter controlled clinical trial with stepped wedge cluster-randomization for impact assessment (2010–2014), with a follow up of 3 months. Paricipants were 1157 consecutive patients with a presumptive diagnosis of acute febrile UTI (787 in validation cohort and 370 in the randomized trial), enrolled at emergency departments of 7 hospitals and 35 primary care centers in the Netherlands. The clinical prediction rule contained 12 predictors of complicated course. In the randomized trial the PRACTICE included guidance on hospitalization for high risk (>100 points) and home discharge for low risk patients (<75 points), in the control period the standard policy regarding hospital admission was applied. Main outcomes were effectiveness of the clinical prediction rule, as measured by primary hospital admission rate, and its safety, as measured by the rate of low-risk patients who needed to be hospitalized for FUTI after initial home-based treatment, and 30-day mortality. Results A total of 370 patients were included in the randomized trial, 237 in the control period and 133 in the intervention period. Use of PRACTICE significantly reduced the primary hospitalization rate (from 219/237, 92%, in the control group to 96/133, 72%, in the intervention group, p < 0.01). The secondary hospital admission rate after initial outpatient treatment was 6% in control patients and 27% in intervention patients (1/17 and 10/37; p < 0.001). Conclusions Although the proposed PRACTICE prediction rule is associated with a lower number of hospital admissions of patients presenting to the ED with presumptive febrile urinary tract infection, futher improvement is necessary to reduce the occurrence of secondary hospital admissions. Trial registration NTR4480 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4480, registered retrospectively 25 mrt 2014 (during enrollment of subjects). Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2509-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janneke E Stalenhoef
- Department of Infectious Diseases, Leiden University Medical Center, C5-P, PO Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Willize E van der Starre
- Department of Infectious Diseases, Leiden University Medical Center, C5-P, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Albert M Vollaard
- Department of Infectious Diseases, Leiden University Medical Center, C5-P, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nathalie M Delfos
- Dept of Internal Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | | | - Ted Koster
- Dept of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | - Hans C Ablij
- Dept of Internal Medicine, Alrijne Hospital, Leiden, The Netherlands
| | - Jan W Van't Wout
- Dept of Internal Medicine, MCH-Bronovo, The Hague, The Netherlands
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14
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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15
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Abstract
PURPOSE OF REVIEW To review the recent advances in the diagnostic and therapeutic approach to adults presenting with febrile urinary tract infection (UTI) in the emergency department (ED). RECENT FINDINGS Recent research suggests overdiagnosis and therefore overtreatment of UTI in the ED, especially in the elderly. Antimicrobial pretreatment, an indwelling catheter, and malignancy are independent risk factors for bacteremia with uropathogens that cannot be cultured from urine. A simple clinical prediction rule can predict clinically relevant radiologic findings in patients with invasive UTI. Procalcitonin is a marker for bacteremia; pro-adrenomedullin predicts a complicated course and 30-day mortality in complicated UTI. Several reports have identified the risk factors for resistant uropathogens in community-acquired febrile UTI. Adherence to the guidelines and early culture-guided intravenous-to-oral switch reduces the length of hospitalization. SUMMARY An effective strategy is needed to improve the diagnosis of UTIs in acute care. Further research regarding biomarker-guided triage might improve the management of patients with febrile UTI. Future efforts should be directed toward the improvement of adherence to UTI treatment guidelines.
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16
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van der Starre WE, Zunder SM, Vollaard AM, van Nieuwkoop C, Stalenhoef JE, Delfos NM, Van't Wout JW, Spelt IC, Blom JW, Leyten EMS, Koster T, Ablij HC, van Dissel JT. Prognostic value of pro-adrenomedullin, procalcitonin and C-reactive protein in predicting outcome of febrile urinary tract infection. Clin Microbiol Infect 2015; 20:1048-54. [PMID: 25039648 DOI: 10.1111/1469-0691.12645] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 04/07/2014] [Accepted: 04/14/2014] [Indexed: 01/15/2023]
Abstract
Bacterial infections such as febrile urinary tract infection (fUTI) may run a complicated course that is difficult to foretell on clinical evaluation only. Because the conventional biomarkers erythrocyte sedimentation rate (ESR), leucocyte count, C-reactive protein (CRP) and procalcitonin (PCT) have a limited role in the prediction of a complicated course of disease, a new biomarker-plasma midregional pro-adrenomedullin (MR-proADM)-was evaluated in patients with f UTI. We conducted a prospective multicentre cohort study including consecutive patients with f UTI at 35 primary-care centres and eight emergency departments. Clinical and microbiological data were collected and plasma biomarker levels were measured at presentation to the physician. Survival was assessed after 30 days. Of 494 fUTI patients, median age was 67 (interquartile range 49-78) years, 40% were male; two-thirds of them had significant co-existing medical conditions. Median MR-proADM level was 1.42 (interquartile range 0.67-1.57) nM; significantly elevated MR-proADM levels were measured in patients with bacteraemia, those admitted to the intensive care unit, and in 30-day and 90-day non-survivors, compared with patients without these characteristics. The diagnostic accuracy for predicting 30-day mortality in fUTI, reflected by the area-under-the-curve of receiver operating characteristics were: MR-proADM 0.83 (95% CI 0.71-0.94), PCT 0.71 (95% CI 0.56-0.85); whereas CRP, ESR and leucocyte count lacked diagnostic value in this respect. This study shows that MR-proADM assessed on first contact predicts a complicated course of disease and 30-day mortality in patients with fUTI and in this respect has a higher discriminating accuracy than the currently available biomarkers ESR, CRP, PCT and leucocyte count.
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Affiliation(s)
- W E van der Starre
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
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17
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van der Starre WE, van Nieuwkoop C, Thomson U, Zijderveld-Voshart MSM, Koopman JPR, van der Reijden TJK, van Dissel JT, van de Vosse E. Urinary proteins, vitamin D and genetic polymorphisms as risk factors for febrile urinary tract infection and relation with bacteremia: a case control study. PLoS One 2015; 10:e0121302. [PMID: 25807366 PMCID: PMC4373833 DOI: 10.1371/journal.pone.0121302] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/30/2015] [Indexed: 12/18/2022] Open
Abstract
Objective/Purpose Febrile urinary tract infection (UTI) is a common bacterial disease that may lead to substantial morbidity and mortality especially among the elderly. Little is known about biomarkers that predict a complicated course. Our aim was to determine the role of certain urinary cytokines or antimicrobial proteins, plasma vitamin D level, and genetic variation in host defense of febrile UTI and its relation with bacteremia. Methods A case-control study. Out of a cohort of consecutive adults with febrile UTI (n = 787) included in a multi-center observational cohort study, 46 cases with bacteremic E.coli UTI and 45 cases with non-bacteremic E.coli UTI were randomly selected and compared to 46 controls. Urinary IL-6, IL-8, LL37, β-defensin 2 and uromodulin as well as plasma 25-hydroxyvitamin D were measured. In 440 controls and 707 UTI patients polymorphisms were genotyped in the genes CXCR1, DEFA4, DEFB1, IL6, IL8, MYD88, UMOD, TIRAP, TLR1, TLR2, TLR5 and TNF. Results IL-6, IL-8, and LL37 are different between controls and UTI patients, although these proteins do not distinguish between patients with and without bacteremia. While uromodulin did not differ between groups, inability to produce uromodulin is more common in patients with bacteremia. Most participants in the study, including the controls, had insufficient vitamin D and, at least in winter, UTI patients have lower vitamin D than controls. Associations were found between the CC genotype of IL6 SNP rs1800795 and occurrence of bacteremia and between TLR5 SNP rs5744168 and protection from UTI. The rare GG genotype of IL6 SNP rs1800795 was associated with higher β-defensin 2 production. Conclusion Although no biomarker was able to distinguish between UTI with or without bacteremia, two risk factors for bacteremia were identified. These were inability to produce uromodulin and an IL6 rs1800795 genotype.
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Affiliation(s)
| | - Cees van Nieuwkoop
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, the Hague, The Netherlands
| | - Uginia Thomson
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jan Pieter R. Koopman
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jaap T. van Dissel
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther van de Vosse
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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18
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Buonaiuto VA, Marquez I, De Toro I, Joya C, Ruiz-Mesa JD, Seara R, Plata A, Sobrino B, Palop B, Colmenero JD. Clinical and epidemiological features and prognosis of complicated pyelonephritis: a prospective observational single hospital-based study. BMC Infect Dis 2014; 14:639. [PMID: 25492862 PMCID: PMC4267459 DOI: 10.1186/s12879-014-0639-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/18/2014] [Indexed: 11/23/2022] Open
Abstract
Background Complicated pyelonephritis (cPN), a common cause of hospital admission, is still a poorly-understood entity given the difficulty involved in its correct definition. The aim of this study was to analyze the main epidemiological, clinical, and microbiological characteristics of cPN and its prognosis in a large cohort of patients with cPN. Methods We conducted a prospective, observational study including 1325 consecutive patients older than 14 years diagnosed with cPN and admitted to a tertiary university hospital between 1997–2013. After analyzing the main demographic, clinical and microbiological data, covariates found to be associated with attributable mortality in univariate analysis were included in a multivariate logistic regression model. Results Of the 1325 patients, 689 (52%) were men and 636 (48%) women; median age 63 years, interquartile range [IQR] (46.5-73). Nine hundred and forty patients (70.9%) had functional or structural abnormalities in the urinary tract, 215 (16.2%) were immunocompromised, 152 (11.5%) had undergone a previous urinary tract instrumentation, and 196 (14.8%) had a long-term bladder catheter, nephrostomy tube or ureteral catheter. Urine culture was positive in 813 (67.7%) of the 1251 patients in whom it was done, and in the 1032 patients who had a blood culture, 366 (34%) had bacteraemia. Escherichia coli was the causative agent in 615 episodes (67%), Klebsiella spp in 73 (7.9%) and Proteus ssp in 61 (6.6%). Fourteen point one percent of GNB isolates were ESBL producers. In total, 343 patients (25.9%) developed severe sepsis and 165 (12.5%) septic shock. Crude mortality was 6.5% and attributable mortality was 4.1%. Multivariate analysis showed that an age >75 years (OR 2.77; 95% CI, 1.35-5.68), immunosuppression (OR 3.14; 95% CI, 1.47-6.70), and septic shock (OR 58.49; 95% CI, 26.6-128.5) were independently associated with attributable mortality. Conclusions cPN generates a high morbidity and mortality and likely a great consumption of healthcare resources. This study highlights the factors directly associated with mortality, though further studies are needed in the near future aimed at identifying subgroups of low-risk patients susceptible to outpatient management.
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Affiliation(s)
- Veronica A Buonaiuto
- Infectious Diseases Department, Regional University Hospital, Málaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Ignacio Marquez
- Infectious Diseases Department, Regional University Hospital, Málaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Inmaculada De Toro
- Microbiology Unit, Regional University Hospital, Malaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Carolina Joya
- Critical Care and Emergency Departments, Regional University Hospital, Malaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Juan D Ruiz-Mesa
- Infectious Diseases Department, Regional University Hospital, Málaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Raimundo Seara
- Critical Care and Emergency Departments, Regional University Hospital, Malaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Antonio Plata
- Infectious Diseases Department, Regional University Hospital, Málaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Beatriz Sobrino
- Infectious Diseases Department, Regional University Hospital, Málaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Begoña Palop
- Microbiology Unit, Regional University Hospital, Malaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
| | - Juan D Colmenero
- Infectious Diseases Department, Regional University Hospital, Málaga, Spain. .,IBIMA, Malaga University, Malaga, Spain.
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19
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Litke A, Bossart R, Regez K, Schild U, Guglielmetti M, Conca A, Schäfer P, Reutlinger B, Mueller B, Albrich WC. The potential impact of biomarker-guided triage decisions for patients with urinary tract infections. Infection 2013; 41:799-809. [PMID: 23435720 DOI: 10.1007/s15010-013-0423-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/04/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Current guidelines provide limited evidence as to which patients with urinary tract infection (UTI) require hospitalisation. We evaluated the currently used triage routine and tested whether a set of criteria including biomarkers like proadrenomedullin (proADM) and urea have the potential to improve triage decisions. METHODS Consecutive adults with UTI presenting to our emergency department (ED) were recruited and followed for 30 days. We defined three virtual triage algorithms, which included either guideline-based clinical criteria, optimised admission proADM or urea levels in addition to a set of clinical criteria. We compared actual treatment sites and observed adverse events based on the physician judgment with the proportion of patients assigned to treatment sites according to the three virtual algorithms. Adverse outcome was defined as transfer to the intensive care unit (ICU), death, recurrence of UTI or rehospitalisation for any reason. RESULTS We recruited 127 patients (age 61.8 ± 20.8 years; 73.2 % females) and analysed the data of 123 patients with a final diagnosis of UTI. Of these 123 patients, 27 (22.0 %) were treated as outpatients. Virtual triage based only on clinical signs would have treated only 22 (17.9 %) patients as outpatients, with higher proportions of outpatients equally in both biomarker groups (29.3 %; p = 0.02). There were no significant differences in adverse events between outpatients according to the clinical (4.5 %), proADM (2.8 %) or urea groups (2.8 %). The mean length of stay was 6.6 days, including 2.2 days after reaching medical stability. CONCLUSIONS Adding biomarkers to clinical criteria has the potential to improve risk-based triage without impairing safety. Current rates of admission and length of stay could be shortened in patients with UTI.
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Affiliation(s)
- A Litke
- Medical University Department of the University of Basel, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
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20
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Sandberg T, Skoog G, Hermansson AB, Kahlmeter G, Kuylenstierna N, Lannergård A, Otto G, Settergren B, Ekman GS. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet 2012; 380:484-90. [PMID: 22726802 DOI: 10.1016/s0140-6736(12)60608-4] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Acute pyelonephritis is a common infection in adult women, but there is a paucity of controlled trials of its treatment and the optimum duration of antibiotic treatment has not been properly defined. We compared the efficacy of ciprofloxacin for 7 days and 14 days in women with community-acquired acute pyelonephritis. METHODS In a prospective, non-inferiority trial undertaken at 21 centres of infectious diseases in Sweden, women (aged ≥18 years) who were not pregnant and had a presumptive diagnosis of acute pyelonephritis were randomly assigned to oral treatment with ciprofloxacin 500 mg twice daily for 7 days or 14 days. The first week was open label. A computer-generated randomisation list in block sizes of two was used for treatment allocation in a 1:1 ratio. The study was double-blind and placebo-controlled during the second week of treatment, which was either continuation of ciprofloxacin 500 mg or placebo tablets twice daily according to the randomisation code. Patients, carers, site investigators, and trial coordinating centre staff were masked to group assignment. The primary endpoint was the clinical and bacteriological outcome 10-14 days after completion of treatment with active drug. Analysis was by per protocol. This trial is registered with EudraCT, number 2005-004992-39, and ClinicalTrials.gov, number ISRCTN73338924. FINDINGS 126 of 248 patients were randomly assigned to 7 days and 122 to 14 days of ciprofloxacin. 73 and 83 patients, respectively, were analysed. Short-term clinical cure occurred in 71 (97%) patients treated with ciprofloxacin for 7 days and 80 (96%) treated for 14 days (difference -0·9%; 90% CI -6·5 to 4·8; p=0·004; non-inferiority test). Cumulative efficacy at long-term follow-up was 93% in each group (68 of 73 vs 78 of 84; -0·3%; -7·4 to 7·2; p=0·015). Both regimens were well tolerated. Two patients discontinued ciprofloxacin because of myalgia with 7 days of treatment and itching exanthema with 14 days. Four (5%) of 86 patients assigned to 7 days of treatment who complied with study criteria and six (6%) of 93 assigned to 14 days reported an adverse event after the first week of treatment that was possibly or probably related to the study drug. In those assigned to 7 days, no patient had mucosal candida infection after the first week versus five treated for 14 days (p=0·036). INTERPRETATION Our results show that acute pyelonephritis in women, including older women and those with a more severe infection, can be treated successfully and safely with oral ciprofloxacin for 7 days. Short courses of antibiotics should be favoured in an era of increasing resistance. FUNDING Swedish Strategic Programme against Antibiotic Resistance (Strama).
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Affiliation(s)
- Torsten Sandberg
- Department of Infectious Diseases, Sahlgrenska University Hospital, Göteborg, Sweden.
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21
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van der Starre WE, van Dissel JT, van Nieuwkoop C. Treatment duration of febrile urinary tract infections. Curr Infect Dis Rep 2011; 13:571-8. [PMID: 21882085 PMCID: PMC3207126 DOI: 10.1007/s11908-011-0211-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although febrile urinary tract infections (UTIs) are relatively common in adults, data on optimal treatment duration are limited. Randomized controlled trials specifically addressing the elderly and patients with comorbidities have not been performed. This review highlights current available evidence. Premenopausal, non-pregnant women without comorbidities can be treated with a 5–7 day regimen of fluoroquinolones in countries with low levels of fluoroquinolone resistance, or, if proven susceptible, with 14 days of trimethoprim-sulfamethoxazole. Oral β-lactams are less effective compared with fluoroquinolones and trimethoprim-sulfamethoxazole. In men with mild to moderate febrile UTI, a 2-week regimen of an oral fluoroquinolone is likely sufficient. Although data are limited, this possibly holds even in the elderly patients with comorbidities or bacteremia.
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Affiliation(s)
- Willize E. van der Starre
- Department of Infectious Diseases, Leiden University Medical Center, Postbox 9600, 2300 RC Leiden, the Netherlands
| | - Jaap T. van Dissel
- Department of Infectious Diseases, Leiden University Medical Center, Postbox 9600, 2300 RC Leiden, the Netherlands
| | - Cees van Nieuwkoop
- Department of Infectious Diseases, Leiden University Medical Center, Postbox 9600, 2300 RC Leiden, the Netherlands
- Department of Internal Medicine, Haga Hospital, Leyweg 275, 2545 CH The Hague, the Netherlands
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Abstract
Urinary tract infection remains a common problem for many populations. Recent studies have expanded our understanding of the host innate immune response and its role in the familial association observed for recurrent uncomplicated urinary tract infection in healthy women. Therapeutic management for uncomplicated infection has been compromised by increasing antimicrobial resistance, particularly global dissemination of the CTXM-15 extended spectrum β-lactamase (ESBL) producing Escherichia coli ST-131 strain. Prevention strategies exploring non-antimicrobial approaches continue to show limited promise, and approaches to limit empiric antimicrobials are now being explored. For complicated urinary tract infection, increasing antimicrobial resistance limits therapeutic options for many patients. In addition to ESBL producing E. coli, NDM-1 E. coli and Klebsiella pneumoniae and other resistant Gram negatives, such as Acinetobacter species, are being isolated more frequently. There has been renewed interest in catheter-acquired urinary tract infection, the most common health-care associated infection, with several recent evidence-based guidelines for infection prevention available. However, technologic progress in development of adherence-resistant catheter materials remains disappointing.
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Abstract
BACKGROUND Urinary tract infections (UTIs) are a common problem in the elderly population. The spectrum of disease varies from a relatively benign cystitis to potentially life-threatening pyelonephritis. OBJECTIVE This review covers the management of asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter-associated bacteriuria/symptomatic UTIs, and antibiotic prophylaxis for recurrent infections in elderly men and women. METHODS Literature was obtained from English-language searches of MEDLINE (1966-April 2011), Cochrane Library, BIOSIS (1993-April 2011), and EMBASE (1970-April 2011). Further publications were identified from citations of resulting articles. Search terms included, but were not limited to, urinary tract infections, asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter associated urinary tract infections, recurrent urinary tract infections, and elderly. RESULTS The prevalence of UTIs in elderly women depends on the location in which these women are living. For elderly women living in the community, UTIs compromise the second most common infection, whereas in residents of long-term care facilities (LTCFs) and hospitalized subjects, it is the number one cause of infection. The spectrum of patient presentation varies from classic signs and symptoms in the independent elderly population to atypical presentations, including increased lethargy, delirium, blunted fever response, and anorexia. Although there are few guidelines specifically directed toward the management of UTIs in the elderly population, therapy generally mirrors the recommendations for the younger adult age groups. When choosing a treatment regimen, special attention must be given to the severity of illness, living conditions, existing comorbidities, presence of external devices, local antibiotic resistance patterns, and the ability of the patient to comply with therapy. CONCLUSIONS Improved guidelines for the diagnosis and management of UTIs in the elderly population are needed. Better techniques to evaluate and prevent catheter-associated bacteriuria and UTIs await improved diagnostic modalities and catheter technologies. Alternative methods for prophylaxis of patients who suffer from recurrent infections must be found while minimizing the risk of developing or propagating antibiotic resistance.
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Bibliography. Female urology. Current world literature. Curr Opin Urol 2011; 21:343-6. [PMID: 21654401 DOI: 10.1097/mou.0b013e3283486a38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ha YE, Kang CI, Joo EJ, Park SY, Kang SJ, Wi YM, Chung DR, Peck KR, Lee NY, Song JH. Clinical implications of healthcare-associated infection in patients with community-onset acute pyelonephritis. ACTA ACUST UNITED AC 2011; 43:587-95. [DOI: 10.3109/00365548.2011.572907] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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van Nieuwkoop C, Bonten TN, van't Wout JW, Kuijper EJ, Groeneveld GH, Becker MJ, Koster T, Wattel-Louis GH, Delfos NM, Ablij HC, Leyten EMS, van Dissel JT. Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome: a prospective observational study. CRITICAL CARE (LONDON, ENGLAND) 2010. [PMID: 21083886 DOI: 10.1186/cc9328.epub] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and cost-effectiveness of this practice have been criticized. This study aimed to evaluate clinical characteristics and the biomarker procalcitonin (PCT) as an aid in predicting bacteremia. METHODS A prospective observational multicenter cohort study included consecutive adults with febrile UTI in 35 primary care units and 8 emergency departments of 7 regional hospitals. Clinical and microbiological data were collected and PCT and time to positivity (TTP) of blood culture were measured. RESULTS Of 581 evaluable patients, 136 (23%) had bacteremia. The median age was 66 years (interquartile range 46 to 78 years) and 219 (38%) were male. We evaluated three different models: a clinical model including seven bed-side characteristics, the clinical model plus PCT, and a PCT only model. The diagnostic abilities of these models as reflected by area under the curve of the receiver operating characteristic were 0.71 (95% confidence interval (CI): 0.66 to 0.76), 0.79 (95% CI: 0.75 to 0.83) and 0.73 (95% CI: 0.68 to 0.77) respectively. Calculating corresponding sensitivity and specificity for the presence of bacteremia after each step of adding a significant predictor in the model yielded that the PCT > 0.25 μg/l only model had the best diagnostic performance (sensitivity 0.95; 95% CI: 0.89 to 0.98, specificity 0.50; 95% CI: 0.46 to 0.55). Using PCT as a single decision tool, this would result in 40% fewer blood cultures being taken, while still identifying 94 to 99% of patients with bacteremia.The TTP of E. coli positive blood cultures was linearly correlated with the PCT log value; the higher the PCT the shorter the TTP (R(2) = 0.278, P = 0.007). CONCLUSIONS PCT accurately predicts the presence of bacteremia and bacterial load in patients with febrile UTI. This may be a helpful biomarker to limit use of blood culture resources.
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Affiliation(s)
- Cees van Nieuwkoop
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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van Nieuwkoop C, Bonten TN, van't Wout JW, Kuijper EJ, Groeneveld GH, Becker MJ, Koster T, Wattel-Louis GH, Delfos NM, Ablij HC, Leyten EMS, van Dissel JT. Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R206. [PMID: 21083886 PMCID: PMC3220019 DOI: 10.1186/cc9328] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 07/08/2010] [Accepted: 11/17/2010] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and cost-effectiveness of this practice have been criticized. This study aimed to evaluate clinical characteristics and the biomarker procalcitonin (PCT) as an aid in predicting bacteremia. METHODS A prospective observational multicenter cohort study included consecutive adults with febrile UTI in 35 primary care units and 8 emergency departments of 7 regional hospitals. Clinical and microbiological data were collected and PCT and time to positivity (TTP) of blood culture were measured. RESULTS Of 581 evaluable patients, 136 (23%) had bacteremia. The median age was 66 years (interquartile range 46 to 78 years) and 219 (38%) were male. We evaluated three different models: a clinical model including seven bed-side characteristics, the clinical model plus PCT, and a PCT only model. The diagnostic abilities of these models as reflected by area under the curve of the receiver operating characteristic were 0.71 (95% confidence interval (CI): 0.66 to 0.76), 0.79 (95% CI: 0.75 to 0.83) and 0.73 (95% CI: 0.68 to 0.77) respectively. Calculating corresponding sensitivity and specificity for the presence of bacteremia after each step of adding a significant predictor in the model yielded that the PCT > 0.25 μg/l only model had the best diagnostic performance (sensitivity 0.95; 95% CI: 0.89 to 0.98, specificity 0.50; 95% CI: 0.46 to 0.55). Using PCT as a single decision tool, this would result in 40% fewer blood cultures being taken, while still identifying 94 to 99% of patients with bacteremia.The TTP of E. coli positive blood cultures was linearly correlated with the PCT log value; the higher the PCT the shorter the TTP (R(2) = 0.278, P = 0.007). CONCLUSIONS PCT accurately predicts the presence of bacteremia and bacterial load in patients with febrile UTI. This may be a helpful biomarker to limit use of blood culture resources.
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Affiliation(s)
- Cees van Nieuwkoop
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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