Bacteriuria in elderly institutionalized men

Management of Asymptomatic Bacteriuria in Non-Catheterized Adults

Understanding the management of asymptomatic bacteriuria (ASB) is important given the prevalence of the condition, associated risks in certain patient populations, and the risks associated with inappropriate antibiotic administration. Generally, screening and treatment is only recommended in pregnant women and in those undergoing urologic procedures that will violate the urothelium. Knowing the appropriate time to screen and treat ASB is critical for managing high-risk patients and preventing the growth of antibiotic resistance. Recent research into the protective nature of avirulent strains of Escherichia coli might offer a new approach to management of ASB.

Management of Bacteriuria and Urinary Tract Infections in the Older Adult

Urinary tract infection (UTI) is one of the most frequent bacterial infections diagnosed in older adults and the most common reason for antibiotic prescriptions in nursing homes. Distinguishing between asymptomatic bacteriuria and UTI in older adults can be challenging and implementing a systematic approach to diagnosis using standard toolkits or algorithms is recommended for patients residing in post-acute and long-term care settings. This article reviews the pathophysiology, microbiology, diagnostic approach, treatment, and approaches to prophylaxis in the older adult.

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria

Importance

Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events.

Objective

To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB.

Design, Setting, and Participants

This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022.

Exposure

Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion.

Main Outcomes and Measures

Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration.

Results

Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00).

Conclusions and Relevance

This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

Correlation of Pyuria and Bacteriuria in Acute Care

BACKGROUND

Pyuria is often used as an import marker in the diagnosis of urinary tract infection. The interpretation of pyuria may be especially important in patients with nonspecific complaints. There is a paucity of data to demonstrate the utility of pyuria alone in the diagnosis of bacteriuria or urinary tract infection. This study aims to further define the relationship of pyuria and positive bacterial growth in urine culture, as well as the diagnostic utility of different urine white blood cell cutoff points.

METHOD

A total of 46,127 patients older than the age of 18 were selected from the inpatient population of HCA Healthcare System Capital Division. Urine microscopy results were stratified by white blood cell count and correlated with positivity of urine culture bacterial growth. The optimal urine white blood cell cutoff was derived based on the receiver operating characteristic curve plot.

RESULTS

Urine microscopy finding of white blood cell 0-5 cell/hpf, 5-10 cell/hpf, 10-25 cell/hpf, and higher than 25 cell/hpf was associated with 25.4%, 28.2%, 33%, and 53.8% rates of bacteriuria, respectively. The receiver operating characteristic curve plot demonstrated that pyuria alone did not provide adequate diagnostic accuracy to predict bacteriuria. The optimal cutoff point for the best combination of sensitivity and specificity was found to be 25 cell/hpf.

CONCLUSION

Pyuria alone provides inadequate diagnostic accuracy for predicting bacteriuria. Urine white blood cell count greater than 25 cell/hpf was found to be the optimal cutoff to detect bacteriuria. The result of this study supports the current guideline recommendation against antibiotic treatment based on urine analysis alone. It also informs future design of randomized controlled trial that investigates interventional strategies for patients with pyuria and nonspecific complaints.

Antibiotics versus no treatment for asymptomatic bacteriuria in residents of aged care facilities: a systematic review and meta-analysis

BACKGROUND

Asymptomatic bacteriuria (ASB) is common among residents of residential aged care facilities (RACFs). However, differentiating between an established urinary tract infection and ASB in older adults is difficult. As a result, the overuse of dipstick urinalysis, as well as the subsequent initiation of antibiotics, is common in RACFs.

AIM

To find, appraise, and synthesise studies that reported the effectiveness, harms, and adverse events associated with antibiotic treatment for older patients with ASB residing in RACFs.

DESIGN AND SETTING

A systematic review using standard Cochrane methods of RACF residents with ASB using antibiotics against placebo, or no treatment.

METHOD

Three electronic databases (PubMed, EMBASE, and CENTRAL), clinical trial registries, and forward-backward reference checks of included studies were searched.

RESULTS

Nine randomised controlled trials, comprising 1391 participants were included; two of which used a placebo comparator, and the remaining seven used no therapy control groups. There was a relatively small number of studies assessed per outcome and an overall moderate risk of bias. Outcomes related to mortality, development of ASB, and complications were comparable between the two groups. Antibiotic therapy was associated with a higher number of adverse effects (four studies; 303 participants; risk ratio [RR] 5.62, 95% confidence interval [CI] = 1.07 to 29.55, P = 0.04) and bacteriological cure (nine studies; 888 participants; RR 1.89, 95% CI = 1.08 to 3.32, P = 0.03).

CONCLUSION

Overall, although antibiotic treatment was associated with bacteriological cure, it was also associated with significantly more adverse effects. The harms and lack of clinical benefit of antibiotic use for older patients in RACFs may outweigh the benefits.

International travel and travelers' diarrhea - Increased risk of urinary tract infection

BACKGROUND

Urinary tract infections (UTIs) rank among the most common infections encountered in health care, with an annual incidence of 12% for women. Despite the vast numbers of international travels (over 1.5 billion annually), no prospective studies have had primary focus on UTIs during travel.

METHODS

We recruited in 2008-17 international travelers who all filled out pre- and post-travel questionnaires. Incidence rates of UTI were calculated separately for both sexes. Multivariable analyses were conducted to identify risk factors for UTI during travel.

RESULTS

In total 15/517 (2,9%) travelers acquired UTI during travel, yielding an annual incidence of 62% for female and 18% for male travelers. Travelers' diarrhea (TD) was identified as a factor predisposing to UTI (OR 9.2, 95% CI 1.5-+∞, p = 0.011); all UTI cases were recorded by travelers with TD.

CONCLUSIONS

To our knowledge, this is the first prospective study with a primary focus on UTI during travel. Our data reveal that among travelers the incidence of UTI far exceeds that reported for the general population. TD was identified as a major risk factor for the infection. Our results highlight the need for TD prevention as a means of also preventing UTI during travel.

Prevalence of and factors associated with atypical presentation in bacteremic urinary tract infection

A delay in the diagnosis of urinary tract infection (UTI) is not uncommon. Atypical presentation is often cited as one of the causes of diagnostic delays. However, few studies have investigated the prevalence of atypical presentation and determined factors associated with atypical presentation at initial contact among patients with UTI. Therefore, a retrospective and prospective cohort study using chart review was conducted in two acute care hospitals. We included 285 consecutive patients hospitalized for bacteremic UTI. The primary outcome was atypical presentation, defined as the absence of any urinary tract symptom or sign at initial contact. Of all patients, the median age was 82 years, 186 (65.3%) were women, and 53 (18.6%) had dementia. Urinary tract symptoms and signs were absent at initial contact in 144 patients (50.5%; 95% CI 44.7–56.4%). The multivariable analysis revealed that older age, male sex, dementia, and early visit from symptom onset were significantly associated with an increased risk of atypical presentation. Patients with atypical presentation were less likely to receive a correct diagnosis at initial contact than patients with urinary tract symptoms and signs (OR 0.30; 95% CI 0.17–0.51). Atypical presentation in patients with bacteremic UTI is common and negatively affects the correct diagnosis of UTI.

Asymptomatic Bacteriuria (ABU) in Elderly: Prevalence, Virulence, Phylogeny, Antibiotic Resistance and Complement C3 in Urine

Background: The incidence of asymptomatic bacteriuria (ABU) increases with age and is most common for persons 80 years of age and above and in elderly living in nursing homes. The distinction between ABU and urinary tract infection (UTI) is often difficult, especially in individuals, who are unable to communicate their symptoms, and there is a lack of objective methods to distinguish between the two entities. This can lead to overuse of antibiotics, which results in the selection and dissemination of antibiotic resistant isolates. Materials and methods: From voided midstream urine samples of 211 participants ≥60 years old from nursing homes, an activity center and a general practitioners clinic, we collected 19 ABU, 16 UTI and 22 control urine samples and compared them with respect to levels of complement component C3 in urine as determined by an ELISA assay relative to creatinine levels in the same urine samples, as measured by a creatinine assay. Further, we studied all Escherichia coli isolates for selected virulence genes by multiplex PCR, and by whole-genome sequencing (WGS) for genotypes and phylogenetic clustering. Antibiotic susceptibility was determined by microtiter broth dilution. Results: We identified a prevalence of ABU of 18.9% in nursing home residents, whereas ABU was only found in 4% of elderly living in the community (p < 0.001). E. coli from ABU patients were significantly more antibiotic resistant than E. coli from UTIs (p = 0.01). Prevalence of classical virulence genes, detected by multiplex PCR, was similar in E. coli isolates from ABU and UTI patients. Whole-genome sequencing of the E. coli isolates showed no specific clustering of ABU isolates compared to UTI isolates. Three isolates from three different individuals from one of the nursing homes showed signs of transmission. We demonstrated a significantly increased level of C3/creatinine ratio in ABU and UTI samples compared to healthy controls; however, there was no significant difference between the ABU and UTI group with respect to C3 level, or virulence factor genes. Conclusion: ABU was significantly more prevalent in the elderly residing in nursing homes than in the elderly living at home. Antibiotic resistance was more prevalent in E. coli from nursing homes than in UTI isolates, but there was no difference in prevalence of virulence associated genes between the two groups and no phylogenetic clustering, as determined by WGS relative to the two types of E. coli bacteriuria. The similar complement C3 response in ABU and UTI patients may indicate that ABU should be reconsidered as an infection albeit without symptoms.

Burning for Treatment: Impact of Staff Education on Asymptomatic Bacteriuria Management in the Elderly

Background

Studies indicate that elderly patients are often inappropriately treated with antimicrobials for asymptomatic bacteriuria (ASB). Interprofessional education may help improve the assessment and management of ASB.

Methods

Retrospective chart audits were conducted on two cohorts of positive urine cultures (n = 201) obtained from a geriatric acute care unit to determine the incidence of treated ASB. The first cohort (n = 101) was analyzed from January to July 2017. Education was provided to unit staff (e.g., nurses, physicians, pharmacists) in Fall 2017. The second cohort (n = 100) was analyzed from January to July 2018. Descriptive statistics were used to summarize and compare the results from the cohorts.

Results

152 patients (n = 201 positive urine cultures) were reviewed: 74% (159) of positive urine cultures were ASB and 21% (42) were urinary tract infections. The incidence of treated ASB was 15% (30) and untreated ASB was 65% (129). The incidence of UTI, treated ASB, and untreated ASB were not significantly different between the two cohorts examined.

Conclusion

The implementation of education did not result in lasting changes in ASB management. Our study suggests that future systemic solutions are necessary to reduce the incidence of treated ASB in the geriatric population.

Incidence and Outcomes of Staphylococcus aureus Bacteriuria: A Population-based Study

BACKGROUND

Staphylococcus aureus bacteriuria (SABU) may represent multiple processes ranging from asymptomatic colonization to a marker of S. aureus bacteremia (SAB). Our objective was to describe SABU at a population-based level and determine patient characteristics associated with SAB.

METHODS

A retrospective study was performed using electronic databases. All urine cultures positive for S. aureus between 2010 and 2013 within the Calgary Health Zone were included. Patient characteristics were compared among patients with and without SAB and risk factors identified using multiple logistic regression modeling.

RESULTS

A total of 2540 urine cultures positive for S. aureus from 2054 patients were analyzed. The incidence of SABU was greatest among geriatric males with multiple comorbidities. SAB occurred in 175 (6.9%) of SABU patients. Those with SAB were more likely to be hospitalized, male, have a recent urinary procedure, have pure S. aureus culture in urine, and have laboratory findings suggesting systemic infection. Patients with isolated SABU were more likely to be ≥65 years, have dementia, and have abnormal urinalyses with pyuria and urine nitrites. In-hospital mortality in patients with SABU and SABU+SAB was 9.2% and 17.5%, respectively. Patients with SABU detected ≥48 hours before SAB had the highest risk of death.

CONCLUSIONS

Less than 7% of patients with SABU have or will develop SAB. Characteristics associated with SABU were identified that established higher risk for systemic infection. Investigating SABU patients with these characteristics for systemic infection is warranted because a delay in diagnosis is associated with increased mortality.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Sociodemographic correlates of urine culture test utilization in Calgary, Alberta

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.

Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study

BACKGROUND

Despite clinical practice guidelines, asymptomatic bacteriuria (ASB) in older people is frequently treated. A common reason for treating ASB is a change in mental status.

OBJECTIVE

To determine how often asymptomatic UTI is treated in older medically ill delirious individuals and its association with functional recovery.

METHODS

Consecutive older medical in-patients were screened for delirium, and followed in hospital. Treatment for asymptomatic UTI was defined as documented treatment for a possible urinary tract infection with antibiotics, without concurrent infectious or urinary symptoms. The primary outcome was functional recovery at discharge or 3 months post-discharge. Poor functional recovery was defined by any one of death, new permanent long-term institutionalization or decreased ability to perform activities of daily living.

RESULTS

The study sample comprised 343 delirious in-patients, of which 237 (69%) had poor functional recovery. Ninety two (27%) delirious in-patients were treated for asymptomatic UTI. Treatment for asymptomatic UTI was associated with poor functional recovery compared to other delirious in-patients (RR 1.30, 95% CI: 1.14-1.48 overall). Similar results were seen when the analysis was restricted to only bacteriuric delirious individuals. Seven (7.5%) individuals treated for asymptomatic UTI developed Clostridium difficile infection compared to eight (3.2%) in the remainder of the delirious cohort (OR 2.45, 95% CI: 0.86-6.96).

CONCLUSIONS

These results suggest that treatment of asymptomatic UTI in older medical in-patients with delirium is common, and of questionable benefit. Further research is needed to establish guidelines to minimize over-treatment of UTI in older delirious in-patients.

Geriatric Infectious Diseases: Current Concepts on Diagnosis and Management

New information on infectious diseases in older adults has become available in the past 20 years. In this review, in-depth discussions on the general problem of geriatric infectious diseases (epidemiology, pathogenesis, age-related host defenses, clinical manifestations, diagnostic approach); diagnosis and management of bacterial pneumonia, urinary tract infection, and Clostridium difficile infection; and the unique challenges of diagnosing and managing infections in a long-term care setting are presented.

Asymptomatic Bacteriuria and Bacterial Interference

Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.

[Urinary tract infections in the elderly]

Urinary tract infections (UTIs) and asymptomatic bacteriuria are frequent in elderly patients. Distinguishing UTI from asymptomatic bacteriuria in older adults, particularly those living in long-term care facilities, might be a challenge for physicians due to the presence of confounding factors, such as an overactive bladder, prostate enlargement, and an indwelling bladder catheter. The absence of standards in the definition and treatment of UTI in the elderly frequently leads to overtreatment. Consequently, antibiotic selection pressure increases and as a result multidrug-resistant organisms might arise. On the other hand, insufficient treatment can result in prolonged and complicated courses of infections or increased morbidity. This review covers the definition, prevalence, diagnosis and management of UTI in older adults.

Implementation of an antimicrobial stewardship program targeting residents with urinary tract infections in three community long-term care facilities: a quasi-experimental study using time-series analysis

BACKGROUND

Asymptomatic bacteriuria in the elderly commonly results in antibiotic administration and, in turn, contributes to antimicrobial resistance, adverse drug events, and increased costs. This is a major problem in the long-term care facility (LTCF) setting, where residents frequently transition to and from the acute-care setting, often transporting drug-resistant organisms across the continuum of care. The goal of this study was to assess the feasibility and efficacy of antimicrobial stewardship programs (ASPs) targeting urinary tract infections (UTIs) at community LTCFs.

METHODS

This was a quasi-experimental study targeting antibiotic prescriptions for UTI using time-series analysis with 6-month retrospective pre-intervention and 6-month intervention period at three community LTCFs. The ASP team (infectious diseases (ID) pharmacist and ID physician) performed weekly prospective audit and feedback of consecutive prescriptions for UTI. Loeb clinical consensus criteria were used to assess appropriateness of antibiotics; recommendations were communicated to the primary treating provider by the ID pharmacist. Resident outcomes were recorded at subsequent visits. Generalized estimating equations using segmented regression were used to evaluate the impact of the ASP intervention on rates of antibiotic prescribing and antibiotic resistance.

RESULTS

One-hundred and four antibiotic prescriptions for UTI were evaluated during the intervention, and recommendations were made for change in therapy in 40 (38 %), out of which 10 (25 %) were implemented. Only eight (8 %) residents started on antibiotics for UTI met clinical criteria for antibiotic initiation. An immediate 26 % decrease in antibiotic prescriptions for UTI during the ASP was identified with a 6 % reduction continuing through the intervention period (95 % Confidence Interval ([CI)] for the difference: -8 to -3 %). Similarly, a 25 % immediate decrease in all antibiotic prescriptions was noted after introduction of the ASP with a 5 % reduction continuing throughout the intervention period (95 % CI: -8 to -2 %). No significant effect was noted on resistant organisms or Clostridium difficile.

CONCLUSION

Weekly prospective audit and feedback ASP in three community LTCFs over 6 months resulted in antibiotic utilization decreases but many lost opportunities for intervention.

Bacteruria and Urinary Tract Infections in the Elderly

Both urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) are common problems among elderly adults and represent a significant health care burden. Despite their frequency, differentiating between ASB and true UTI remains controversial among health care providers. Several challenges exist in the evaluation of urinary symptoms in the elderly patient. Symptoms of UTI are variable; problems are encountered in the collection, testing, and interpretation of urine specimens; and results of urinalysis are often misinterpreted and mishandled. Multiple studies have shown no morbidity or mortality benefit to antibiotic therapy in either community or long-term care facility residents with ASB.

Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections

BACKGROUND

Women suffering from recurrent urinary tract infections (rUTIs) are routinely treated for asymptomatic bacteriuria (AB), but the consequences of this procedure on antibiotic resistance are not fully known. The aim of this study was to evaluate the impact of AB treatment on antibiotic resistance among women with rUTIs.

METHODS

The study population consisted of 2 groups of women who had previously been enrolled in a randomized clinical trial: group A was not treated, and group B was treated. All women were scheduled for follow-up visits every 6 months, or more frequently if symptoms arose. Microbiological evaluation was performed only in symptomatic women. All women were followed up for a mean of 38.8 months to analyze data from urine cultures and antibiograms.

RESULTS

The previous study population consisted of 673 women, but 123 did not attend the entire follow-up period. For the final analysis, 257 of the remaining 550 patients were assigned to group A, and 293 to group B. At the end of follow-up, the difference in recurrence rates was statistically significant (P < .001): 97 (37.7%) in group A versus 204 (69.6%) in group B. Isolated Escherichia coli from group B showed higher resistance to amoxicillin-clavulanic acid (P = .03), trimethoprim-sulfamethoxazole (P = .01), and ciprofloxacin (P = .03) than that from group A.

CONCLUSIONS

This study shows that AB treatment is associated with a higher occurrence of antibiotic-resistant bacteria, indicating that AB treatment in women with rUTIs is potentially dangerous.

Urinary tract infection diagnosis and response to therapy in long-term care: A prospective observational study

BACKGROUND

The prevalence of asymptomatic bacteriuria among residents of long-term care (LTC) facilities is high, and is a source of inappropriate antibiotic prescription.

OBJECTIVE

To establish symptoms and signs associated with a positive urine culture, and to determine whether antibiotic therapy is associated with functional improvement.

METHODS

A total of 101 LTC patients were prospectively observed after submission of urine for culture.

RESULTS

The culture positivity rate was consistent with the expected asymptomatic bacteriuria rate. Change in mental status and male sex were associated with culture positivity. Treatment decisions were not consistent with culture results. Treatment did not lead to improvement in activities of daily living scores at two days or seven days.

DISCUSSION

Significant growth cannot be well predicted based on clinical variables; thus, the decision to submit urine is somewhat arbitrary. Because urine culture testing and treatment does not lead to functional improvement, restricting access to the test may be reasonable.

CONCLUSION

Urine culture testing in LTC facilities does not lead to functional improvement.

Antibiotics for asymptomatic bacteriuria

BACKGROUND

Asymptomatic bacteriuria is commonly detected in women aged up to 60 years, patients with diabetes, and the elderly. The benefit of antibiotic treatment for this condition is controversial.

OBJECTIVES

To assess the effectiveness and safety of antibiotics treatment for asymptomatic bacteriuria in adults. Specific objectives were to assess 1) the effectiveness of antibiotics for preventing development of symptomatic UTI, UTI-related complications, overall mortality, UTI-related mortality, and resolution of bacteriuria; 2) the development of resistance to antibiotic treatment by comparing resistance of grown bacteria in urine before and after therapy; and 3) the frequency of adverse events.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register up to 24 February 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing antibiotics to placebo or no treatment for asymptomatic bacteriuria in adults were included. The outcomes of interest were the development of symptomatic urinary tract infection (UTI), complications, death, any adverse event, development of antibiotic resistance, bacteriological cure, and decline in kidney function.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed study quality. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

We included nine studies (1614 participants) in this review. Symptomatic UTI (RR 1.11, 95% CI 0.51 to 2.43), complications (RR 0.78, 95% CI 0. 35 to 1.74), and death (RR 0.99, 95% CI 0.70 to 1.41) were similar between the antibiotic and placebo or no treatment arms. Antibiotics were more effective for bacteriological cure (RR 2.32, 95% CI 1.11 to 4.83) but also more adverse events developed in this group (RR 3.77, 95% CI 1.40 to 10.15). No decline in the kidney function was observed across the studies; minimal data were available on the emergence of resistant strains after antimicrobial treatment.The included studies were of medium and high quality, used different treatments for different durations of treatment and follow-up, different populations, but this did not appear to influence the results of review.

AUTHORS' CONCLUSIONS

No differences were observed between antibiotics versus no treatment of asymptomatic bacteriuria for the development of symptomatic UTI, complications or death. Antibiotics were superior to no treatment for the bacteriological cure but with significantly more adverse events. There was no clinical benefit from treating asymptomatic bacteriuria in the studies included in this review.

Antimicrobial treatment of asymptomatic bacteriuria in noncatheterized adults: a systematic review

Asymptomatic bacteriuria (ASB) is a common clinical finding characterized by the presence of bacteria in the urine of an individual without signs or symptoms suggestive of urinary tract infection. Despite available guidelines on the diagnosis and management of ASB, it is often managed inappropriately. We performed a systematic review of clinical trials evaluating antimicrobial therapy for ASB, identified translational barriers to evidence-based practice, and we offer strategies to optimize antimicrobial use for ASB. We conducted a systematic search of the PubMed, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health databases, and the Cochrane Library. Randomized controlled trials, cohort trials, case-control studies, and meta-analyses published in the English language were included in this review if they addressed treatment of ASB with at least one antimicrobial agent in nonpregnant adults. Articles were excluded if they evaluated patients with indwelling urinary catheters or were not clinical trials. Of the 304 articles identified from the search, 287 were excluded; thus 17 articles met the inclusion criteria. Although treatment of ASB with antimicrobial therapy may improve short-term microbiologic outcomes, the clinical significance is diminished because the effect is not sustained, there is no measurable improvement in morbidity or mortality, and some data indicate that therapy is deleterious. Several translational barriers that preclude adoption of evidence-based practice are identified. Treatment guidelines may not achieve their desired effect and underscore the need for additional methods to translate clinical trial data into practice. Clinical pharmacists are a core member of the antimicrobial stewardship team and in an important position to participate in initiatives that promote appropriate antimicrobial use. We suggest a multifaceted approach consisting of education and frequent routine prospective audits with feedback coupled with appropriate process and outcome measures.

Successfully reducing antibiotic prescribing in nursing homes

OBJECTIVES

To determine whether antibiotic prescribing can be reduced in nursing homes using a quality improvement (QI) program that involves providers, staff, residents, and families.

DESIGN

A 9-month quasi-experimental trial of a QI program in 12 nursing homes (6 comparison, 6 intervention) conducted from March to November 2011.

SETTING

Nursing homes in two regions of North Carolina, roughly half of whose residents received care from a single practice of long-term care providers.

PARTICIPANTS

All residents, including 1,497 who were prescribed antibiotics.

INTERVENTION

In the intervention sites, providers in the single practice and nursing home nurses received training related to prescribing guidelines, including situations for which antibiotics are generally not indicated, and nursing home residents and their families were sensitized to matters related to antibiotic prescribing. Feedback on prescribing was shared with providers and nursing home staff monthly.

MEASUREMENTS

Rates of antibiotic prescribing for presumed urinary tract, skin and soft tissue, and respiratory infections.

RESULTS

The QI program reduced the number of prescriptions ordered between baseline and follow-up more in intervention than in comparison nursing homes (adjusted incidence rate ratio = 0.86, 95% confidence interval = 0.79-0.95). Based on baseline prescribing rates of 12.95 prescriptions per 1,000 resident-days, this estimated adjusted incidence rate ratio implies 1.8 prescriptions avoided per 1,000 resident-days.

CONCLUSION

This magnitude of effect is unusual in efforts to reduce antibiotic use in nursing homes. Outcomes could be attributed to the commitment of the providers; outreach to providers and staff; and a focus on common clinical situations in which antibiotics are generally not indicated; and suggest that similar results can be achieved on a wider scale if similar commitment is obtained and education provided.

Urinary tract infection in older adults

Urinary tract infection and asymptomatic bacteriuria are common in older adults. Unlike in younger adults, distinguishing symptomatic urinary tract infection from asymptomatic bacteriuria is problematic, as older adults, particularly those living in long-term care facilities, are less likely to present with localized genitourinary symptoms. Consensus guidelines have been published to assist clinicians with diagnosis and treatment of urinary tract infection; however, a single evidence-based approach to diagnosis of urinary tract infection does not exist. In the absence of a gold standard definition of urinary tract infection that clinicians agree upon, overtreatment with antibiotics for suspected urinary tract infection remains a significant problem, and leads to a variety of negative consequences including the development of multidrug-resistant organisms. Future studies improving the diagnostic accuracy of urinary tract infections are needed. This review will cover the prevalence, diagnosis and diagnostic challenges, management, and prevention of urinary tract infection and asymptomatic bacteriuria in older adults.

Diagnostic criteria for urinary tract infection in hospitalized elderly patients over 75 years of age: a multicenter cross-sectional study

INTRODUCTION

Urinary tract infection (UTI) is one of the most frequent infections in geriatric patients. Nevertheless, the diagnosis remains difficult because of the high prevalence of asymptomatic bacteriuria (AB). We studied the diagnosis criteria used by physicians in geriatric patients 75 years of age or more.

METHOD

A multicenter study was carried out in October 2009 in acute care wards (geriatrics, infectious diseases, internal medicine). During 1 week, the local investigator collected all positive urine microscopy and culture in geriatric patients 75 years of age or more and filled out a questionnaire on the final diagnosis (AB, cystitis, pyelonephritis, prostatitis), symptoms, clinical signs, and other infectious diagnosis.

RESULTS

Two hundred and forty-one questionnaires were filled out in 48 wards. Physicians diagnosed AB in 91 patients (37.8%), cystitis in 72 (29.9%), pyelonephritis in 48 (19.9%), prostatitis in 20 (8.3%). 28.2% of patients were asymptomatic; 35% presented with clinical signs. General signs were significantly associated with invasive infection and the absence of functional signs with AB. Among the patients presenting with an invasive UTI, 27.9% also presented with another infection. This other infection was not statistically associated with AB, cystitis, or invasive UTI.

CONCLUSION

Too many urine microscopy and culture procedures are not justified, and too many patients are diagnosed with several infections. Usual functional and clinical signs are important for the diagnosis but are infrequent. It seems necessary to review the range of clinical presentations and diagnostic criteria for UTI in geriatric patients.

American Geriatrics Society identifies five things that healthcare providers and patients should question

Given the American Geriatrics Society's (AGS) commitment to improving health care for older adults by, among other means, educating older people and their caregivers about their health and healthcare choices, the AGS was delighted when, in late 2011, the American Board of Internal Medicine Foundation invited the Society to join its "Choosing Wisely(®) " campaign. Choosing Wisely is designed to engage patients, healthcare professionals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Ideally, these discussions should examine whether the tests and procedures are evidence-based, whether any risks they pose might overshadow their potential benefits, whether they are redundant, and whether they are truly necessary. In addition to improving the quality of care, the initiative aims to rein in unneeded healthcare spending. According to a 2008 Congressional Budget Office report, as much as 30% of healthcare spending in the United States may be unnecessary.

Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes

BACKGROUND

Urinary tract infections (UTIs) are the most commonly treated infection among nursing home residents. Even in the absence of specific (e.g., dysuria) or non-specific (e.g., fever) signs or symptoms, residents frequently receive an antibiotic for a suspected infection. This research investigates factors associated with the use of antibiotics to treat asymptomatic bacteriuria (ASB) among nursing home residents.

METHODS

This was a cross-sectional study involving multi-level multivariate analyses of antibiotic prescription data for residents in four nursing homes in central Texas. Participants included all nursing home residents in these homes who, over a six-month period, received an antibiotic for a suspected UTI. We investigated what factors affected the likelihood that a resident receiving an antibiotic for a suspected UTI was asymptomatic.

RESULTS

The most powerful predictor of antibiotic treatment for ASB was the presence of an indwelling urinary catheter. Over 80 percent of antibiotic prescriptions written for catheterized individuals were written for individuals with ASB. For those without a catheter, record reviews identified 204 antibiotic prescriptions among 151 residents treated for a suspected UTI. Almost 50% of these prescriptions were for residents with no documented UTI symptoms. Almost three-quarters of these antibiotics were ordered after laboratory results were available to clinicians. Multivariate analyses indicated that resident characteristics did not affect the likelihood that an antibiotic was prescribed for ASB. The only statistically significant factor was the identity of the nursing home in which a resident resided.

CONCLUSIONS

We confirm the findings of earlier research indicating frequent use of antibiotics for ASB in nursing homes, especially for residents with urinary catheters. In this sample of nursing home residents, half of the antibiotic prescriptions for a suspected UTI in residents without catheters occurred with no documented signs or symptoms of a UTI. Urine studies were performed in almost all suspected UTI cases in which an antibiotic was prescribed. Efforts to improve antibiotic stewardship in nursing homes must address clinical decision-making solely on the basis of diagnostic testing in the absence of signs or symptoms of a UTI.

Consequences of asymptomatic bacteriuria in the elderly

Asymptotic bacteriuria increases with advancing age for the ambulatory population. Men and women who are resident in long-term care facilities have an exceptionally high prevalence of bacteriuria. Despite this high prevalence and a high incidence of bacteriuria, urinary infection contributes little to morbidity and mortality in the elderly. While urinary infection is the most common source of bacteremic infection in the elderly, episodes of symptomatic urinary are infrequent relative to respiratory, gut, and skin infections. Substantial long-term complications of asymptomatic bacteriuria in the elderly have not been identified and there is no convincing evidence that asymptotic bacteriuria is associated with impaired survival. Further studies of the impact of asymptomatic bacteriuria in elderly populations to better define the association with symptomatic infection are needed.

The management of urinary infections: what have we learned in the past decade?

User-friendly, cost-effective practices to manage urinary infection should become routine. The vast majority of inflections are relatively easy to treat and many of these can be prevented with appropriate interventions. Additional research is urgently needed to compare various clinical strategies and determine which is most acceptable to patients at a reasonable cost with satisfactory health outcomes.

Pyuria in institutionalized elderly subjects

Two hundred and forty-three urine specimens from 76 elderly institutionalized residents were obtained for urine culture, quantitative leukocyte count and urinalysis. Significant bacteriuria was present in 153 specimens (63%), including 33 (22%) with more than one organism. Pyuria (greater than or equal to 10 leukocytes/mm(3)) was present in 214 specimens (88%), including 116 (97%) with single organism bacteriuria, 27 (82%) with multiple organism bacteriuria, and 71 (80%) without significant bacteriuria. The leukocyte esterase test had a positive predictive value of 99% for pyuria but a negative predictive value of only 30%. The quantitative level of pyuria was associated with the level of proteinuria and inversely with pH. A relatively constant level of pyuria tended to persist over months to years in a given individual if bacteriuria persisted. Pyuria is significantly associated with bacteriuria in the institutionalized elderly, but is also common in the nonbacteriuric. The clinical significance of pyuria requires further assessment.

Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients

Reducing health care-associated urinary tract infection (UTI) is a National Patient Safety Goal. The purpose of this investigation was to establish a colony count threshold to predict clinically significant UTIs that develop in hospitalized patients. A total of 185 cases were reviewed sequentially by 2 physicians. The information extracted included subjective complaints, presence of an indwelling urinary catheter, clinical signs and symptoms, WBC count, urinalysis, and urine culture results. The first reviewer recorded whether the patient was diagnosed and treated for a UTI by the clinician. The second reviewer determined if the patient met National Healthcare Safety Network guidelines for nosocomial UTI. Compared with patients with colony counts less than 100,000 colony-forming units per milliliter (CFU/mL), patients with colony counts 100,000 CFU/mL or more were 73.86 times more likely to have a clinically significant UTI (odds ratio, 73.86; 95% confidence interval, 24.23 ∼ 225.15; P < .0001; c-statistic, 0.859). Reporting positive results only for patients with 100,000 CFU/mL or more would have reduced the number of positive cultures by 38%. These data suggest that reporting colony counts less than 100,000 CFU/mL encourages treatment of non-clinically significant UTIs in hospitalized patients, causing inappropriate antibiotic use.

Antibiotic policy

There is a clear association between antibiotic use and resistance both on individual and population levels. In the European Union, countries with large antibiotic consumption have higher resistance rates. Antibiotic resistance leads to failed treatments, prolonged hospitalisations, increased costs and deaths. With few new antibiotics in the Research & Development pipeline, prudent antibiotic use is the only option to delay the development of resistance. Antibiotic policy consists of prescribing strategies to optimise the indication, selection, dosing, route of administration, duration and timing of antibiotic therapy to maximise clinical cure or prevention of infection whilst limiting the unintended consequences of antibiotic use, including toxicity and selection of resistant microorganisms. A secondary goal is to reduce healthcare costs without adversely affecting the quality of care. The purpose of this paper is to provide the evidence base of prudent antibiotic policy. Special emphasis is placed on urinary tract infections. The value and support of antibiotic committees, guidelines, ID consultants and/or antimicrobial stewardship teams to prolong the efficacy of available antibiotics will be discussed.

Urinary tract infections in the elderly population

BACKGROUND

Urinary tract infections (UTIs) are a common problem in the elderly population. The spectrum of disease varies from a relatively benign cystitis to potentially life-threatening pyelonephritis.

OBJECTIVE

This review covers the management of asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter-associated bacteriuria/symptomatic UTIs, and antibiotic prophylaxis for recurrent infections in elderly men and women.

METHODS

Literature was obtained from English-language searches of MEDLINE (1966-April 2011), Cochrane Library, BIOSIS (1993-April 2011), and EMBASE (1970-April 2011). Further publications were identified from citations of resulting articles. Search terms included, but were not limited to, urinary tract infections, asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, antibiotic resistance, catheter associated urinary tract infections, recurrent urinary tract infections, and elderly.

RESULTS

The prevalence of UTIs in elderly women depends on the location in which these women are living. For elderly women living in the community, UTIs compromise the second most common infection, whereas in residents of long-term care facilities (LTCFs) and hospitalized subjects, it is the number one cause of infection. The spectrum of patient presentation varies from classic signs and symptoms in the independent elderly population to atypical presentations, including increased lethargy, delirium, blunted fever response, and anorexia. Although there are few guidelines specifically directed toward the management of UTIs in the elderly population, therapy generally mirrors the recommendations for the younger adult age groups. When choosing a treatment regimen, special attention must be given to the severity of illness, living conditions, existing comorbidities, presence of external devices, local antibiotic resistance patterns, and the ability of the patient to comply with therapy.

CONCLUSIONS

Improved guidelines for the diagnosis and management of UTIs in the elderly population are needed. Better techniques to evaluate and prevent catheter-associated bacteriuria and UTIs await improved diagnostic modalities and catheter technologies. Alternative methods for prophylaxis of patients who suffer from recurrent infections must be found while minimizing the risk of developing or propagating antibiotic resistance.

Positive urine cultures: A major cause of inappropriate antimicrobial use in hospitals?

INTRODUCTION

Urine specimens are among the most common samples submitted for culture to microbiology laboratories. The objectives of the present study were to describe the indications for obtaining urine cultures in a cohort of hospitalized patients, and to determine the appropriateness of antimicrobial therapy in response to urine culture results.

METHODS

The study was performed at a teaching hospital with an adjoining long-term care facility from June 1 to July 31, 2006. The medical records of nonpregnant adult patients with and without bacteriuria were reviewed. A symptomatic urinary tract infection was defined as the presence of bacteriuria in a patient with fever or urinary symptoms; asymptomatic bacteriuria was defined as bacteriuria without urinary symptoms and no infection evident at another site.

RESULTS

Medical records of 335 eligible patients (64% male; mean age 68 years) were reviewed, including all 137 with bacteriuria, and 198 with negative urine cultures. In total, 51% of the urine specimens were obtained from an indwelling urinary catheter, and 28% were voided urine samples. Confusion (57%) and fever (36%) were the most common indications noted for obtaining the urine cultures. Only 34 patients (25% of those with positive urine cultures) met the criteria for a symptomatic urinary tract infection; 67 (49%) had asymptomatic bacteriuria and 36 (26%) had infection at a nonurinary site. Of those with asymptomatic bacteriuria, 64% received antimicrobial therapy for a total of 347 days. Confused patients with asymptomatic bacteriuria were more likely to be treated than were bacteriuric patients without altered mental status (OR 1.8, 95% CI 1.2 to 4.1; P=0.03).

CONCLUSIONS

Urine cultures are frequently obtained from hospitalizedpatients,evenintheabsenceofurinarysymptoms.Asymptomatic bacteriuria is often treated in these patients, and accounts for a substantial burden of inappropriate antimicrobial use in hospitals. Effective strategies to improve urine culture ordering and antimicrobial utilization in hospitals need to be implemented.

Complicated urinary tract infection in adults

BACKGROUND

Complicated urinary tract infection occurs in individuals with functional or structural abnormalities of the genitourinary tract.

OBJECTIVE

To review current knowledge relevant to complicated urinary tract infection, and to provide evidence-based recommendations for management.

METHODS

The literature was reviewed through a PubMed search, and additional articles were identified by journal reference review. A draft guideline was prepared and critically reviewed by members of the Association of Medical Microbiology and Infectious Disease Canada Guidelines Committee, with modifications incorporated following the review.

RESULTS

Many urological abnormalities may be associated with complicated urinary infection. There is a wide spectrum of potential infecting organisms, and isolated bacteria tend to be more resistant to antimicrobial therapy. Morbidity and infection outcomes in subjects with complicated urinary infection are principally determined by the underlying abnormality rather than the infection. Principles of management include uniform collection of a urine specimen for culture before antimicrobial therapy, characterization of the underlying genitourinary abnormality, and nontreatment of asymptomatic bacteriuria except before an invasive genitourinary procedure. The antimicrobial regimen is determined by clinical presentation, patient tolerance, renal function and known or anticipated infecting organisms. If the underlying abnormality contributing to the urinary infection cannot be corrected, then early post-treatment recurrence of infection is anticipated.

CONCLUSIONS

The management of complicated urinary infection is individualized depending on patient variables and the infecting organism. Further clinical investigations are necessary to assist in determining optimal antimicrobial regimens.

Unnecessary use of fluoroquinolone antibiotics in hospitalized patients

BACKGROUND

Fluoroquinolones are among the most commonly prescribed antimicrobials and are an important risk factor for colonization and infection with fluoroquinolone-resistant gram-negative bacilli and for Clostridium difficile infection (CDI). In this study, our aim was to determine current patterns of inappropriate fluoroquinolone prescribing among hospitalized patients, and to test the hypothesis that longer than necessary treatment durations account for a significant proportion of unnecessary fluoroquinolone use.

METHODS

We conducted a 6-week prospective, observational study to determine the frequency of, reasons for, and adverse effects associated with unnecessary fluoroquinolone use in a tertiary-care academic medical center. For randomly-selected adult inpatients receiving fluoroquinolones, therapy was determined to be necessary or unnecessary based on published guidelines or standard principles of infectious diseases. Adverse effects were determined based on chart review 6 weeks after completion of therapy.

RESULTS

Of 1,773 days of fluoroquinolone therapy, 690 (39%) were deemed unnecessary. The most common reasons for unnecessary therapy included administration of antimicrobials for non-infectious or non-bacterial syndromes (292 days-of-therapy) and administration of antimicrobials for longer than necessary durations (234 days-of-therapy). The most common syndrome associated with unnecessary therapy was urinary tract infection or asymptomatic bacteriuria (30% of all unnecessary days-of-therapy). Twenty-seven percent (60/227) of regimens were associated with adverse effects possibly attributable to therapy, including gastrointestinal adverse effects (14% of regimens), colonization by resistant pathogens (8% of regimens), and CDI (4% of regimens).

CONCLUSIONS

In our institution, 39% of all days of fluoroquinolone therapy were unnecessary. Interventions that focus on improving adherence with current guidelines for duration of antimicrobial therapy and for management of urinary syndromes could significantly reduce overuse of fluoroquinolones.

Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: a cross-sectional study of 32 nursing homes

BACKGROUND

The high prevalence of bacteriuria in elderly individuals makes it difficult to know if a new symptom is related to bacteria in the urine. There are different views concerning this relationship and bacteriuria often leads to antibiotic treatments. The aim of this study was to investigate the relationship between bacteria in the urine and new or increased restlessness, fatigue, confusion, aggressiveness, not being herself/himself, dysuria, urgency and fever in individuals at nursing homes for elderly when statistically considering the high prevalence of asymptomatic bacteriuria in this population.

METHODS

In this cross-sectional study symptoms were registered and voided urine specimens were collected for urinary cultures from 651 elderly individuals. Logistic regressions were performed to evaluate the statistical correlation between bacteriuria and presence of a symptom at group level. To estimate the clinical relevance of statistical correlations at group level positive and negative etiological predictive values (EPV) were calculated.

RESULTS

Logistic regression indicated some correlations at group level. Aside from Escherichia coli in the urine and not being herself/himself existing at least one month, but less than three months, EPV indicated no clinically useful correlation between any symptoms in this study and findings of bacteriuria.

CONCLUSIONS

Urinary cultures provide little or no useful information when evaluating diffuse symptoms among elderly residents of nursing homes. Either common urinary tract pathogens are irrelevant, or urine culture is an inappropriate test.

Single-dose antibiotic prophylaxis for urinary catheter removal does not reduce the risk of urinary tract infection in surgical patients: a randomized double-blind placebo-controlled trial

We conducted a double-blind, placebo-controlled randomized trial to assess the effect of single-dose prophylaxis using co-trimoxazole (960 mg) (n = 46) or ciprofloxacin (500 mg) (n = 43) vs. placebo (n = 51) before urinary catheter removal on significant bacteriuria (SBU) (primary outcome) and urinary tract infection (UTI) in surgical patients with scheduled bladder drainage for 3-14 days. SBU was determined directly after catheter removal, and UTI 12-14 days after catheter removal. After 12-14 days, incidences of SBU were 19%, 19% and 33% for patients receiving ciprofloxacin, co-trimoxazole and placebo, respectively (p ns), and incidences of UTI were 3%, 0% and 3% for patients receiving ciprofloxacin, co-trimoxazole and placebo, respectively (p ns).