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Smith EEA, Nachimuthu N, Flynn J, Balasubramanyam A, Negrete JA, Trautner BW, Al Mohajer M. Assessing clinicians' and trainees' knowledge and practice of the IDSA guidelines for asymptomatic bacteriuria in older adults. Infect Control Hosp Epidemiol 2024; 45:664-666. [PMID: 38251669 DOI: 10.1017/ice.2023.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
A survey of advanced practice clinicians (APCs), physicians, residents, and medical students at an academic medical center and community practices in southeastern Texas revealed a gap in knowledge and practice related to testing and treatment for asymptomatic bacteriuria (ASB) in older adults.
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Affiliation(s)
| | | | - John Flynn
- Baylor College of Medicine, Houston, Texas
- CommonSpirit Health Texas Division, Houston, Texas
| | | | | | - Barbara W Trautner
- Michael E. DeBakey Veterans Affairs' Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Pishdad R, Auwaerter PG, Kalyani RR. Diabetes, SGLT-2 Inhibitors, and Urinary Tract Infection: a Review. Curr Diab Rep 2024; 24:108-117. [PMID: 38427314 DOI: 10.1007/s11892-024-01537-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW The aim of this review is to focus on epidemiology, pathogenesis, risk factors, management, and complications of UTI in people with diabetes as well as reviewing the association of SGLT-2 inhibitors with genitourinary infections. RECENT FINDINGS Individuals diagnosed with T2DM are more prone to experiencing UTIs and recurrent UTIs compared to individuals without T2DM. T2DM is associated with an increased risk of any genitourinary infections (GUI), urinary tract infections (UTIs), and genital infections (GIs) across all age categories. SGLT2 inhibitors are a relatively new class of anti-hyperglycemic agents, and studies suggest that they are associated with an increased risk of genitourinary infections. The management of diabetes and lifestyle modifications with a patient-centric approach are the most recognized methods for preventing critical long-term complications including genitourinary manifestations of diabetes. The available data regarding the association of SGLT-2 inhibitors with genitourinary infections is more comprehensive compared to that with UTIs. Further research is needed to better understand the mechanisms underlining the association between SGLT-2 inhibitors and genital infections and UTIs.
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Affiliation(s)
- Reza Pishdad
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Paul G Auwaerter
- Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rita R Kalyani
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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O’Brien WJ, Schweizer ML, Strymish J, Beck BF, Au V, Chan JA, Brown M, Itani KMF, Dukes KC, Walhof JF, Gupta K. Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture. JAMA Netw Open 2024; 7:e240900. [PMID: 38436958 PMCID: PMC10912952 DOI: 10.1001/jamanetworkopen.2024.0900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/11/2024] [Indexed: 03/05/2024] Open
Abstract
Importance Although recent guidelines recommend against performance of preoperative urine culture before nongenitourinary surgery, many clinicians still order preoperative urine cultures and prescribe antibiotics for treatment of asymptomatic bacteriuria in an effort to reduce infection risk. Objective To assess the association between preoperative urine culture testing and postoperative urinary tract infection (UTI) or surgical site infection (SSI), independent of baseline patient characteristics or type of surgery. Design, Setting, and Participants This cohort study analyzed surgical procedures performed from January 1, 2017, to December 31, 2019, at any of 112 US Department of Veterans Affairs (VA) medical centers. The cohort comprised VA enrollees who underwent major elective noncardiac, nonurological operations. Machine learning and inverse probability of treatment weighting (IPTW) were used to balance the characteristics between those who did and did not undergo a urine culture. Data analyses were performed between January 2023 and January 2024. Exposures Performance of urine culture within 30 days prior to surgery. Main Outcomes and Measures The 2 main outcomes were UTI and SSI occurring within 30 days after surgery. Weighted logistic regression was used to estimate odds ratios (ORs) for postoperative infection based on treatment status. Results A total of 250 389 VA enrollees who underwent 288 858 surgical procedures were included, with 88.9% (256 753) of surgical procedures received by males and 48.9% (141 340) received by patients 65 years or older. Baseline characteristics were well balanced among treatment groups after applying IPTW weights. Preoperative urine culture was performed for 10.5% of surgical procedures (30 384 of 288 858). The IPTW analysis found that preoperative urine culture was not associated with SSI (adjusted OR [AOR], 0.99; 95% CI, 0.90-1.10) or postoperative UTI (AOR, 1.18; 95% CI, 0.98-1.40). In analyses limited to orthopedic surgery and neurosurgery as a proxy for prosthetic implants, the adjusted risks for UTI and SSI were also not associated with preoperative urine culture performance. Conclusions and Relevance This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants.
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Affiliation(s)
- William J. O’Brien
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Marin L. Schweizer
- William S. Middleton VA Hospital, Madison, Wisconsin
- Department of Medicine, University of Wisconsin-Madison, Madison
| | | | - Brice F. Beck
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Vanessa Au
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Jeffrey A. Chan
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Madisen Brown
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Kamal M. F. Itani
- VA Boston Health Care System Department of Surgery, Boston University and Harvard Medical School, Boston, Massachusetts
| | - Kimberly C. Dukes
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Carver College of Medicine, The University of Iowa, Iowa City
| | - Julia Friberg Walhof
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Kalpana Gupta
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- VA Boston Department of Medicine, Boston, Massachusetts
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Bradley MS, Meckes N, Krishnamurti T. Decision-making and Treatment Preferences Surrounding Bacteriuria in Nonpregnant Women: A Qualitative Investigation. Int Urogynecol J 2024; 35:661-666. [PMID: 38324184 DOI: 10.1007/s00192-024-05725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/24/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Best practices suggest nontreatment for asymptomatic bacteriuria in a nonpregnant population, yet there is little literature on patient preference or understanding of asymptomatic bacteriuria treatment. We hypothesize that there might be core factors that affect antibiotic preferences and care-seeking decisions for urinary tract infection and asymptomatic bacteriuria in a postmenopausal population. METHODS We performed semi-structured interviews with postmenopausal individuals who had been previously treated for at least one patient-reported urinary tract infection. Interviews covered a discussion about their approach to seeking antibiotics for management and knowledge/preferences for asymptomatic bacteriuria management. Two authors independently coded the interviews and identified a set of symptom-related knowledge and experiences that relate to care-seeking and treatment preferences. We then graphically represented a mental model of antibiotic-seeking practices as an influence diagram, illustrating how knowledge and values affect preferences for care. RESULTS We performed 30 interviews of participants with a mean age of 69.4 (SD 6.4). Among participants, there were four core factors that influence antibiotic seeking for bacteriuria. Participants noted concern for sequelae from untreated bacteria as their primary motivation, but also noted past experiences, information sources, and testing results as themes that affected their mental model surrounding bacteriuria treatment. CONCLUSIONS The cognitive approach to care-seeking and treatment preference for bacteriuria is influenced by a few central factors. An improved ability to allay concerns either by provider discussions or educational materials are necessary to bridge the gap from the existence of evidence-based guidelines to patient and provider comfort with adherence to these guidelines.
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Affiliation(s)
- Megan S Bradley
- Department of Obstetrics, Gynecology and Reproductive Science, Division of Urogynecology, University of Pittsburgh Medical Center - Magee Womens Hospital, 300 Halket St, Rm 2324, Pittsburgh, PA, 15213, USA.
| | - Nicole Meckes
- Department of Obstetrics, Gynecology and Reproductive Science, Division of Urogynecology, University of Pittsburgh Medical Center - Magee Womens Hospital, 300 Halket St, Rm 2324, Pittsburgh, PA, 15213, USA
| | - Tamar Krishnamurti
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Matovelle P, Olivan-Blázquez B, Magallón-Botaya R, García-Sangenís A, Monfà R, Morros R, Navarro Sanmartín A, Mateos-Nozal J, Sáez Bejar C, Rodríguez Jiménez C, López Pérez E, Llor C. Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis. Antibiotics (Basel) 2024; 13:152. [PMID: 38391537 PMCID: PMC10885965 DOI: 10.3390/antibiotics13020152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.
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Affiliation(s)
- Priscila Matovelle
- Geriatrics Department, Hospital San Juan de Dios, 50006 Zaragoza, Spain
- Geriatrics Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Bárbara Olivan-Blázquez
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, 50009 Zaragoza, Spain
| | - Rosa Magallón-Botaya
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Medicine Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Ana García-Sangenís
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | - Ramon Monfà
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | | | - Jesús Mateos-Nozal
- Geriatrics Department, Hospital Universitario Ramón y Cajal (IRYCIS), 28034 Madrid, Spain
| | - Carmen Sáez Bejar
- Internal Medicine Department, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria (IIS-Princesa), 28006 Madrid, Spain
- Research Institute of Princesa (IIS Princesa), 28006 Madrid, Spain
| | - Consuelo Rodríguez Jiménez
- Pharmacology Department, Complejo Hospitalario Universitario de Canarias, 38320 Santa Cruz de Tenerife, Spain
| | | | - Carl Llor
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
- Institut Català de la Salut, 08038 Barcelona, Spain
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, 5230 Odense, Denmark
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Claeys KC, Weston LE, Pineles L, Morgan DJ, Krein SL. Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment. Infect Control Hosp Epidemiol 2023; 44:1932-1941. [PMID: 37424224 PMCID: PMC10776821 DOI: 10.1017/ice.2023.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Urine-culture diagnostic stewardship aims to decrease misdiagnosis of urinary tract infections (UTIs); however, these interventions are not widely adopted. We examined UTI diagnosis and management practices to identify barriers to and facilitators of diagnostic stewardship implementation. METHODS Using a qualitative descriptive design, we conducted semistructured interviews at 3 Veterans' Affairs medical centers. Interviews were conducted between November 2021 and May 2022 via Zoom videoconferencing using an interview guide and visual prototypes of proposed interventions. Interviewees were asked about current practices and thoughts on proposed interventions for urine-culture ordering, processing, and reporting. We used a rapid analysis matrix approach to summarize key interview findings and compare practices and perceptions across sites. RESULTS We interviewed 31 stakeholders and end users. All sites had an antimicrobial stewardship program but limited initiatives targeting appropriate diagnosis and management of UTIs. The majority of those interviewed identified the importance of diagnostic stewardship. Perceptions of specific interventions ranged widely by site. For urine-culture ordering, all 3 sites agreed that documentation of symptomology would improve culturing practices but did not want it to interrupt workflow. Representatives at 2 sites expressed interest in conditional urine-culture processing and 1 was opposed. All sites had similar mechanisms to report culture results but varied in perceptions of the proposed interventions. Feedback from end users was used to develop a general diagnostic stewardship implementation checklist. CONCLUSION Interviewees thought diagnostic stewardship was important. Qualitative assessment involving key stakeholders in the UTI diagnostic process improved understanding of site-specific beliefs and practices to better implement interventions for urine-culture ordering, processing, and reporting.
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Affiliation(s)
- Kimberly C. Claeys
- department of Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Lauren E. Weston
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Arbor, Michigan
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel J. Morgan
- VA Maryland Healthcare System, Department of Epidemiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Arbor, Michigan
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
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Impact of electronic alerts on repeat urine culture testing: Analysis from a large academic medical center. Infect Control Hosp Epidemiol 2023; 44:345-347. [PMID: 36594249 DOI: 10.1017/ice.2022.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Penney JA, Rodday AM, Sebastiani P, Snydman DR, Doron SI. Impact of provider-selected indication requirement on urine test utilization and positivity. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e103. [PMID: 36483372 PMCID: PMC9726588 DOI: 10.1017/ash.2022.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate the impact of the addition of an indication specification requirement to isolated urine-culture ordering on testing utilization. DESIGN Retrospective study utilizing interrupted time series analysis with negative binomial regression. The preintervention period was October 1, 2018-November 11, 2019, and the postintervention period was November 12, 2019-October 31, 2020. The primary outcome was isolated culture rate per 1,000 patient days. Secondary outcomes were the proportion of all urine tests ordered as isolated urine culture and culture positivity. An exploratory analysis assessed the appropriateness of selected testing indications. SETTING A 415-bed, urban, academic medical center. PATIENTS Adult patients with urine testing performed during hospital admission. In total, 1,494 unique isolated urine-culture orders were included in the analysis. INTERVENTIONS On November 12, 2019, the laboratory order interface was changed to require the ordering provider to select an indication for isolated urine culture. RESULTS Isolated urine-culture rates did not significantly change after the intervention (11.2-7.8 cultures per 1,000 patient days; P = .17) nor did culture positivity (26.9% vs 26.8%). Most ordering providers left the indication for testing blank, and of those charts reviewed, 67% did not have a documented condition for which isolated urine culture was the most appropriate initial test. CONCLUSIONS The addition of an order-specification requirement for isolated urine-culture testing did not significantly affect ordering practices. The test remains overused as the initial diagnostic evaluation for a suspected urinary tract infection. Further provider education and continued changes in provider workflow are needed to achieve lasting change in practice.
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Affiliation(s)
- Jessica A. Penney
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Paola Sebastiani
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - David R. Snydman
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
| | - Shira I. Doron
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
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Bradley MS, Stanger M, Ford C, Lowder J, Handa VL. Characteristics Associated With Repeated Evaluations for Urinary Tract Infections in Older Women: A Case-Control Study. Female Pelvic Med Reconstr Surg 2022; 28:e133-e136. [PMID: 35234180 PMCID: PMC9035018 DOI: 10.1097/spv.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of this study were to estimate the incidence of repeated evaluations for urinary tract infection (UTI) after a single occurrence and to identify characteristics associated with repeated evaluations in a female Medicare population. METHODS This was a case-control study of women aged 65 years or older undergoing incident outpatient evaluation for UTI between the years of 2011 and 2018. We defined UTI evaluation as an outpatient encounter with diagnostic codes for UTI and an order for urine culture. We excluded women with diagnostic codes suggestive of a complicated UTI. Among all women with an incident UTI evaluation, cases were defined as those with repeated evaluations, defined as either a total of ≥2 UTI evaluations in 6 months and/or ≥3 in 1 year. The characteristics of cases versus controls were compared with both an unadjusted and adjusted logistic regression model. RESULTS Our overall cohort consisted of 169,958, of which 13,779 (8.1%) had repeated evaluations for UTI. In unadjusted analyses, cases were more likely to be older than 75 years, of White race, and to have cardiovascular conditions, diabetes, dementia, renal disease, and chronic obstructive pulmonary disease (all P's < 0.01) as compared with controls. In adjusted analysis, ages 75 years to 84 years (P < 0.01) and ages older than 84 years (P < 0.01) along with multiple medical comorbidities were significant risk factors for repeated evaluations for UTI. Black women had lower odds of repeated evaluations for UTI (P < 0.01). CONCLUSIONS Among women with a single UTI evaluation, repeated evaluations for UTI were associated with older age, White race, and medical comorbidities. Future studies should investigate racial disparities seen in care-delivery behavior and/or care-seeking behavior.
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Affiliation(s)
- Megan S Bradley
- From the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael Stanger
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Cassie Ford
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Jerry Lowder
- Department of Obstetrics and Gynecology, Washington University-St Louis School of Medicine, St Louis, MO
| | - Victoria L Handa
- Department of Obstetrics and Gynecology, Johns Hopkins University, Baltimore, MD
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Laguë A, Boucher V, Joo P, Yadav K, Morasse C, Émond M. Investigation and treatment of asymptomatic bacteriuria in older patients with delirium: a cross-sectional survey of Canadian physicians. CAN J EMERG MED 2022; 24:61-67. [PMID: 34181215 DOI: 10.1007/s43678-021-00148-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/11/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Current guidelines suggest assessing non-infectious causes and careful observation before giving antibiotics to delirious patients with asymptomatic bacteriuria. Our study aims to describe the current practice of Canadian physicians regarding the investigation and treatment of asymptomatic bacteriuria in delirious older patients (aged ≥ 65 years). METHODS Our team of medical experts designed and reviewed a cross-sectional online survey. Study participants were physicians who conduct their clinical practice in Canada and care for older patients with delirium in their current practice. Potential study participants were reached through Canadian associations: Canadian Geriatrics Society, the Canadian Association of Emergency Physicians, the Association des Médecins d'Urgence du Québec and members of Choosing Wisely Canada. RESULTS 297 physicians were included. The main results show 79.4% of our participants request a urine dipstick or urinalysis in delirious patients and 52.4% immediately order a urine culture with the urinalysis. If bacteriuria is found in delirious but afebrile patients without urinary symptoms, 38% of physicians immediately treat with antibiotics, 33.8% wait for culture before initiating treatment, 14.4% treat if no other cause is found for delirium and only 13.7% would refrain from giving antibiotics. Results from respondents were similar for delirious patients with known cognitive impairment. Participants were almost unanimous (92.5%) in saying they need clear guidelines regarding the treatment of bacteriuria in older delirious patients. CONCLUSIONS This survey highlights the heterogeneous clinical management of asymptomatic bacteriuria in delirious patients and the need for clear guidelines for patients.
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Affiliation(s)
- Antoine Laguë
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec - Université Laval, 1401, 18ièmerue, Québec, QC, G1J 1Z4, Canada
- VITAM - Centre de Recherche en Santé Durable, Québec, QC, Canada
- Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Valérie Boucher
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec - Université Laval, 1401, 18ièmerue, Québec, QC, G1J 1Z4, Canada
- VITAM - Centre de Recherche en Santé Durable, Québec, QC, Canada
- Faculté de Médecine, Université Laval, Québec, QC, Canada
- Centre D'Excellence Sur Le Vieillissement de Québec, Québec, QC, Canada
| | - Pil Joo
- University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Marcel Émond
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec - Université Laval, 1401, 18ièmerue, Québec, QC, G1J 1Z4, Canada.
- VITAM - Centre de Recherche en Santé Durable, Québec, QC, Canada.
- Faculté de Médecine, Université Laval, Québec, QC, Canada.
- Centre D'Excellence Sur Le Vieillissement de Québec, Québec, QC, Canada.
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Kabbani S, Wang SW, Ditz LL, Gouin KA, Palms D, Rowe TA, Hyun DY, Chi NW, Stone ND, Hicks LA. Description of antibiotic use variability among US nursing homes using electronic health record data. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2021; 1:e58. [PMID: 36168476 PMCID: PMC9495428 DOI: 10.1017/ash.2021.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/06/2022]
Abstract
Background Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders. Methods A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models. Results In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5-10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software). Conclusions Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.
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Affiliation(s)
- Sarah Kabbani
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | | | | | - Katryna A. Gouin
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Danielle Palms
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Theresa A. Rowe
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - David Y. Hyun
- The Pew Charitable Trusts, Washington, DC, United States
| | | | - Nimalie D. Stone
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Lauri A. Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
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Advani S, Vaughn VM. Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges. Curr Infect Dis Rep 2021; 23:16. [PMID: 34602864 PMCID: PMC8486281 DOI: 10.1007/s11908-021-00760-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting. RECENT FINDINGS Quality improvement initiatives aimed at reducing inappropriate treatment of asymptomatic bacteriuria often focus on optimizing urine test utilization (i.e., urine culture stewardship). Urine culture stewardship interventions in acute care hospitals span the spectrum of quality improvement initiatives, ranging from strong systems-based interventions like suppression of urine culture results to weaker interventions that focus on clinician education alone. While most urine culture stewardship interventions have met with some success, overall results are mixed, and implementation strategies to improve sustainability are not well understood. SUMMARY Successful diagnostic stewardship interventions are based on an assessment of underlying key drivers and focus on multifaceted and complementary approaches. Individual intervention components have varying impacts on effectiveness, provider autonomy, and sustainability. The best urine culture stewardship strategies ultimately include both technical and socio-adaptive components with long-term, iterative feedback required for sustainability.
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Affiliation(s)
- Sonali Advani
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Infection Control Outreach Network, Durham, NC, USA
| | - Valerie M. Vaughn
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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13
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Green SB, Stover KR, Barber K, Bouchard JL, Brown ML, Deri CR, Francis BJ, Gauthier TP, Hayes JE, Marx AH, McGee EU, Mediwala K, Musgrove RJ, Slain D, Stramel SA, Bland CM, Bookstaver PB. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020. Open Forum Infect Dis 2021; 8:ofab422. [PMID: 34557559 PMCID: PMC8454524 DOI: 10.1093/ofid/ofab422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
The number of articles related to antimicrobial stewardship published each year has increased significantly over the last decade. Keeping up with the literature, particularly the most innovative, well-designed, or applicable to one’s own practice area, can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network reviewed antimicrobial stewardship–related, peer-reviewed literature from 2020 that detailed actionable interventions. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for teaching and training, and to identify novel or optimized stewardship opportunities within one’s institution.
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Affiliation(s)
- Sarah B Green
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Katie Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Matthew L Brown
- Department of Pharmacy, University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Bailey J Francis
- Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, North Carolina, USA
| | - Timothy P Gauthier
- Baptist Health South Florida, Clinical Pharmacy Enterprise, Miami, Florida, USA
| | - Jillian E Hayes
- Department of Pharmacy AdventHealth Orlando, Orlando, Florida, USA
| | - Ashley H Marx
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Edoabasi U McGee
- Department of Pharmacy Practice, Philadelphia College of Osteopathic Medicine-Georgia Campus, School of Pharmacy, Suwanee, Georgia, USA
| | - Krutika Mediwala
- Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Rachel J Musgrove
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Douglas Slain
- Department of Clinical Pharmacy and Section of Infectious Diseases, West Virginia University, Morgantown, West Virginia, USA
| | - Stefanie A Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, Texas, USA
| | - Christopher M Bland
- Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Georgia, USA
| | - P Brandon Bookstaver
- Department of Pharmacy, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
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Treatment of Asymptomatic Bacteriuria after Implementation of an Inpatient Urine Culture Algorithm in the Electronic Medical Record. PHARMACY 2021; 9:pharmacy9030138. [PMID: 34449690 PMCID: PMC8396163 DOI: 10.3390/pharmacy9030138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022] Open
Abstract
Ordering urine cultures in patients without pyuria is associated with the inappropriate treatment of asymptomatic bacteriuria (ASB). In 2015, our institution implemented recommendations based on practice guidelines for the management of ASB and revised the urine culture ordering process to limit cultures in immunocompetent patients without pyuria. The purpose of this study was to determine how the treatment of ASB has changed over time since altering the urine culture ordering process to reduce unnecessary cultures at an academic medical center. A quasi-experimental study was conducted for inpatients with urine cultures from January to March of 2014, 2015, 2016 and 2020. The primary outcome was the antibiotic treatment of asymptomatic bacteriuria for over 24 h. The secondary outcomes were the total days of antibiotic therapy, type of antibiotic prescribed and overall urine culture rates at the hospital. A total of 200 inpatients with ASB were included, 50 at random from each year. In both 2014 and 2015, 70% of the patients with ASB received antibiotic treatment. Antibiotics were prescribed to 68% and 54% of patients with ASB in 2016 and 2020, respectively. The average duration of therapy decreased from 5.12 days in 2014 to 3.46 days in 2020. Although the urine cultures were reduced, there was no immediate impact in the prescribing rates for patients with ASB after implementing this institutional guidance and an altered urine culture ordering process. Over time, there was an observed improvement in prescribing and the total days of antibiotic therapy. This could be attributed to increased familiarity with the guidelines, culture ordering practices or improved documentation. Based on these findings, additional provider education is needed to reinforce the guideline recommendations on the management of ASB.
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15
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Conditional reflex to urine culture: Evaluation of a diagnostic stewardship intervention within the Veterans' Affairs and Centers for Disease Control and Prevention Practice-Based Research Network. Infect Control Hosp Epidemiol 2020; 42:176-181. [PMID: 32838829 DOI: 10.1017/ice.2020.400] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention. DESIGN We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression. SETTING The study included 6 acute-care hospitals within the Veterans' Health Administration across the United States. PARTICIPANTS Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included. METHODS At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days. RESULTS The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49). CONCLUSIONS Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.
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16
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Frontera JA, Wang E, Phillips M, Radford M, Sterling S, Delorenzo K, Saxena A, Yaghi S, Zhou T, Kahn DE, Lord AS, Weisstuch J. Protocolized Urine Sampling is Associated with Reduced Catheter-associated Urinary Tract Infections: A Pre- and Postintervention Study. Clin Infect Dis 2020; 73:e2690-e2696. [DOI: 10.1093/cid/ciaa1152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/31/2020] [Indexed: 12/21/2022] Open
Abstract
Abstract
Background
Standard urine sampling and testing techniques do not mitigate against detection of colonization, resulting in false positive catheter-associated urinary tract infections (CAUTI). We aimed to evaluate whether a novel protocol for urine sampling and testing reduces rates of CAUTI.
Methods
A preintervention and postintervention study with a contemporaneous control group was conducted at 2 campuses (test and control) of the same academic medical center. The test campus implemented a protocol requiring urinary catheter removal prior to urine sampling from a new catheter or sterile straight catheterization, along with urine bacteria and pyuria screening prior to culture. Primary outcomes were test campus CAUTI rates, compared between each 9-month pre- and postintervention epoch. Secondary outcomes included the percent reductions in CAUTI rates, compared between the test campus and a propensity score–matched cohort at the control campus.
Results
A total of 7991 patients from the test campus were included in the primary analysis, and 4264 were included in the propensity score–matched secondary analysis. In the primary analysis, the number of CAUTI cases per 1000 patients was reduced by 77% (6.6 to 1.5), the number of CAUTI cases per 1000 catheter days was reduced by 63% (5.9 to 2.2), and the number of urinary catheter days per patient was reduced by 37% (1.1 to 0.69; all P values ≤ .001). In the propensity score–matched analysis, the number of CAUTI cases per 1000 patients was reduced by 82% at the test campus, versus 57% at the control campus; the number of CAUTI cases per 1000 catheter days declined by 68% versus 57%, respectively; and the number of urinary catheter days per patient decreased by 44% versus 1%, respectively (all P values < .001).
Conclusions
Protocolized urine sampling and testing aimed at minimizing contamination by colonization was associated with significantly reduced CAUTI infection rates and urinary catheter days.
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Affiliation(s)
- Jennifer A Frontera
- Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - Erwin Wang
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Michael Phillips
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Martha Radford
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Stephanie Sterling
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Karen Delorenzo
- Department of Nursing, New York University School of Medicine, New York, New York, USA
| | - Archana Saxena
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Shadi Yaghi
- Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - Ting Zhou
- Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - D Ethan Kahn
- Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - Aaron S Lord
- Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - Joseph Weisstuch
- Department of Medicine, New York University School of Medicine, New York, New York, USA
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17
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Lacerda Mariano L, Ingersoll MA. The immune response to infection in the bladder. Nat Rev Urol 2020; 17:439-458. [PMID: 32661333 DOI: 10.1038/s41585-020-0350-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2020] [Indexed: 12/22/2022]
Abstract
The bladder is continuously protected by passive defences such as a mucus layer, antimicrobial peptides and secretory immunoglobulins; however, these defences are occasionally overcome by invading bacteria that can induce a strong host inflammatory response in the bladder. The urothelium and resident immune cells produce additional defence molecules, cytokines and chemokines, which recruit inflammatory cells to the infected tissue. Resident and recruited immune cells act together to eradicate bacteria from the bladder and to develop lasting immune memory against infection. However, urinary tract infection (UTI) is commonly recurrent, suggesting that the induction of a memory response in the bladder is inadequate to prevent reinfection. Additionally, infection seems to induce long-lasting changes in the urothelium, which can render the tissue more susceptible to future infection. The innate immune response is well-studied in the field of UTI, but considerably less is known about how adaptive immunity develops and how repair mechanisms restore bladder homeostasis following infection. Furthermore, data demonstrate that sex-based differences in immunity affect resolution and infection can lead to tissue remodelling in the bladder following resolution of UTI. To combat the rise in antimicrobial resistance, innovative therapeutic approaches to bladder infection are currently in development. Improving our understanding of how the bladder responds to infection will support the development of improved treatments for UTI, particularly for those at risk of recurrent infection.
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Affiliation(s)
- Livia Lacerda Mariano
- Department of Immunology, Institut Pasteur, Paris, France.,Inserm, U1223, Paris, France
| | - Molly A Ingersoll
- Department of Immunology, Institut Pasteur, Paris, France. .,Inserm, U1223, Paris, France.
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18
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Rodriguez-Mañas L. Urinary tract infections in the elderly: a review of disease characteristics and current treatment options. Drugs Context 2020; 9:dic-2020-4-13. [PMID: 32699546 PMCID: PMC7357682 DOI: 10.7573/dic.2020-4-13] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/15/2022] Open
Abstract
Urinary tract infections (UTIs) are common in the elderly, and cover a range of conditions from asymptomatic bacteriuria to urosepsis. Risk factors for developing symptomatic UTIs include immunosenescence, exposure to nosocomial pathogens, multiple comorbidities, and a history of UTIs. European guidelines on urological infections recommend antimicrobial treatment only for symptomatic UTIs. Non-antimicrobial options to treat and prevent UTIs include among others cranberry products, OM-89 Escherichia coli bacterial lysate vaccine, and estrogen therapy in postmenopausal women, although evidence for their efficacy is weak. Another non-antimicrobial option to control and prevent UTIs is a medical device (Utipro Plus®) containing xyloglucan, gelatin, propolis, and extracts of Hibiscus sabdariffa. The device acts in the intestine as a mechanical barrier to protect against invasion by uropathogenic E. coli strains. A randomized controlled trial of Utipro Plus® in patients with uncomplicated UTIs provided good-quality evidence of its efficacy compared with placebo. In an observational study of Utipro Plus® in patients with recurrent UTIs, more than 80% women reported a return to their pre-UTI clinical status and about 30% transitioned from symptomatic UTIs to asymptomatic bacteriuria. New treatment strategies that offer a safe and effective non-antimicrobial means of managing UTIs could have an important role in the elderly.
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19
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Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: A multicenter experience. Infect Control Hosp Epidemiol 2020; 41:564-570. [PMID: 32131910 DOI: 10.1017/ice.2020.37] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite evidence to the contrary, many practitioners continue to inappropriately screen for and treat bacteria in the urine of clinically asymptomatic patients. The purpose of this study was to evaluate the impact of a new order set on the number of urine culture performed, antibiotic days of therapy (DOT), catheter-associated urinary tract infections (CAUTI), and associated financial impact. DESIGN A quasi-experimental before-and-after intervention. SETTING We conducted this study at 5 Catholic Health Initiative (CHI) hospitals in Texas that use the same electronic health record (EHR) system. PATIENTS The study populations included adult patients who had urine culture performed from June 2017 to June 2019. INTERVENTION The intervention (implemented June 25, 2018) was the addition of a new order set in the electronic health record that required practitioners to choose an indication for the type of urine study. The primary outcome was number of urine cultures performed adjusted for the number of total patient days. RESULTS Following implementation of the new order set, the number of urine cultures performed among the 5 sites decreased from 1,175.8 tests per 10,000 patient days before the intervention to 701.4 after the intervention (40.4% reduction; P < .01). Antibiotic DOT for patients with a urinary tract infection indication decreased from 102.5 to 86.9 per 1,000 patient days (15.2% reduction; P < .01). The CAUTI standardized infection ratio was 1.0 before the intervention and 0.8 after the intervention (P = .23). The estimated yearly savings following the intervention was US$535,181. CONCLUSIONS The addition of a new order set resulted in decreases in the number of urine cultures performed and the antibiotic DOT, as well as substantial financial savings.
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20
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Advani SD, Gao CA, Datta R, Sann L, Smith C, Leapman MS, Hittelman AB, Sabetta J, Dembry LM, Martinello RA, Juthani-Mehta M. Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines. Open Forum Infect Dis 2019; 6:5532507. [PMID: 31375836 PMCID: PMC6677670 DOI: 10.1093/ofid/ofz305] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters. Methods We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines. Results On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by “pan-culturing” rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures. Conclusions Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.
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Affiliation(s)
- Sonali D Advani
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Catherine A Gao
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Rupak Datta
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence Sann
- Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Cindy Smith
- Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Michael S Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Adam B Hittelman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Louise-Marie Dembry
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Richard A Martinello
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut.,Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Manisha Juthani-Mehta
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
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21
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The evolution of catheter-associated urinary tract infection (CAUTI): Is it time for more inclusive metrics? Infect Control Hosp Epidemiol 2019; 40:681-685. [PMID: 30915925 DOI: 10.1017/ice.2019.43] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Catheter-associated urinary tract infection (CAUTI) has long been considered a preventable healthcare-associated infection. Many federal agencies, the Centers for Medicare and Medicaid Services (CMS), and public and private healthcare organizations have implemented strategies aimed at preventing CAUTIs. To monitor progress in CAUTI prevention, the National Healthcare Safety Network (NHSN) CAUTI metric has been adopted nationally as the primary outcome measure and has been refined over the past decades. However, this surveillance metric may underestimate infectious and noninfectious catheter harm. We suggest evolving to more inclusive performance metrics to better reflect quality improvement efforts underway in hospitals. The standardized device utilization ratio (SUR) provides a good surrogate for preventable catheter harm. On the other hand, a population-based metric that combines both standardized infection ratio (SIR) and SUR would address both infectious and noninfectious harm, while adjusting for population risk. Finally, electronically captured catheter-associated bacteriuria may contribute essential information on local testing stewardship.
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22
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Claeys KC, Blanco N, Morgan DJ, Leekha S, Sullivan KV. Advances and Challenges in the Diagnosis and Treatment of Urinary Tract Infections: the Need for Diagnostic Stewardship. Curr Infect Dis Rep 2019; 21:11. [PMID: 30834993 DOI: 10.1007/s11908-019-0668-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Kimberly C Claeys
- Infectious Diseases, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, 20 N. Pine Street, Baltimore, MD, 21201, USA
| | - Natalia Blanco
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Kaede V Sullivan
- Department of Pathology and Laboratory Medicine, Lewis Katz School of Medicine at Temple University, 3500 N. Broad St, Philadelphia, PA, 19140, USA.
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23
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Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infect Control Hosp Epidemiol 2019; 40:281-286. [PMID: 30786940 DOI: 10.1017/ice.2018.356] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices. DESIGN Retrospective before-and-after study. SETTING A 1,250-bed academic tertiary-care referral center. PATIENTS Hospitalized adults who had ≥1 urine culture performed during their stay. INTERVENTION The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends. RESULTS During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05). CONCLUSIONS Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.
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Abstract
"Urinary tract infection (UTI) is a common diagnosis in companion animal practice and is responsible for a significant proportion of antimicrobial use in veterinary medicine. The veterinary community has begun to follow the standards of care in human medicine and shift its definition of an UTI based on culture results and toward the presence of lower urinary tract symptoms. An improved understanding of the pathophysiology of UTI, risk factors for clinical disease, and the implementation of more reliable in-house diagnostic testing can lead to improved outcomes for patients and reduce inappropriate treatment. Investigation of antibiotic-sparing therapies holds some promise as well."
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Affiliation(s)
- Julie K Byron
- Veterinary Clinical Sciences, The Ohio State University, Columbus, OH 43210, USA.
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25
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Richards KA, Cesario S, Best SL, Deeren SM, Bushman W, Safdar N. Reflex urine culture testing in an ambulatory urology clinic: Implications for antibiotic stewardship in urology. Int J Urol 2018; 26:69-74. [PMID: 30221416 DOI: 10.1111/iju.13803] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 08/20/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the performance characteristics of urinalysis and urine microscopy parameters for predicting urine culture results and to implement a reflex urine culture program. METHODS We reviewed the charts of all patients presenting to our clinic January-March 2013 and June-August 2014, excluding those who were catheter-dependent or with urinary diversions. We assessed the association of urinalysis and urine microscopy parameters on urine culture outcomes defining a positive urinalysis as nitrite-positive and/or the presence of ≥5 white blood cells per high-powered field with bacteria and a positive urine culture as ≥10 000 colony-forming units/mL excluding diphtheroids. We carried out logistic regression to assess for predictors of positive urine culture to inform implementation of a reflex urine culture program. RESULTS A total of 2764 patients were evaluated. Logistic regression using urinalysis variables identified positive nitrites (odds ratio 18.6, P < 0.001) and large leukocyte esterase (odds ratio 41.8, P < 0.001) as the strongest predictors of positive urine culture. Logistic regression using urine microscopy variables identified >50 white blood cells per high-powered field (odds ratio 13.6, P < 0.001) and moderate/many bacteria (odds ratio 16.8, P < 0.001) as the strongest predictors of positive urine culture. We used our positive urinalysis definition to implement the reflex urine culture program and noted a 60% reduction in urine culture rates over the first 3 months of implementation. CONCLUSIONS A urine positive for nitrites and/or ≥50 white blood cells per high powered field with bacteria seems to have a strong association with a positive urine culture and the best negative predictive value. A reflex urine culture program is an effective strategy to decrease the rates of unnecessary urine culture and their associated costs.
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Affiliation(s)
- Kyle A Richards
- Section of Urology, Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.,Department of Urology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Stacy Cesario
- Section of Urology, Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Sara L Best
- Section of Urology, Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.,Department of Urology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Susan M Deeren
- Section of Urology, Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Wade Bushman
- Section of Urology, Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.,Department of Urology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.,Section of Infectious Disease, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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No need for a urine culture in elderly hospitalized patients with a negative dipstick test result. Eur J Clin Microbiol Infect Dis 2018; 37:1459-1464. [DOI: 10.1007/s10096-018-3271-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
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Honkanen M, Jämsen E, Karppelin M, Huttunen R, Huhtala H, Eskelinen A, Syrjänen J. The impact of preoperative bacteriuria on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow up. Clin Microbiol Infect 2018; 24:376-380. [DOI: 10.1016/j.cmi.2017.07.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 01/07/2023]
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Urine Culture on Admission Impacts Antibiotic Use and Length of Stay: A Retrospective Cohort Study. Infect Control Hosp Epidemiol 2018; 39:547-554. [DOI: 10.1017/ice.2018.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVETo examine the impact of urine culture testing on day 1 of admission on inpatient antibiotic use and hospital length of stay (LOS).DESIGNWe performed a retrospective cohort study using a national dataset from 2009 to 2014.SETTINGThe study used data from 230 hospitals in the United States.PARTICIPANTSAdmissions for adults 18 years and older were included in this study. Hospitalizations were matched with coarsened exact matching by facility, patient age, gender, Medicare severity-diagnosis related group (MS-DRG), and 3 measures of disease severity.METHODSA multilevel Poisson model and a multilevel linear regression model were used to determine the impact of an admission urine culture on inpatient antibiotic use and LOS.RESULTSMatching produced a cohort of 88,481 patients (n=41,070 with a culture on day 1, n=47,411 without a culture). A urine culture on admission led to an increase in days of inpatient antibiotic use (incidence rate ratio, 1.26; P<.001) and resulted in an additional 36,607 days of inpatient antibiotic treatment. Urine culture on admission resulted in a 2.1% increase in LOS (P=.004). The predicted difference in bed days of care between admissions with and without a urine culture resulted in 6,071 additional bed days of care. The impact of urine culture testing varied by admitting diagnosis.CONCLUSIONSPatients with a urine culture sent on day 1 of hospital admission receive more days of antibiotics and have a longer hospital stay than patients who do not have a urine culture. Targeted interventions may reduce the potential harms associated with low-yield urine cultures on day 1.Infect Control Hosp Epidemiol 2018;39:547–554
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Kalinderi K, Delkos D, Kalinderis M, Athanasiadis A, Kalogiannidis I. Urinary tract infection during pregnancy: current concepts on a common multifaceted problem. J OBSTET GYNAECOL 2018; 38:448-453. [DOI: 10.1080/01443615.2017.1370579] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kallirhoe Kalinderi
- 3rd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Delkos
- 3rd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michail Kalinderis
- Department of Obstetrics and Gynaecology, King’s College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, UK
| | - Apostolos Athanasiadis
- 3rd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kalogiannidis
- 3rd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Griener TP, Naugler C, Chan WW, Church DL. Sociodemographic correlates of urine culture test utilization in Calgary, Alberta. BMC Urol 2018; 18:2. [PMID: 29310636 PMCID: PMC5759274 DOI: 10.1186/s12894-018-0315-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 01/01/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Many clinical practice guidelines encourage diagnosis and empiric treatment of lower urinary tract infection without laboratory investigation; however, urine culture testing remains one of the largest volume tests in the clinical microbiology laboratory. In this study, we sought to determine if there were specific patient groups to which increased testing was directed. To do so, we combined laboratory data on testing rates with Census Canada sociodemographic data. METHODS Urine culture testing data was obtained from the Calgary Laboratory Services information system for 2011. We examined all census dissemination areas within the city of Calgary and, for each area, testing rates were determined for age and gender cohorts. We then compared these testing rates to sociodemographic factors obtained from Census Canada and used Poisson regression and generalized estimating equations to test associations between testing rates and sociodemographic variables. RESULTS Per capita urine culture testing is increasing in Calgary. For 2011, 100,901 individuals (9.2% of all people) received urine cultures and were included in this analysis. The majority of cultures were received from the community (67.9%). Substantial differences in rate of testing were observed across the city. Most notably, urine culture testing was drastically lower in areas of high (≥ $100000) household income (RR = 0.07, p < 0.0001) and higher employment rate (RR = 0.36, p < 0.0001). Aboriginal - First Nations status (RR = 0.29, p = 0.0008) and Chinese visible minority (RR = 0.67, p = 0.0005) were also associated with decreased testing. Recent immigration and visible minority status of South Asian, Filipino or Black were not significant predictors of urine culture testing. Females were more likely to be tested than males (RR = 2.58, p < 0.0001) and individuals aged 15-39 were the most likely to be tested (RR = 1.69, p < 0.0001). CONCLUSIONS Considerable differences exist in urine culture testing across Calgary and these are associated with a number of sociodemographic factors. In particular, areas of lower socioeconomic standing had significantly increased rates of testing. These observations highlight specific groups that should be targeted to improve healthcare delivery and, in turn, enhance laboratory utilization.
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Affiliation(s)
- Thomas P Griener
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.,Division of Microbiology, Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.,Department of Family Medicine, University of Calgary, Calgary, AB, Canada
| | - Wilson W Chan
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.,Division of Microbiology, Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Deirdre L Church
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada. .,Division of Microbiology, Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada. .,Department of Medicine, University of Calgary, Calgary, AB, Canada. .,1W-410, Diagnostic and Scientific Centre, 9-3535 Research Road NW, Calgary, AB, T2L 2K8, Canada.
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Redwood R, Knobloch MJ, Pellegrini DC, Ziegler MJ, Pulia M, Safdar N. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control 2018; 7:4. [PMID: 29340148 PMCID: PMC5759376 DOI: 10.1186/s13756-017-0278-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/14/2017] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Robert Redwood
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, Wisconsin 53705 USA
| | - Mary Jo Knobloch
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, Wisconsin 53705 USA.,William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, Wisconsin 53705 USA
| | - Daniela C Pellegrini
- Department of Infectious Disease, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, Illinois 60637 USA
| | - Matthew J Ziegler
- Division of Infectious Disease, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania 19104 USA
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Madison, Wisconsin 53705 USA
| | - Nasia Safdar
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, Wisconsin 53705 USA.,William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, Wisconsin 53705 USA
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Garcia R, Spitzer ED. Promoting appropriate urine culture management to improve health care outcomes and the accuracy of catheter-associated urinary tract infections. Am J Infect Control 2017; 45:1143-1153. [PMID: 28476493 DOI: 10.1016/j.ajic.2017.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 12/16/2022]
Abstract
Published literature indicates that the unjustified ordering or improper collection of urine for urinalysis or culture from either catheterized patients or those without indwelling devices, or misinterpretation of positive results, often leads to adverse health care events, including increased financial burdens, overreporting of mandated catheter-associated urinary tract infection events, overtreatment of patients with antimicrobial agents, selection of multidrug-resistant organisms, and Clostridium difficile infection. Moreover, national guidelines that provide evidence-based direction on core processes that form the basis for subsequent clinical therapy decisions or surveillance interpretations; that is, the appropriate ordering and collection of urine for laboratory testing and the treatment of patients with symptomatic urinary tract infection, are not widely known or lack adherence. This article provides published evidence on the influence of inappropriate ordering of urine specimens and subsequent treatment of asymptomatic bacteriuria and associated adverse effects; reviews research on bacterial contamination and preservation; and delineates best practices in the collection, handling, and testing of urine specimens for culture or for biochemical analysis in both catheterized and noncatheterized patients. The goal is to provide infection preventionists (IPs) with a cohesive evidence-based framework that will assist them in facilitating the implementation of a urine culture management program that reduces patient harms, enhances the accuracy of catheter-associated urinary tract infection surveillance, improves antibiotic stewardship, and reduces costs.
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Mandal J. Significance of Asymptomatic Bacteriuria. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10310957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Since the recognition of asymptomatic bacteriuria (ABU), several studies have questioned its significance. It is a very common condition, observed in many healthy individuals. Current guidelines mandate that ABU should not be treated in all cases, as it does not seem to improve the outcome. Conditional restrictions for treatment of ABU can be relaxed in certain situations, with minimal exceptions to the rule.
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Affiliation(s)
- Jharna Mandal
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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Abstract
Uropathogenic Escherichia coli (UPEC) are opportunistic human pathogens that primarily circulate as part of commensal intestinal microbiota. Though they have the ability to survive and proliferate in various urinary tract compartments, the urinary tract is a transient, occasional habitat for UPEC. Because of this, most of the UPEC traits have originally evolved to serve in intestinal colonization and transmission. Some of these bacterial traits serve as virulence factors - they are critical to or assist in survival of UPEC as pathogens, and the structure and/or function may be specialized for the infection. Other traits could serve as anti-virulence factors - they represent liability in the urinary tract and are under selection to be lost or inactivated during the infection. Inactivation, variation, or other changes of the bacterial genes that increase the pathogen's fitness during the infection are called pathoadaptive mutations. This chapter describes examples of pathoadaptive mutations in UPEC and provides rationale for their further in-depth study.
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Sundén F, Butler D, Wullt B. Triggered Urine Interleukin-6 Correlates to Severity of Symptoms in Nonfebrile Lower Urinary Tract Infections. J Urol 2017; 198:107-115. [DOI: 10.1016/j.juro.2017.01.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Fredrik Sundén
- Department of Surgery, Helsingborg Hospital (FS), Helsingborg, Sweden
- Division of Microbiology, Immunology and Glycobiology, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Daniel Butler
- Department of Surgery, Helsingborg Hospital (FS), Helsingborg, Sweden
- Division of Microbiology, Immunology and Glycobiology, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Björn Wullt
- Department of Surgery, Helsingborg Hospital (FS), Helsingborg, Sweden
- Division of Microbiology, Immunology and Glycobiology, Department of Laboratory Medicine, Lund University, Lund, Sweden
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Sendi P, Borens O, Wahl P, Clauss M, Uçkay I. Management of Asymptomatic Bacteriuria, Urinary Catheters and Symptomatic Urinary Tract Infections in Patients Undergoing Surgery for Joint Replacement: A Position Paper of the Expert Group 'Infection' of swissorthopaedics. J Bone Jt Infect 2017; 2:154-159. [PMID: 28894690 PMCID: PMC5592375 DOI: 10.7150/jbji.20425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/23/2017] [Indexed: 12/31/2022] Open
Abstract
In this position paper, we review definitions related to this subject and the corresponding literature. Our recommendations include the following statements. Asymptomatic bacteriuria, asymptomatic leukocyturia, urine discolouration, odd smell or positive nitrite sediments are not an indication for antimicrobial treatment. Antimicrobial treatment of asymptomatic bacteriuria does not prevent periprosthetic joint infection, but is associated with adverse events, costs and antibiotic resistance development. Urine analyses or urine cultures in asymptomatic patients undergoing orthopaedic implants should be avoided. Indwelling urinary catheters are the most frequent reason for healthcare-associated urinary tract infections and should be avoided or removed as soon as possible.
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Affiliation(s)
- Parham Sendi
- Department of Infectious Diseases, Bern University Hospital, University of Bern.,Institute for Infectious Diseases, University of Bern
| | - Olivier Borens
- Orthopedic Septic Surgical Unit, Department of Surgery and Anaesthesiology, Lausanne University Hospital, Lausanne
| | - Peter Wahl
- Division for Orthopaedic and Trauma Surgery, Cantonal Hospital Winterthur, Switzerland
| | - Martin Clauss
- Clinic for Orthopedics and Trauma Surgery and Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland Liestal, Switzerland
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva.,Orthopedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland
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Naik AD, Skelton F, Amspoker AB, Glasgow RA, Trautner BW. A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria. PLoS One 2017; 12:e0174415. [PMID: 28350833 PMCID: PMC5370115 DOI: 10.1371/journal.pone.0174415] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/08/2017] [Indexed: 02/02/2023] Open
Abstract
Objectives Guidelines for managing catheter-associated urinary tract infection (CAUTI) and asymptomatic bacteria (ASB) are poorly translated into routine care due in part to cognitive diagnostic errors. This study determines if the accuracy for CAUTI and ASB diagnosis and treatment improves after implementation of a fast and frugal algorithm compared with traditional education methods. Materials and methods A pre and post-intervention with contemporaneous comparison site involving inpatient and long term care wards at two regional Veterans Affairs Systems in United States. Participants included 216 internal medicine residents and 16 primary care clinicians. Intervention clinicians received training with a fast and frugal algorithm. Comparison site clinicians received guidelines education. Diagnosis and treatment accuracy compared with a criterion standard was assessed during similar three-month, pre- and post-intervention periods. Sensitivity, specificity, and likelihood ratios were compared for both periods at each site. Results Bacteriuria management was evaluated against criterion standard in 196 cases pre-implementation and 117 cases post-implementation. Accuracy of bacteriuria management among intervention participants was significantly higher, post-implementation, than those at the comparison site (Intervention: positive likelihood ratio (LR+) = 8.5, specificity = 0.89, 95% confidence interval (CI) = 0.78−1.00; comparison: LR+ = 4.62, specificity (95%CI) = 0.79 (0.63−0.95). Further, improvements at the intervention site were statistically significant (pre-implementation: LR+ = 2.1, specificity (95%CI) = 0.60 (0.50−0.71); post-implementation: LR+ = 8.5, specificity (95%CI) = 0.89 (0.78−1.00). At both sites, there were similar improvements in negative LR from pre- to post-implementation: [Intervention site = 0.28 to 0.08; comparison site = 0.13 to 0.04]. Inappropriate management of ASB declined markedly from 32 (40%) to 3 (11%) cases at the intervention site. Conclusions A fast and frugal algorithm improves diagnosis and treatment accuracy for CAUTI and reduces inappropriate treatment of ASB. Fast and frugal algorithms that realign diagnostic intuitions and treatment norms can enhance translation of evidence into practice.
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Affiliation(s)
- Aanand D. Naik
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail: (AN); (BT)
| | - Felicia Skelton
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Amber B. Amspoker
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Russell A. Glasgow
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, United States of America
| | - Barbara W. Trautner
- Houston Center of Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail: (AN); (BT)
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Grigoryan L, Naik AD, Horwitz D, Cadena J, Patterson JE, Zoorob R, Trautner BW. Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention. Am J Infect Control 2016; 44:1544-1548. [PMID: 27397910 DOI: 10.1016/j.ajic.2016.04.238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/22/2016] [Accepted: 04/22/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lack of guideline knowledge and cognitive biases are barriers that drive overtreatment of catheter-associated asymptomatic bacteriuria (ASB). We explored whether providers' knowledge and attitudes toward management of ASB differed before and after a multifaceted guidelines implementation intervention, reported elsewhere. METHODS We surveyed providers' knowledge of guidelines, cognitive-behavioral constructs, and self-reported familiarity with the relevant Infectious Diseases Society of America guidelines. The survey was administered to providers in the preintervention (n = 169) and postintervention (n = 157) periods at the intervention site and postintervention (n = 65) at the comparison site. RESULTS At the intervention site, the mean knowledge score increased significantly during the postintervention period (from 57.5%-69.9%; P < .0001) and fewer providers reported following incorrect cognitive cues (pyuria and organism type) for treatment of ASB. The knowledge of guidelines was higher in the postintervention sample after adjusting for provider type in the multiple linear regression analysis. Cognitive behavioral constructs (ie, self-efficacy, behavior, social norms, and risk perceptions) and self-reported familiarity with the guidelines also significantly improved during the postintervention period. CONCLUSIONS We identified and targeted specific barriers that drive overtreatment of ASB. Guideline implementation interventions targeting cognitive biases are essential for encouraging the application of ASB guidelines into practice.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Aanand D Naik
- Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Deborah Horwitz
- Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jose Cadena
- South Texas Veterans Healthcare System, San Antonio, TX; Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Jan E Patterson
- South Texas Veterans Healthcare System, San Antonio, TX; Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Roger Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Barbara W Trautner
- Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX.
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Prevalence of Asymptomatic Bacteriuria in Hospitalized Patients. Infect Control Hosp Epidemiol 2016; 37:749-51. [PMID: 26984672 DOI: 10.1017/ice.2016.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Livorsi D, Comer AR, Matthias MS, Perencevich EN, Bair MJ. Barriers to guideline-concordant antibiotic use among inpatient physicians: A case vignette qualitative study. J Hosp Med 2016; 11:174-80. [PMID: 26443327 PMCID: PMC4779411 DOI: 10.1002/jhm.2495] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/11/2015] [Accepted: 09/15/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Greater adherence to antibiotic-prescribing guidelines may promote more judicious antibiotic use, which could benefit individual patients and society at large. OBJECTIVE To assess physician knowledge and acceptance of antibiotic-prescribing guidelines through the use of case vignettes. DESIGN We conducted semistructured interviews with 30 inpatient physicians. Participants were asked to respond to 3 hypothetical case vignettes: (1) a skin and soft tissue infection (SSTI), (2) suspected hospital-acquired pneumonia (HAP), and (3) asymptomatic bacteriuria (ASB). All participants received feedback according to guidelines from the Infectious Diseases Society of America (IDSA) and were asked to discuss their level of comfort with following these guidelines. SETTING Two acute care teaching hospitals for adult patients. INTERVENTION None. MEASUREMENTS Data from transcribed interviews were analyzed using emergent thematic analysis. RESULTS Participants were receptive to guidelines and believed they were useful. However, participants' responses to the case vignettes demonstrated that IDSA guideline recommendations were not routinely followed for SSTI, HAP, and ASB. We identified 3 barriers to guideline-concordant care: (1) physicians' lack of awareness of specific guideline recommendations; (2) tension between adhering to guidelines and the desire to individualize patient care; and (3) skepticism of certain guideline recommendations. CONCLUSIONS Case vignettes may be useful tools to assess physician knowledge and acceptance of antibiotic-prescribing guidelines. Using case vignettes, we identified 3 barriers to following IDSA guidelines. Efforts to improve guideline-concordant antibiotic prescribing should focus on reducing such barriers at the local level.
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Affiliation(s)
- Daniel Livorsi
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
| | - Amber R Comer
- Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Marianne S Matthias
- VA Health Services Research and Development Service Center for Health Information and Communication, Richard Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eli N Perencevich
- Iowa City VA Health Care System, Iowa City, Iowa
- Division of General Internal Medicine and Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Matthew J Bair
- VA Health Services Research and Development Service Center for Health Information and Communication, Richard Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
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Alfano M, Canducci F, Nebuloni M, Clementi M, Montorsi F, Salonia A. The interplay of extracellular matrix and microbiome in urothelial bladder cancer. Nat Rev Urol 2016; 13:77-90. [PMID: 26666363 PMCID: PMC7097604 DOI: 10.1038/nrurol.2015.292] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Many pathological changes in solid tumours are caused by the accumulation of genetic mutations and epigenetic molecular alterations. In addition, tumour progression is profoundly influenced by the environment surrounding the transformed cells. The interplay between tumour cells and their microenvironment has been recognized as one of the key determinants of cancer development and is being extensively investigated. Data suggest that both the extracellular matrix and the microbiota represent microenvironments that contribute to the onset and progression of tumours. Through the introduction of omics technologies and pyrosequencing analyses, a detailed investigation of these two microenvironments is now possible. In urological research, assessment of their dysregulation has become increasingly important to provide diagnostic, prognostic and predictive biomarkers for urothelial bladder cancer. Understanding the roles of the extracellular matrix and microbiota, two key components of the urothelial mucosa, in the sequelae of pathogenic events that occur in the development and progression of urothelial carcinomas will be important to overcome the shortcomings in current bladder cancer treatment strategies.
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Affiliation(s)
- Massimo Alfano
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan Italy
| | - Filippo Canducci
- Department of Biotechnology and Life Sciences, Università degli Studi dell'Insubria, Via Dunant 3, 21100 Varese Italy
| | - Manuela Nebuloni
- Department of Clinical Sciences, Pathology Unit, L. Sacco Hospital, Università degli Studi di Milano, Via Giovanni Battista Grassi 74, 20157 Milan Italy
| | - Massimo Clementi
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132 Milan Italy
| | - Francesco Montorsi
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132 Milan Italy
| | - Andrea Salonia
- Università Vita-Salute San Raffaele, Via Olgettina 60, 20132 Milan Italy
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43
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O'Donnell JM, Nácul FE. Antimicrobial Use in Surgical Intensive Care. SURGICAL INTENSIVE CARE MEDICINE 2016. [PMCID: PMC7123647 DOI: 10.1007/978-3-319-19668-8_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- John M. O'Donnell
- Department of Surgical Critical Care; Lahey Hospital and Medical Center, Division of Surgery, Burlington, Massachusetts USA
| | - Flávio E. Nácul
- Surgical Critical Care Medicine, Pr�-Card�o Hospital, Critical Care Medicine, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro Brazil
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44
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Garnizov TM. Asymptomatic bacteriuria in pregnancy from the perspective of public health and maternal health care: review and case report. BIOTECHNOL BIOTEC EQ 2015. [DOI: 10.1080/13102818.2015.1114429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Teodor Markov Garnizov
- Department of Obstetrics and Gynecology, Postpartum Unit, Medical University of Sofia, University Obstetrics and Gynecology Hospital “Maichin Dom”, Sofia, Bulgaria
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45
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Wooten D, Kahn K, Grein JD, Eells SJ, Miller LG. The association of patient complexities with antibiotic ordering. J Hosp Med 2015; 10:446-52. [PMID: 25873035 DOI: 10.1002/jhm.2367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/23/2015] [Accepted: 03/25/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Antibiotic treatment decisions for medically complex patients are complicated, as the risk of undertreatment may be severe, whereas overtreatment may be associated with adverse effects and the emergence of antibiotic resistant pathogens. OBJECTIVE To determine the influence of patient complexities on providers' decisions to prescribe antibiotics in 3 common hospital-based clinical vignettes. DESIGN A physician survey. SETTING Three urban medical centers in Los Angeles County, California. PARTICIPANTS Hospital-based physicians. MEASUREMENTS Physicians were presented 3 clinical vignettes, with variations by patient age, comorbidity burden, functional status, and follow-up, and asked to choose the best antibiotic regimen. We described the association of additional patient complexity on the proportion of guideline-adherent antibiotic choices. RESULTS In the survey, 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with either older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P < 0.01). CONCLUSIONS In 3 vignettes depicting common clinical scenarios among hospitalized adults, inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities. Treatment guidelines should consider addressing medically complex patients in the context of infection management.
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Affiliation(s)
- Darcy Wooten
- Division of Infectious Diseases, Harbor-UCLA Medical Center, and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- Division of Infectious Diseases, UCSD Medical Center, San Diego, California
| | - Katherine Kahn
- UCLA Clinical and Translational Science Institute, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, and the RAND Corporation, Santa Monica, California
| | - Jonathan D Grein
- UCLA Clinical and Translational Science Institute, Los Angeles, California
- Department of Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Samantha J Eells
- Division of Infectious Diseases, Harbor-UCLA Medical Center, and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Loren G Miller
- Division of Infectious Diseases, Harbor-UCLA Medical Center, and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
- UCLA Clinical and Translational Science Institute, Los Angeles, California
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46
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Zhu Z, Wang J, Lopez AI, Yu F, Huang Y, Kumar A, Li S, Zhang L, Cai C. Surfaces Presenting α-Phenyl Mannoside Derivatives Enable Formation of Stable, High Coverage, Non-pathogenic Escherichia coli Biofilms against Pathogen Colonization. Biomater Sci 2015; 3:781-880. [PMID: 26029359 PMCID: PMC4443871 DOI: 10.1039/c5bm00076a] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Prevention of pathogenic colonization on medical devices over a long period of time remains a great challenge, especially in a high-nutrient environment that accelerates production of biomass leading to biofouling of the device. Since biofouling and the subsequent pathogen colonization is eventually inevitable, a new strategy using non-pathogenic bacteria as living guards against pathogenic colonization on medical devices has attracted increasing interest. Crucial to the success of this strategy is to pre-establish a high coverage and stable biofilm of benign bacteria on the surface. Silicone elastomers are one of the most widely used materials in biomedical devices. In this work, we modified silicone surfaces to promote formation of high coverage and stable biofilms by a non-pathogenic Escherichia coli strain 83972 with type 1 fimbriae (fim+) to interfere the colonization of an aggressive biofilm-forming, uropathogenic Enterococcus faecalis. Although it is well known that mannoside surfaces promote the initial adherence of fim+ E. coli through binding to the FimH receptor at the tip of the type 1 fimbriae, it is not clear whether the fast initial adherence could lead to a high coverage and stable protective biofilm. To explore the role of mannoside ligands, we synthesized a series of alkyl and aryl mannosides varied in structure and immobilized them on silicone surfaces pre-coated with poly(amidoamine) (PAMAM) dendrimer. We found that stable and densely packed benign E. coli biofilms were formed on the surfaces presenting biphenyl mannoside with the highest initial adherence of fim+ E. coli. These non-pathogenic biofilms prevented the colonization of E. faecalis for 11 days at a high concentration (108 CFU mL-1, 100,000 times above the diagnostic threshold for urinary tract infection) in the nutrient-rich Lysogeny Broth (LB) media. The result shows a correlation among the initial adherence of fim+ E. coli 83972, the coverage and long-term stability of the resultant biofilms, as well as their efficiency for preventing the pathogen colonization.
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Affiliation(s)
- Zhiling Zhu
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
| | - Jun Wang
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
| | - Analette I. Lopez
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
| | - Fei Yu
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
| | - Yongkai Huang
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
| | - Amit Kumar
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
| | - Siheng Li
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
| | - Lijuan Zhang
- School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, P R China
| | - Chengzhi Cai
- 112 Fleming Building, Department of Chemistry, University of Houston, Houston, Texas, 77204, USA. Fax: +1-713-743-2709; Tel: +1-713-743-2710
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Eberl M, Friberg IM, Liuzzi AR, Morgan MP, Topley N. Pathogen-Specific Immune Fingerprints during Acute Infection: The Diagnostic Potential of Human γδ T-Cells. Front Immunol 2014; 5:572. [PMID: 25431573 PMCID: PMC4230182 DOI: 10.3389/fimmu.2014.00572] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 10/26/2014] [Indexed: 12/21/2022] Open
Affiliation(s)
- Matthias Eberl
- Cardiff Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Ida M. Friberg
- Cardiff Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Anna Rita Liuzzi
- Cardiff Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Matt P. Morgan
- Cardiff Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Nicholas Topley
- Institute of Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
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48
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Sajankila N, Como JJ, Claridge JA. Upcoming rules and benchmarks concerning the monitoring of and the payment for surgical infections. Surg Clin North Am 2014; 94:1219-31. [PMID: 25440120 DOI: 10.1016/j.suc.2014.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
There has been a good deal of dialogue about pay for performance and linking outcomes with reimbursement, especially given the recent national health care legislation. Many such concerns are caused by upcoming changes that have been outlined in the Affordable Care Act. This article discusses these upcoming changes and reviews some of the literature that supports them, specifically those related to surgical infections. Likewise, the lack of support for some of these changes in the academic literature is discussed. Finally, some of the proposed key benchmarks and the methodologies behind the design of those benchmarks are discussed.
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Affiliation(s)
- Nitin Sajankila
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109-1998, USA
| | - John J Como
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109-1998, USA
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109-1998, USA.
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49
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Trautner BW, Petersen NJ, Hysong SJ, Horwitz D, Kelly PA, Naik AD. Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care. Am J Infect Control 2014; 42:653-8. [PMID: 24713596 DOI: 10.1016/j.ajic.2014.02.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inappropriate use of antibiotics to treat asymptomatic bacteriuria (ASB) is a significant contributor to antibiotic overuse in hospitalized patients despite evidence-based guidelines on ASB management. We surveyed whether accurate knowledge of how to manage catheter-associated urine cultures was associated with level of training, familiarity with ASB guidelines, and various cognitive-behavioral constructs. METHODS We used a survey to measure respondents' knowledge of how to manage catheter-associated bacteriuria, familiarity with the content of the relevant Infectious Diseases Society of America guidelines, and cognitive-behavioral constructs. The survey was administered to 169 residents and staff providers. RESULTS The mean knowledge score was 57.5%, or slightly over one-half of the questions answered correctly. The overall knowledge score improved significantly with level of training (P < .0001). Only 42% of respondents reported greater than minimal recall of ASB guideline contents. Self-efficacy, behavior, risk perceptions, social norms, and guideline familiarity were individually correlated with knowledge score (P < .01). In multivariable analysis, behavior, risk perception, and year of training were correlated with knowledge score (P < .05). CONCLUSIONS Knowledge of how to manage catheter-associated bacteriuria according to evidence-based guidelines increases with experience. Addressing both knowledge gaps and relevant cognitive biases early in training may decrease the inappropriate use of antibiotics to treat ASB.
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Affiliation(s)
- Barbara W Trautner
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.
| | - Nancy J Petersen
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Deborah Horwitz
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - P Adam Kelly
- Southeast Louisiana Veterans Health Care System, New Orleans, LA; Section of General Internal Medicine and Geriatrics, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Section of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, TX
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50
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Duncan RA. Prosthetic joint replacement: should orthopedists check urine because it's there? Clin Infect Dis 2014; 59:48-50. [PMID: 24723277 DOI: 10.1093/cid/ciu243] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Robert A Duncan
- Center for Infectious Diseases and Prevention, Lahey Hospital and Medical Center, Burlington, Massachusetts
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