Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults

European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines

BACKGROUND AND OBJECTIVE

Urological infections significantly impact the wellbeing and quality of life of individuals owing to their widespread occurrence and diverse clinical manifestations. The objective of the guidelines panel was to provide evidence-based guidance on the diagnosis, treatment, and prevention of urinary tract infections (UTIs) and male accessory-gland infections, while addressing crucial public health aspects related to infection control and antimicrobial stewardship.

METHODS

For the 2024 guidelines on urological infections, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.

KEY FINDINGS AND LIMITATIONS

Key recommendations emphasise the importance of a thorough medical history and physical examination for patients with urological infections. The guidelines stress the role of antimicrobial stewardship to combat the rising threat of antimicrobial resistance, providing recommendations for antibiotic selection, dosing, and duration on the basis of the latest evidence.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This overview of the 2024 EAU guidelines offers valuable insights into managing urological infections and are designed for effective integration into clinical practice.

PATIENT SUMMARY

The European Association of Urology has issued an updated guideline on urological infections. The guidelines provide recommendations for diagnosis, treatment, and prevention, with a particular focus on minimising antibiotic use because of the increasing global threat of antimicrobial resistance.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Urinary Tract Infection in Male Patients: Challenges in Management

Urinary tract infections in male patients share many of the management principles as used in the management of female patients, including the need to accurately define the clinical syndrome, choose empirical therapy based on the severity of illness and the potential for antimicrobial resistance, and consider the need for source control in severely ill patients. The microbiology of the causative organisms is more unpredictable compared to female patients, and data to inform treatment decisions from clinical trials specific to male patients are relatively scarce.

Systematic Review and Meta-Analysis Provide no Guidance on Management of Asymptomatic Bacteriuria within the First Year after Kidney Transplantation

(1) Background: Urinary tract infections (UTIs) are among the most frequent complications in kidney transplant (KT) recipients. Asymptomatic bacteriuria (ASB) may be a risk factor for UTIs and graft rejection. We aimed to evaluate available evidence regarding the benefit of screening and treatment of ASB within the first year after KT. (2) Evidence acquisition: A systematic literature search was conducted in MEDLINE, the Cochrane Library CENTRAL and Embase. Inclusion criteria were manuscripts in English addressing the management of ASB after KT. The PICO questions concerned Patients (adults receiving a KT), Intervention (screening, diagnosis and treatment of ASB), Control (screening and no antibiotic treatment) and Outcome (UTIs, sepsis, kidney failure and death). (3) Evidence synthesis: The systematic review identified 151 studies, and 16 full-text articles were evaluated. Seven were excluded because they did not evaluate the effect of treatment of ASB. There was no evidence for a higher incidence of lower UTIs, acute pyelonephritis, graft loss, or mortality in patients not treated with antibiotics for ASB. Analysis of comparative non-randomized and observational studies did not provide supplementary evidence to guide clinical recommendations. We believe this lack of evidence is due to confounding risk factors that are not being considered in the stratification of study patients.

Diabetes, SGLT-2 Inhibitors, and Urinary Tract Infection: a Review

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.

Appropriate prescription of cytobacteriological urine examinations in older adults

Cytobacteriological urine examinations (CBEU) are frequently ordered for the older adults, sometimes without straightforward indication and with the risk of prescribing empirical antibiotics. The aim of this study was to evaluate the relevance of the CBEU prescription and empiric antibiotic therapy in our geriatric hospital. Among 129 patients (mean age 84 years, sex ratio 0.69), 229 CBEU were collected with 20.9% of inappropriate indication. Cultures were sterile in 43% (n = 99) of cases and positive in 57% (n = 130) cases. Gram-negative bacilli dominated the isolated bacteria (76.9%) followed by gram-positive cocci (17.6%). In 113 patients, probabilistic antibiotic therapy was prescribed of which 68 treatments were initiated before the CBEU. Ceftriaxone and amoxicillin plus clavulanic acid were the main therapeutic option used representing 70.8% of cases. Antibiotic therapy was re-evaluated after 3 days in 74.3% of patients. Efforts to reduce the number of useless ECBUs by training doctors to follow official guidelines are a priority.

Exploring variations in recommended first-choice therapy for complicated urinary tract infections in males: Insights from outpatient settings across age, race, and ethnicity

INTRODUCTION

There are known disparities in the treatment of infectious diseases. However, disparities in treatment of complicated urinary tract infections (UTIs) are largely uninvestigated.

OBJECTIVES

We characterized UTI treatment among males in Veterans Affairs (VA) outpatient settings by age, race, and ethnicity and identified demographic characteristics predictive of recommended first-choice antibiotic therapy.

METHODS

We conducted a national, retrospective cohort study of male VA patients diagnosed with a UTI and dispensed an outpatient antibiotic from January 2010 through December 2020. Recommended first-choice therapy for complicated UTI was defined as use of a recommended first-line antibiotic drug choice regardless of area of involvement (ciprofloxacin, levofloxacin, or sulfamethoxazole/trimethoprim) and a recommended duration of 7 to 10 days of therapy. Multivariable models were used to identify demographic predictors of recommended first-choice therapy (adjusted odds ratio [aOR] > 1).

RESULTS

We identified a total of 157,898 males diagnosed and treated for a UTI in the outpatient setting. The average antibiotic duration was 9.4 days (±standard deviation [SD] 4.6), and 47.6% of patients were treated with ciprofloxacin, 25.1% with sulfamethoxazole/trimethoprim, 7.6% with nitrofurantoin, and 6.6% with levofloxacin. Only half of the male patients (50.6%, n = 79,928) were treated with recommended first-choice therapy (first-line drug choice and appropriate duration); 77.6% (n = 122,590) were treated with a recommended antibiotic choice and 65.9% (n = 104,070) with a recommended duration. Age 18-49 years (aOR 1.07, 95% confidence interval [CI] 1.03-1.11) versus age ≥65 years was the only demographic factor predictive of recommended first-choice therapy.

CONCLUSIONS

Nearly half of the patients included in this study did not receive recommended first-choice therapies; however, racial and ethnic disparities were not identified. Underutilization of recommended first-choice antibiotic therapy in complicated UTIs continues to be an area of focus for antimicrobial stewardship programs.

Asymptomatic Urinary Tract Infection Treatment in Adults Admitted to Inpatient Psychiatry: A Retrospective COHORT study

Introduction: Treatment of asymptomatic bacteriuria remains prevalent despite recommendations against treatment in most patient populations. Rates of asymptomatic treatment of urinary tract infection (UTI) has not been thoroughly evaluated within the inpatient psychiatry population. The objective of this study is to describe the rate of antibiotic use for the treatment of asymptomatic UTI in psychiatric inpatients and investigate factors contributing to overuse. Methods: This IRB approved retrospective cohort study evaluated adults admitted to inpatient psychiatry from May 1, 2021 to May 1, 2022 that received an antibiotic for UTI. The primary outcome assessed the rate of asymptomatic treatment, defined as treatment without urinary symptoms. Secondary outcomes evaluated most frequently prescribed antibiotics, determined the impact of altered mental status (AMS) on treatment, and correlated the incidence of UTI treatment with primary psychiatric disorder. Results: One hundred nine patients were identified and 61 were included for analysis. The rate of asymptomatic treatment for UTI was 84%. The most prescribed antibiotic was nitrofurantoin (48%). All patients with AMS (23%) were asymptomatic. Altered mental status did not significantly impact the rate of empiric treatment (P = .098). Primary psychiatric disorder did not significantly impact rate of empiric treatment for UTI (P = .696). Common disorders in this population were depression, schizophrenia, and bipolar disorder with rates of asymptomatic treatment of 79% (n = 19), 87% (n = 13), and 78% (n = 7), respectively. Discussion: Frequent asymptomatic treatment of UTI was identified in this inpatient psychiatry population. These results emphasize the need for antibiotic monitoring and stewardship in this setting.

Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria

Importance

Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common.

Objectives

To determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB.

Design, Setting, and Participants

This cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023.

Main Outcomes and Measures

The primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient's risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia.

Results

Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia.

Conclusions and Relevance

In patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.

Clinico-microbiological Profile and Outcomes of Asymptomatic Bacteriuria in Pregnancy

Background

Asymptomatic bacteriuria (ASB) during pregnancy can lead to symptomatic urinary tract infection (UTI), with increased fetal and maternal morbidity and mortality. We evaluated the incidence, clinical and microbiological profile, and outcome of ASB in pregnant women attending our antenatal clinic.

Materials and Methods

This prospective study was conducted on 3769 pregnant women in a routine antenatal clinic at a tertiary care center. Participants were divided into two groups, ASB and non-bacteriuria. Data were collected in a standard proforma and analyzed using the software Statistical Package for the Social Sciences (SPSS) v. 20.

Results

The incidence of ASB was 3.29% (124/3769). Majority of the women were in the age group of 21-30 years (78.76%, n = 89). Escherichia coli (61.06%) was the most common organism isolated. Maternal anemia (30.08% and 2.93% in the ASB and non-bacteriuria groups, respectively), low birth weight (LBW; 42.5% and 27.98% in the ASB and non-bacteriuria groups, respectively), intrauterine death (4.4% and 1.4% in the ASB and non-bacteriuria groups, respectively), and preterm delivery (37.2% and 22.31% in the ASB and non-bacteriuria groups, respectively) were were associated with ASB (P = 0.001).

Conclusion

ASB was associated with maternal anemia, preterm delivery, intrauterine death, and LBW. Early detection and treatment of ASB may result in favorable maternal outcome.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lower Urinary Tract Inflammation and Infection: Key Microbiological and Immunological Aspects

The urinary system, primarily responsible for the filtration of blood and waste, is affected by several infectious and inflammatory conditions. Focusing on the lower tract, this review outlines the physiological and immune landscape of the urethra and bladder, addressing key immunological and microbiological aspects of important infectious/inflammatory conditions. The conditions addressed include urethritis, interstitial cystitis/bladder pain syndrome, urinary tract infections, and urosepsis. Key aspects of each condition are addressed, including epidemiology, pathophysiology, and clinical considerations. Finally, therapeutic options are outlined, highlighting gaps in the knowledge and novel therapeutic approaches.

Antibiotic prophylaxis for onabotulinum toxin A injections: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

To our knowledge, there are no evidence-based recommendations regarding the optimal prophylactic antibiotic regimen for intradetrusor onabotulinum toxin type A (BTX) injections. This systematic review and meta-analysis was aimed at investigating the optimal prophylactic antibiotic regimen to decrease urinary tract infection (UTI) in patients undergoing BTX for overactive bladder syndrome (OAB).

METHODS

A systematic search of MEDLINE, Embase, CINAHL, and Web of Science was conducted from inception through 30 June 2022. All randomized controlled trials and prospective trials with > 20 subjects undergoing BTX injections for OAB in adults that described prophylactic antibiotic regimens were included. Meta-analysis performed to assess UTI rates in patients with idiopathic OAB using the inverse variance method for pooling.

RESULTS

A total of 27 studies (9 randomized controlled trials, 18 prospective) were included, representing 2,100 patients (69% women) with 19 studies of idiopathic OAB patients only, 6 of neurogenic only, and 2 including both. No studies directly compared antibiotic regimens for the prevention of UTI. Included studies favor the use of antibiotics in patients with idiopathic OAB and favor continuing antibiotics for 2-3 days after the procedure for prevention of UTI. Given the heterogeneity of the data, direct comparisons of antibiotic type or duration could not be performed. Meta-analysis found a 10% UTI rate at 4 weeks and 15% at 12 weeks post-injection.

CONCLUSIONS

Although there are insufficient data to support the use of a specific antibiotic regimen, available studies favor the use of prophylactic antibiotics for 2-3 days in idiopathic OAB patients undergoing BTX injection. Future trials are needed to determine the optimal regimens to prevent UTI in patients undergoing BTX for OAB.

Development and validation of artificial intelligence models to predict urinary tract infections and secondary bloodstream infections in adult patients

BACKGROUND

Traditional culture methods are time-consuming, making it difficult to utilize the results in the early stage of urinary tract infection (UTI) management, and automated urinalyses alone show insufficient performance for diagnosing UTIs. Several models have been proposed to predict urine culture positivity based on urinalysis. However, most of them have not been externally validated or consisted solely of urinalysis data obtained using one specific commercial analyzer.

METHODS

A total of 259,187 patients were enrolled to develop artificial intelligence (AI) models. AI models were developed and validated for the diagnosis of UTI and urinary tract related-bloodstream infection (UT-BSI). The predictive performance of conventional urinalysis and AI algorithms were assessed by the areas under the receiver operating characteristic curve (AUROC). We also visualized feature importance rankings as Shapley additive explanation bar plots.

RESULTS

In the two cohorts, the positive rates of urine culture tests were 25.2% and 30.4%, and the proportions of cases classified as UT-BSI were 1.8% and 1.6%. As a result of predicting UTI from the automated urinalysis, the AUROC were 0.745 (0.743-0.746) and 0.740 (0.737-0.743), and most AI algorithms presented excellent discriminant performance (AUROC > 0.9). In the external validation dataset, the XGBoost model achieved the best values in predicting both UTI (AUROC 0.967 [0.966-0.968]) and UT-BSI (AUROC 0.955 [0.951-0.959]). A reduced model using ten parameters was also derived.

CONCLUSIONS

We found that AI models can improve the early prediction of urine culture positivity and UT-BSI by combining automated urinalysis with other clinical information. Clinical utilization of the model can reduce the risk of delayed antimicrobial therapy in patients with nonspecific symptoms of UTI and classify patients with UT-BSI who require further treatment and close monitoring.

Glycoengineering directs de novo biomanufacturing of UPEC O21 O-antigen polysaccharide based glycoprotein

Glycoproteins, in which polysaccharides are usually attached to proteins, are an important class of biomolecules that are widely used as therapeutic agents in clinical treatments for decades. Uropathogenic Escherichia coli (UPEC) O21 has been identified as a serogroup that induces urinary tract infections, with a global increasing number among women and young children. Therefore, there is an urgent need to establish protective vaccines against UPEC infection. Herein, we engineered non-pathogenic E. coli MG1655 to achieve robust, cost-effective de novo biosynthesis of O21 O-antigen polysaccharide-based glycoprotein against UPEC O21. Specifically, this glycoengineered E. coli MG1655 was manipulated for high-efficient glucose-glycerol co-utilization and for the gene cluster installation and O-glycosylation machinery assembly. The key pathways of UDP-sugar precursors were also strengthened to enforce more carbon flux towards the glycosyl donors, which enhanced the glycoprotein titer by 5.6-fold. Further optimization of culture conditions yielded glycoproteins of up to 35.34 mg/L. Glycopeptide MS confirmed the preciset biosynthesis of glycoprotein. This glycoprotein elicited antigen-specific IgG immune responses and significantly reduced kidney and bladder colonization. This bacterial cell-based glyco-platform and optimized strategies can provide a guideline for the biosynthesis of other value-added glycoproteins.

Older adults' and caregivers' perceptions about urinary tract infection and asymptomatic bacteriuria guidelines: a qualitative exploration

Objective

To explore older adults' and caregivers' knowledge and perceptions of guidelines for appropriate antibiotics use for bacteria in the urine.

Design

Semi-structured qualitative interviews.

Setting

Infectious disease clinics, community senior living facilities, memory care clinics, and general public.

Participants

Patients 65 years or older diagnosed with a urinary tract infection (UTI) in the past two years, or caregivers of such patients.

Methods

We conducted interviews between March and July 2023. We developed an interview guide based on the COM-B (capability, opportunity, motivation-behavior) behavior change framework. We thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques.

Results

Thirty participants (21 patients, 9 caregivers) enrolled. Most participants understood UTI symptoms such as pain during urination and frequent urination. However, communication with multiple clinicians, misinformation, and unclear symptoms that overlapped with other health issues clouded their understanding of asymptomatic bacteriuria (ASB) and UTIs. Some participants worried that clinicians would be dismissive of symptoms if they suggested a diagnosis of ASB without prescribing antibiotics. Many participants felt that the benefits of taking antibiotics for ASB outweighed harms, though some mentioned fears of personal antibiotic resistance if taking unnecessary antibiotics. No participants mentioned the public health impact of potential antibiotic resistance. Most participants trusted information from clinicians over brochures or websites but wanted to review information after clinical conversations.

Conclusion

Clinician-focused interventions to reduce antibiotic use for ASB should also address patient concerns during clinical visits, and provide standardized high-quality educational materials at the end of the visit.

Evaluating the utility of routine urine culture and antibiotic treatment in children with neurogenic bladder undergoing intradetrusor OnabotulinumtoxinA injection

INTRODUCTION

OnabotulinumtoxinA is used as treatment for refractory idiopathic and neurogenic detrusor overactivity in children. Many patients perform intermittent self-catheterization and therefore have higher rates of asymptomatic bacteriuria, which may increase their risk of symptomatic urinary tract infection (UTI) following treatment. Multiple injections are often needed due to the short-term efficacy of onabotulinumtoxinA treatment, which may also increase the risk of UTI.

OBJECTIVE

We aim to evaluate whether a sterile urinary tract is necessary to decrease the risk of postoperative UTI in pediatric patients treated with onabotulinumtoxinA.

STUDY DESIGN

A retrospective review of patients undergoing intradetrusor onabotulinumtoxinA injection from 2014 to 2021 was performed. Demographic data, clinical characteristics, antibiotic treatment and culture results were collected. A positive urine culture was defined as ≥ 103 CFU/ml of uropathogenic bacteria. Our primary outcome was symptomatic UTI within 14 days of the procedure.

RESULTS

103 patients underwent 158 treatments with onabotulinumtoxinA. The incidence of postoperative UTI was 3.2%. The incidence of symptomatic postoperative UTI in patients with asymptomatic bacteriuria compared to those with sterile urine was not significantly different (3.8% vs 0%, p = 0.57). Obtaining a preoperative urinalysis or urine culture did not affect the incidence of postoperative UTI (p = 0.54). The number needed to treat with antibiotics to prevent one postoperative UTI was 27. The incidence of postoperative UTI was highest in patients with low-risk bladders (p = 0.043). Prior history of multi-drug resistant UTI was a risk factor for postoperative UTI (p = 0.048).

DISCUSSION

For children undergoing onabotulinumtoxinA injection, there are no evidence-based recommendations regarding antibiotic prophylaxis and the need to screen for and treat asymptomatic bacteruria prior to treatment. Our study addresses this important clinical question, and shows no difference in the rate of postoperative UTI between patients with asymptomatic bacteriuria and those with sterile urine. Patients with a history of multi-drug resistant UTI are at increased risk of symptomatic postoperative UTI and may benefit from preoperative urine testing and treatment. Limitations of our retrospective study include its small sample size in the face of such a low incidence of our primary outcome.

CONCLUSIONS

The risk of UTI following onabotulinumtoxinA injection in children is low. The presence of sterile urine at the time of surgery does not significantly decrease the risk of postoperative UTI. Routine treatment of asymptomatic bacteriuria prior to surgery results in a large number of patients receiving unnecessary antibiotics. As a result, we recommend against preoperative urine testing for most asymptomatic patients.

Development and validation of a parsimonious prediction model for positive urine cultures in outpatient visits

Urine culture is often considered the gold standard for detecting the presence of bacteria in the urine. Since culture is expensive and often requires 24-48 hours, clinicians often rely on urine dipstick test, which is considerably cheaper than culture and provides instant results. Despite its ease of use, urine dipstick test may lack sensitivity and specificity. In this paper, we use a real-world dataset consisting of 17,572 outpatient encounters who underwent urine cultures, collected between 2015 and 2021 at a large multi-specialty hospital in Abu Dhabi, United Arab Emirates. We develop and evaluate a simple parsimonious prediction model for positive urine cultures based on a minimal input set of ten features selected from the patient's presenting vital signs, history, and dipstick results. In a test set of 5,339 encounters, the parsimonious model achieves an area under the receiver operating characteristic curve (AUROC) of 0.828 (95% CI: 0.810-0.844) for predicting a bacterial count ≥ 105 CFU/ml, outperforming a model that uses dipstick features only that achieves an AUROC of 0.786 (95% CI: 0.769-0.806). Our proposed model can be easily deployed at point-of-care, highlighting its value in improving the efficiency of clinical workflows, especially in low-resource settings.

Incidence and risk factors of asymptomatic bacteriuria in patients with type 2 diabetes mellitus: a meta-analysis

BACKGROUND

The prevalence of type 2 diabetes mellitus (T2DM) is increasing each year and has become one of the most prominent health concerns worldwide. Patients with T2DM are prone to infectious diseases, and urinary tract infections are also widespread. Despite a comprehensive understanding of urinary tract infection (UTI), there is a lack of research regarding primary prevention strategies for asymptomatic bacteriuria (ASB).

OBJECTIVE

To clarify the incidence and risk factors of asymptomatic urinary tract infection in patients with T2DM by meta-analysis to provide evidence for preventing UTI. Help patients, their families, and caregivers to identify the risk factors of patients in time and intervene to reduce the incidence of ASB in patients with T2DM. Fill in the gaps in existing research.

STUDY DESIGN

Meta-analyses were conducted in line with PRISMA guidelines.

METHODS

Eleven databases were systematically searched for articles about ASB in T2DM, and the retrieval time was selected from the establishment of the database to February 5, 2023. Literature screening, quality evaluation, and meta-analysis were independently performed by two researchers according to the inclusion and exclusion criteria, and a meta-analysis was performed using Stata 17.0.

RESULTS

Fourteen articles were included, including cohort and case-control studies. A meta-analysis of 4044 patients with T2DM was included. The incidence of ASB in patients with T2DM was 23.7%(95% CI (0.183, 0.291); P < 0.001). After controlling for confounding variables, the following risk factors were associated with ASB in patients with T2DM: age (WMD = 3.18, 95% CI (1.91, 4.45), I2 = 75.5%, P < 0.001), female sex (OR = 1.07, 95% CI(1.02, 1.12), I2 = 79.3%, P = 0.002), duration of type 2 diabetes (WMD = 2.54, 95% CI (1.53, 5.43), I2 = 80.7%, P < 0.001), HbA1c (WMD = 0.63, 95% CI (0.43, 0.84), I2 = 62.6,%. P < 0.001), hypertension (OR = 1.59, 95% CI (1.24, 2.04), I2 = 0%, <0.001), hyperlipidemia (OR = 1.66, 95% CI (1.27, 2.18), I2 = 0%, P < 0.001), Neuropathy (OR = 1.81, 95% CI (1.38, 2.37), I2 = 0%, P < 0.001), proteinuria (OR = 3.00, 95% CI (1.82, 4.95), I2 = 62.7%, P < 0.001).

CONCLUSION

The overall prevalence of ASB in T2DM is 23.7%. Age, female sex, course of T2DM, HbA1C, hypertension, hyperlipidemia, neuropathy, and proteinuria were identified as related risk factors for ASB in T2DM. These findings can provide a robust theoretical basis for preventing and managing ASB in T2DM.

The Risk of Preterm Birth in Low Risk Pregnant Women with Urinary Tract Infections

OBJECTIVE

Urinary tract infections are among the most common infections during pregnancy. The association between symptomatic lower urinary tract infections during pregnancy and fetal and maternal complications such as preterm birth and low birthweight remains unclear. The aim of this research is to evaluate the association between urinary tract infections during pregnancy and maternal and neonatal outcomes, especially preterm birth.

STUDY DESIGN

This study is a secondary analysis of a multicenter prospective cohort study, which included patients between October 2011 and June 2013. The population consists of women with low risk singleton pregnancies. We divided the cohort into women with and without a symptomatic lower urinary tract infection after 20 weeks of gestation. Baseline characteristics and maternal and neonatal outcomes were compared between the two groups. Multivariable logistic regression analysis was used to correct for confounders. The main outcome was spontaneous preterm birth at <37 weeks.

RESULTS

We identified 4,918 pregnant women eligible for enrollment, of whom 9.4% had a symptomatic lower urinary tract infection during their pregnancy. Women with symptomatic lower urinary tract infections were at increased risk for both preterm birth in general (12 vs. 5.1%, adjusted OR 2.5; 95% CI 1.7-3.5) as well as a spontaneous preterm birth at <37 weeks (8.2 vs. 3.7%, adjusted OR 2.3; 95% CI 1.5-3.5). This association was also present for early preterm birth at <34 weeks. Women with symptomatic lower urinary tract infections during pregnancy are also at increased risk of endometritis (8.9 vs. 1.8%, adjusted OR 5.3; 95% CI 1.4-20) and mastitis (7.8 vs. 1.8%, adjusted OR 4.0; 95% CI 1.6-10) postpartum.

CONCLUSION

Low risk women with symptomatic lower urinary tract infections during pregnancy are at increased risk of spontaneous preterm birth. In addition, an increased risk for endometritis and mastitis postpartum was found in women with symptomatic lower urinary tract infection during pregnancy.

KEY POINTS

· UTIs increase the risk of preterm birth.. · UTIs increase the risk of endometritis postpartum.. · UTIs increase the risk of mastitis postpartum..

Urinary tract infections in pregnancy

BACKGROUND

Urinary tract infections (UTIs) are the most common infection among pregnant women and have been associated with maternal and foetal complications. Antimicrobial exposure during pregnancy is not without risk. International guidelines recommend a single screen-and-treat approach to asymptomatic bacteriuria (ASB); however, this approach has been questioned by recent studies.

OBJECTIVES

The aim of this narrative review was to assess the pathophysiology, current risk factors and management of UTI during pregnancy, its impact on pregnancy outcomes, and to develop recommendations on the best use of antimicrobials.

SOURCES

PubMed, Cochrane database, and ClinicalTrials.gov.

CONTENT

Owing to the physiological changes related to pregnancy, pregnant women are at higher risk of UTI. All types of UTIs combined have been estimated to affect approximately 2% to 15% of women. ASB affects 2% to 7% of pregnant women. Recent studies do not provide good-quality evidence for an association between ASB and acute pyelonephritis if ASB is untreated. There is low-to-moderate-quality evidence that treatment of ASB results in a reduction in the incidence of low birth weight and preterm birth, which justifies screening practices for ASB with only a single urine culture in the first trimester. If the clinician opts for treatment, a short course of β-lactams, nitrofurantoin, or fosfomycin should be favoured. Studies on cystitis during pregnancy are limited. Acute pyelonephritis has been shown to be associated with increased maternal complications and in some studies has also been associated with preterm delivery and low birth weight. Preferred antimicrobials for the management of pyelonephritis are amoxicillin combined with an aminoglycoside, third-generation cephalosporins, or carbapenems. Studies on recurrent UTIs during pregnancy are limited, making it difficult to draw conclusions regarding prophylactic measures.

IMPLICATIONS

Further research is required to understand the true incidence of ASB-related complications and the benefit and modalities of screening for ASB and to further explore prophylactic measures.

To screen or not to screen for asymptomatic bacteriuria in pregnancy: A comparative three-year retrospective review between two maternity centres

BACKGROUND

Current national guidance in Ireland states that asymptomatic bacteriuria (AB) should be screened for at 12-16 weeks' gestation and treated with a seven-day course of antimicrobials, due to the potential risk of preterm birth and low birth weight infants (LBWI), however, this is based on low quality evidence.

METHODS

Over a three-year period (2018-2020), a retrospective review was undertaken in two neighbouring maternity hospitals; one of which screens for AB (Rotunda hospital (RH)) and one which does not (National Maternity Hospital (NMH)). Patients were included on the basis of fulfilling the IDSA definition for pyelonephritis and requiring admission for intravenous antibiotics. Rates of antenatal pyelonephritis were compared between hospitals, and between screened and unscreened populations. Secondary outcomes including rates of preterm births and LBWI were compared across sites.

RESULTS

A total of 47,676 deliveries between the two centres (24,768 RH; 22,908 NMH) were assessed, of which 158 patients met inclusion criteria for antenatal pyelonephritis (n = 88 RH, n = 70 NMH). There was no statistically significant difference in the rate of antenatal pyelonephritis (p = 0.34) or preterm births (p = 0.21) across sites. RH had a significantly higher rate of LBWI at 6.45% versus 5.68% of all births in NMH (p=<0.004). Given the screening rate in RH was below 100%, this cohort was further subdivided into 'RH screened' and 'RH unscreened'. There was no statistically significant difference in the rate of antenatal pyelonephritis both between the 'NMH unscreened' group (n = 70) versus the 'RH screened' group (n = 62) (p = 0.53), or in the 'RH screened' group (n = 62) versus the 'RH unscreened' group (n = 26) (p = 0.53).

CONCLUSION

Omission of a screening programme for AB in NMH did not result in higher rates of antenatal pyelonephritis, preterm birth or LBWI. Our findings may inform decision-making on screening protocols and whether selective screening (i.e. screening in high-risk patients only) could be more cost-effective without compromising best quality of care.

Retrospective Cohort Study of Patient-Reported Urinary Tract Infection Signs and Symptoms Among Individuals With Neurogenic Bladder

OBJECTIVE

The aim of the study is to characterize patient-reported signs and symptoms of urinary tract infections in patients with neurogenic bladder to inform development of an intervention to improve the accuracy of urinary tract infection diagnosis.

DESIGN

This is a retrospective cohort study of adults with neurogenic bladder due to spinal cord injury/disorder, multiple sclerosis, and/or Parkinson disease and urinary tract infection encounters at four medical centers between 2017 and 2018. Data were collected through medical record review and analyzed using descriptive statistics and unadjusted logistic regression.

RESULTS

Of 199 patients with neurogenic bladder and urinary tract infections, 37% were diagnosed with multiple sclerosis, 36% spinal cord injury/disorder, and 27% Parkinson disease. Most patients were men (88%) in inpatient or long-term care settings (60%) with bladder catheters (67%). Fever was the most frequent symptom (32%). Only 38% of patients had a urinary tract-specific symptom; 48% had only nonspecific to the urinary tract symptoms. Inpatient encounter setting (odds ratio, 2.5; 95% confidence interval, 1.2-5.2) was associated with greater odds of only having nonspecific urinary tract symptoms.

CONCLUSIONS

In patients with neurogenic bladder and urinary tract infection encounters, nonspecific signs and symptoms are most frequently reported. These results can inform interventions to help providers better elicit and document urinary tract-specific symptoms in patients with neurogenic bladder presenting with possible urinary tract infection, particularly among hospitalized patients.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Describe patient-reported signs and symptoms of urinary tract infection (UTI) in adults with neurogenic bladder (NB) due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), and Parkinson disease (PD); (2) Differentiate urinary tract specific symptoms and nonspecific symptoms reported by adults with NB for suspected UTI and recognize how this may impact UTI diagnosis in this population; and (3) Recognize differences in UTI signs and symptoms reported by patients with NB based on patient and encounter characteristics.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Definitions of Urinary Tract Infection in Current Research: A Systematic Review

Defining urinary tract infection (UTI) is complex, as numerous clinical and diagnostic parameters are involved. In this systematic review, we aimed to gain insight into how UTI is defined across current studies. We included 47 studies, published between January 2019 and May 2022, investigating therapeutic or prophylactic interventions in adult patients with UTI. Signs and symptoms, pyuria, and a positive urine culture were required in 85%, 28%, and 55% of study definitions, respectively. Five studies (11%) required all 3 categories for the diagnosis of UTI. Thresholds for significant bacteriuria varied from 103 to 105 colony-forming units/mL. None of the 12 studies including acute cystitis and 2 of 12 (17%) defining acute pyelonephritis used identical definitions. Complicated UTI was defined by both host factors and systemic involvement in 9 of 14 (64%) studies. In conclusion, UTI definitions are heterogeneous across recent studies, highlighting the need for a consensus-based, research reference standard for UTI.

Urinary Tract Infections After Urogynecologic Surgery: Risk Factors, Timeline, and Uropathogens

IMPORTANCE

Urinary tract infection (UTI) is a common and potentially avoidable postoperative (PO) adverse event after urogynecologic surgery. Understanding pathophysiology will help prevent the associated morbidity of the disease and treatment of PO-UTI.

OBJECTIVE

The objective of this study is to determine the following: (1) risk factors for both PO-UTI and PO recurrent UTI (RUTI) after urogynecologic surgery, (2) temporal distribution of UTI, and (3) uropathogen identification.

STUDY DESIGN

Women undergoing urogynecologic surgery were retrospectively reviewed. Urinary tract infection was defined by culture or antibiotic prescription for symptoms. Recurrent UTI was defined as occurring outside a 6-week perioperative period. The χ 2 test or Fischer exact and Student t tests or Mann-Whitney U test were used as appropriate. Individual odds ratio (OR), 95% confidence interval [CI], and sequential multivariable logistic regression were calculated. Statistical significance was set at P < 0.05.

RESULTS

The 6-week PO-UTI rate after 33,626 procedures was 12.9%. Recurrent UTI increased from 3.7% preoperatively to 4.4% postoperatively ( P < 0.001). A 6-week preoperative UTI and RUTI increased the risk of 6-week PO-UTI (OR, 1.65; 95% CI < 1.26-2.16; P = 0.001 and OR, 2.19; 95% CI, 1.84-2.62; P < 0.001, respectively) and PO-RUTI (OR, 2.95; 95% CI, 2.11-4.11; P < 0.001 and OR, 6.79; 95% CI, 5.61-8.23; P < 0.001, respectively). Compared with pelvic organ prolapse (POP) surgery only, stress urinary incontinence (SUI) surgery (OR 1.57[1.30-1.89]), and combined POP/SUI surgery (OR, 1.36; 95% CI, 1.13-1.63]) increased the risk of PO-RUTI ( P < 0.001). Urinary tract infection within 1 week preoperatively was protective against 6-week PO-UTI (OR, 0.68; 95% CI, 0.48-0.97; P = 0.035). No perioperative factors were protective of PO-RUTI.

CONCLUSIONS

The PO-RUTI rate in the first year after urogynecologic surgery is low; however, SUI procedures may increase PO-RUTI risk. Potentially, modifiable risk factors for both PO-UTI and PO-RUTI include UTI diagnosis within 6 weeks preoperatively or preoperative RUTI diagnosis. Retesting women the week before surgery to ensure adequate treatment of preoperative UTI may reduce 6-week PO-UTI.

A double-blinded randomized placebo-controlled non-inferiority trial protocol for postoperative infections associated with canine pyometra

BACKGROUND

Pyometra is a common infectious condition, especially in elderly bitches. In addition to an infected uterus, dogs may have concurrent urinary tract infection (UTI). The preferred treatment is surgical removal of the ovaries and uterus, whereupon the general prognosis is excellent. In addition, antimicrobial therapy is frequently prescribed for postoperative treatment. However, no research exists on the benefit of postoperative antimicrobial treatment in uncomplicated canine pyometra. Antimicrobial resistance has become a major challenge in treatment of bacterial infections. Diminishing overuse of antimicrobial agents is essential for controlling the development of antimicrobial resistance in both animals and humans.

METHODS

This double-blinded, randomized, placebo-controlled two-arm clinical trial is designed to compare the incidence of postoperative infections associated with surgical treatment of uncomplicated pyometra followed by two different treatment protocols. For the study, 150 dogs presenting with an uncomplicated pyometra and that are to undergo surgical treatment will be recruited. Dogs with body weight < 3 or > 93 kg, complicated pyometra, primary disease increasing the risk of infection, or immunosuppressive medication will be excluded. All dogs will receive one dose of sulfadoxine-trimethoprim intravenously as an antimicrobial prophylaxis. Postoperatively, dogs will be randomized to receive either a five-day course of placebo or an active drug, sulfadiazine-trimethoprim orally. During the surgery microbiological samples will be taken from urine and uterine content. The follow-up includes a control visit in 12 days and an interview of the owner 30 days after surgery. If bacteriuria is detected at the time of surgery, a urinary sample will be cultured for bacterial growth at the control visit. The primary outcome is the incidence of a postoperative surgical site infection (SSI), and the secondary outcome is the occurrence of clinical UTI with bacteriuria. Intention-to-treat and per-protocol analyses will be performed to compare outcome incidences between the treatment groups.

DISCUSSION

Research-based evidence is necessary to create treatment guidelines for judicious use of antimicrobials. The goals of this study are to provide evidence for reducing the use of antimicrobials and targeting the treatment to patients proven to benefit from it. Publishing the trial protocol will increase transparency and promote open science practices.

Can the application of machine learning to electronic health records guide antibiotic prescribing decisions for suspected urinary tract infection in the Emergency Department?

Urinary tract infections (UTIs) are a major cause of emergency hospital admissions, but it remains challenging to diagnose them reliably. Application of machine learning (ML) to routine patient data could support clinical decision-making. We developed a ML model predicting bacteriuria in the ED and evaluated its performance in key patient groups to determine scope for its future use to improve UTI diagnosis and thus guide antibiotic prescribing decisions in clinical practice. We used retrospective electronic health records from a large UK hospital (2011-2019). Non-pregnant adults who attended the ED and had a urine sample cultured were eligible for inclusion. The primary outcome was predominant bacterial growth ≥104 cfu/mL in urine. Predictors included demography, medical history, ED diagnoses, blood tests, and urine flow cytometry. Linear and tree-based models were trained via repeated cross-validation, re-calibrated, and validated on data from 2018/19. Changes in performance were investigated by age, sex, ethnicity, and suspected ED diagnosis, and compared to clinical judgement. Among 12,680 included samples, 4,677 (36.9%) showed bacterial growth. Relying primarily on flow cytometry parameters, our best model achieved an area under the ROC curve (AUC) of 0.813 (95% CI 0.792-0.834) in the test data, and achieved both higher sensitivity and specificity compared to proxies of clinician's judgement. Performance remained stable for white and non-white patients but was lower during a period of laboratory procedure change in 2015, in patients ≥65 years (AUC 0.783, 95% CI 0.752-0.815), and in men (AUC 0.758, 95% CI 0.717-0.798). Performance was also slightly reduced in patients with recorded suspicion of UTI (AUC 0.797, 95% CI 0.765-0.828). Our results suggest scope for use of ML to inform antibiotic prescribing decisions by improving diagnosis of suspected UTI in the ED, but performance varied with patient characteristics. Clinical utility of predictive models for UTI is therefore likely to differ for important patient subgroups including women <65 years, women ≥65 years, and men. Tailored models and decision thresholds may be required that account for differences in achievable performance, background incidence, and risks of infectious complications in these groups.

Utility of Urine Cultures During Febrile Neutropenia Workup in Hematopoietic Stem Cell Transplantation Recipients Without Urinary Symptoms

The utility of obtaining screening urine cultures for febrile neutropenia (FN) during hematopoietic stem cell transplant (HCT) is unknown. In 667 adult HCT patients with FN, only 40 (6%) were found with bacteriuria. Antibiotics were modified in 3 patients (0.4%) based on urine cultures and none developed urinary-associated infectious complications.

Neutrophil (dys)function due to altered immuno-metabolic axis in type 2 diabetes: implications in combating infections

Metabolic and inflammatory pathways are highly interdependent, and both systems are dysregulated in Type 2 diabetes (T2D). T2D is associated with pre-activated inflammatory signaling networks, aberrant cytokine production and increased acute phase reactants which leads to a pro-inflammatory 'feed forward loop'. Nutrient 'excess' conditions in T2D with hyperglycemia, elevated lipids and branched-chain amino acids significantly alter the functions of immune cells including neutrophils. Neutrophils are metabolically active cells and utilizes energy from glycolysis, stored glycogen and β-oxidation while depending on the pentose phosphate pathway for NADPH for performing effector functions such as chemotaxis, phagocytosis and forming extracellular traps. Metabolic changes in T2D result in constitutive activation and impeded acquisition of effector or regulatory activities of neutrophils and render T2D subjects for recurrent infections. Increased flux through the polyol and hexosamine pathways, elevated production of advanced glycation end products (AGEs), and activation of protein kinase C isoforms lead to (a) an enhancement in superoxide generation; (b) the stimulation of inflammatory pathways and subsequently to (c) abnormal host responses. Neutrophil dysfunction diminishes the effectiveness of wound healing, successful tissue regeneration and immune surveillance against offending pathogens. Hence, Metabolic reprogramming in neutrophils determines frequency, severity and duration of infections in T2D. The present review discusses the influence of the altered immuno-metabolic axis on neutrophil dysfunction along with challenges and therapeutic opportunities for clinical management of T2D-associated infections.

Performance of infectious diseases specialists, hospitalists, and other internal medicine physicians in antimicrobial case-based scenarios: Potential impact of antimicrobial stewardship programs at 16 Veterans' Affairs medical centers

OBJECTIVE

As part of a project to implement antimicrobial dashboards at select facilities, we assessed physician attitudes and knowledge regarding antibiotic prescribing.

DESIGN

An online survey explored attitudes toward antimicrobial use and assessed respondents' management of four clinical scenarios: cellulitis, community-acquired pneumonia, non-catheter-associated asymptomatic bacteriuria, and catheter-associated asymptomatic bacteriuria.

SETTING

This study was conducted across 16 Veterans' Affairs (VA) medical centers in 2017.

PARTICIPANTS

Physicians working in inpatient settings specializing in infectious diseases (ID), hospital medicine, and non-ID/hospitalist internal medicine.

METHODS

Scenario responses were scored by assigning +1 for answers most consistent with guidelines, 0 for less guideline-concordant but acceptable answers and -1 for guideline-discordant answers. Scores were normalized to 100% guideline concordant to 100% guideline discordant across all questions within a scenario, and mean scores were calculated across respondents by specialty. Differences in mean score per scenario were tested using analysis of variance (ANOVA).

RESULTS

Overall, 139 physicians completed the survey (19 ID physicians, 62 hospitalists, and 58 other internists). Attitudes were similar across the 3 groups. We detected a significant difference in cellulitis scenario scores (concordance: ID physicians, 76%; hospitalists, 58%; other internists, 52%; P = .0087). Scores were numerically but not significantly different across groups for community-acquired pneumonia (concordance: ID physicians, 75%; hospitalists, 60%; other internists, 56%; P = .0914), for non-catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 65%; hospitalists, 55%; other internists, 40%; P = .322), and for catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 27% concordant; hospitalists, 8% discordant; other internists 13% discordant; P = .12).

CONCLUSIONS

Significant differences in performance regarding management of cellulitis and low overall performance regarding asymptomatic bacteriuria point to these conditions as being potentially high-yield targets for stewardship interventions.

Microbiome in urological diseases: Axis crosstalk and bladder disorders

Since the identification of the human urinary microbiome, numerous studies have characterized this microbial community and improved our knowledge of its association with urinary diseases. This association between urinary diseases and microbiota is not confined to the urinary microbiota; it is interconnected with the microbiota of other organs. The gastrointestinal, vaginal, kidney, and bladder microbiota all affect urinary diseases because they work with their respective organs to control the growth and operation of the immune, metabolic, and nervous systems through dynamic bidirectional communication along the bladder-centered axis. Therefore, disturbances in the microbial communities may result in the emergence of urinary diseases. In this review, we describe the increasing and intriguing evidence of complicated and critical relationships that may contribute to the development and progression of urinary diseases through disruption of the microbiota in various organs.

Antibiotic resistance profile of common uropathogens during COVID-19 pandemic: hospital based epidemiologic study

BACKGROUND

Antimicrobial resistance has a direct impact on the ability to treat common infections, and this was worsened during the COVID-19 pandemic. Worldwide surveillance studies are lacking and resistance rates vary spatially, so frequent local surveillance reports are required to guide antimicrobial stewardship efforts. This study aims to report our common local uropathogens and their antibiogram profiles in our community during the COVID era.

METHODS

A retrospective study included patients referred to our urology units with urine culture and sensitivity. All bacterial strains were identified, and their antibiotic susceptibilities were tested.

RESULTS

Out of 2581 urine culture results recruited, 30% showed microbiological proof of infection. The majority, 486 (63.4%), were isolated from females. The most frequent isolates were Escherichia coli (44.4%) and Staphylococcus aureus (17.8%). The resistance rates ranged from 26.9 to 79.7%. Piperacillin-tazobactam antibiotic had the lowest resistance rate. The multi-drug resistance pattern was recorded in 181 (23.9%) of the isolates; 159/597 (26.6%) Gram-negative and 22/160 (13.8%) Gram-positive isolates.

CONCLUSIONS

Alarming rates of antimicrobial resistance were detected, which stresses the significance of following infection control policies and establishing national antimicrobial stewardship standards.

Asymptomatic Bacteriuria in Kidney Transplant Recipients-A Narrative Review

Urinary tract infections (UTIs) are the most prevalent complications in kidney transplant (KTx) recipients. The most frequent finding in this group of patients is asymptomatic bacteriuria (ASB). Here, we provide an overview of the available evidence regarding ASB in KTx recipients, including its etiopathology, clinical impact and management. There is a growing body of evidence from clinical trials that screening for and treating ASB is not beneficial in most KTx recipients. However, there are insufficient data to recommend or discourage the use of a "screen-and-treat strategy" for ASB during the first 1-2 months post-transplant or in the case of an indwelling urinary catheter. Despite its frequency, ASB after KTx is still an understudied phenomenon.

Asymptomatic Bacteriuria in Patients with Type 2 Diabetes Mellitus

Objectives: Asymptomatic bacteriuria (ASB) is a common finding in patients with diabetes. Moreover, patients with diabetes and ASB have a greater risk for symptomatic urinary tract infections and associated severe complications. The aim of this study was to estimate the prevalence of ASB, as well as to identify independent risk factors and related pathogens associated with ASB in female and male patients with type 2 diabetes mellitus (T2D). Methods: This prospective case-control study was performed at the University hospital, and the Venezeleion General Hospital, Heraklion, Greece between 2012 and 2019. All patients with T2D attending the diabetes and hypertension outpatient clinics at both hospitals were enrolled, and data regarding their medical history and clinical and laboratory profiles were recorded. Asymptomatic patients with positive urine cultures were assigned as cases while those with negative urine cultures were designated as controls. Results: A total of 437 adult patients of which 61% were female and 39% were male patients with a mean age of 70.5 ± 9.6 years, were enrolled. The prevalence of ASB was 20.1%, in total. ASB was noted in 27% of female participants and 9.4% of male participants. Higher glycated hemoglobin (OR = 3.921, 95%CI: 1.521−10.109, p < 0.001) and urinary tract infection within the previous year (OR = 13.254, 95%CI: 2.245−78.241, p < 0.001) were independently positively associated with ASB, while higher levels of vitamin B12 were independently negatively associated with ASB (OR = 0.994 per ng/mL, 95%CI: 0.989−0.999, p < 0.001). Conclusions: Development of ASB was associated with specific factors, some of which may be modifiable. Interestingly, high B12 was found to be negatively associated with ASB.

A critical appraisal of clinical practice guidelines for management of four common complications after spinal cord injury

BACKGROUND CONTEXT

Complications such as pressure sores, pulmonary infection, urinary tract infection (UTI), and venous thromboembolism (VTE) are common after spinal cord injury (SCI). These have serious consequences for patients' physical, social, and vocational well-being. Several authoritative organizations have developed guidelines for managing these complications after SCI.

PURPOSE

We aim to systematically review and appraise guidelines on the management of four common complications (pressure sores, pulmonary infection, UTI, and VTE) after SCI as well as to summarize relevant recommendations and assess the quality of their supporting evidence.

DESIGN

Systematic review.

METHODS

We searched Medline, Embase, Cochrane, and Web of Science, as well as guideline-specific databases (e.g., National Guideline Clearinghouse) and Google Scholar, from January 2000 to January 2022. We included the most updated guidelines developed by specific authoritative organizations. We evaluated the included guidelines using the Appraisal of Guidelines for Research and Evaluation 2nd edition instrument, which measures six domains (e.g., applicability). Recommendations extracted from guidelines were categorized as for, against, or neither for nor against. An evidence assessment was adopted to classify the quality of supporting evidence as poor, fair, or good.

RESULTS

Eleven guidelines from 2005 to 2020 were included, all of which, among the six domains, scored lowest in the domain of applicability. For pressure sores, guidelines recommended for skin inspection, repositioning, and the use of pressure reduction equipment as preventive measures and dressings, debridement, and surgery as treatment measures. For pulmonary infection, guidelines recommended for physical (e.g., the use of an insufflation-exsufflation device) and pharmacological measures (e.g., the use of bronchodilators). For UTI, guidelines recommended for antibiotics as a treatment measure but recommended against cranberries, methenamine salts, and acidification or alkalinization agents as preventive measures. For VTE prophylaxis, five guidelines recommended for low molecular weight heparin (LMWH). Three guidelines recommended against unfractionated heparin, whereas one guideline recommended for it. Most of the supporting evidence was of poor quality (130/139), and the rest was of fair quality (9/139).

CONCLUSIONS

For pressure sores, pulmonary infection, and UTI, evidence of poor to fair quality indicated consistent recommendations for prevention and treatment measures. For VTE, LMWH was consistently recommended, whereas recommendations on the use of unfractionated heparin were controversial.

Recurrent UTI: Questions and Answers on Clinical Practice

Recurrent urinary tract infection (rUTI) management is still a challenge due to the lack of a standard approach and due to the burden of diseases both on personal and societal aspects. Consultations for rUTIs in everyday clinical practice range from 1% to 6% of all medical visits with high social and personal associated costs, such as prescriptions, hospital expenses, days of sick leave due to the disease, and the treatment of related comorbidities. Recurrent UTIs are, then, associated with anxiety and depression due to treatment failures and symptomatic recurrences. Often urologists are asked to give practical recommendations to patients regarding the everyday management of recurrent UTIs. Here, we aim to give to the physicians managing UTI some helpful suggestions for their everyday clinical practice, on the basis of the recent evidence.

The Diagnostic Accuracy Of Procalcitonin for Urinary Tract Infection in Hospitalized Older Adults: a Prospective Study

BACKGROUND

The diagnosis of urinary tract infection (UTI) is challenging among hospitalized older adults, particularly among those with altered mental status.

OBJECTIVE

To determine the diagnostic accuracy of procalcitonin (PCT) for UTI in hospitalized older adults.

DESIGN

We performed a prospective cohort study of older adults (≥65 years old) admitted to a single hospital with evidence of pyuria on urinalysis. PCT was tested on initial blood samples. The reference standard was a clinical definition that included the presence of a positive urine culture and any symptom or sign of infection referable to the genitourinary tract. We also surveyed the treating physicians for their clinical judgment and performed expert adjudication of cases for the determination of UTI.

PARTICIPANTS

Two hundred twenty-nine study participants at a major academic medical center.

MAIN MEASURES

We calculated the area under the receiver operating characteristic curve (AUC) of PCT for the diagnosis of UTI.

KEY RESULTS

In this study cohort, 61 (27%) participants met clinical criteria for UTI. The median age of the overall cohort was 82.6 (IQR 74.9-89.7) years. The AUC of PCT for the diagnosis of UTI was 0.56 (95% CI, 0.46-0.65). A series of sensitivity analyses on UTI definition, which included using a decreased threshold for bacteriuria, the treating physicians' clinical judgment, and independent infectious disease specialist adjudication, confirmed the negative result.

CONCLUSIONS

Our findings demonstrate that PCT has limited value in the diagnosis of UTI among hospitalized older adults. Clinicians should be cautious using PCT for the diagnosis of UTI in hospitalized older adults.

New insights into smoking and urinary tract infections during pregnancy using pregnancy-pair design: A population-based register study

INTRODUCTION

Pregnancy itself predisposes to urinary tract infections (UTI). There appears to be a higher prevalence of infections and genitourinary diseases among pregnant smokers than among non-smokers. The present study is a retrospective observational register study aiming to investigate whether maternal smoking is associated with the prevalence of UTIs during pregnancy by utilizing a pregnancy-pair analysis.

MATERIAL AND METHODS

Information about pregnancies and maternal smoking was obtained from the Finnish Medical Birth Register. The study sample consisted of all singleton pregnancies (n = 723 433) of women giving birth between January 2006 and December 2018 in Finland. Information on maternal smoking was collected in three categories: (1) non-smoking; (2) quit smoking during the first trimester; and (3) continued smoking throughout the pregnancy. Information about maternal UTI diagnoses during pregnancy was received from the Hospital Discharge Register and the Medical Birth Register. UTIs were categorized as lower and upper UTIs according to the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 diagnosis codes. Risks were calculated as odds ratios (OR) by logistic regression with 95% confidence intervals (CI) further adjusted for maternal characteristics (aOR). Finally, pregnancy-pair analyses were performed: mothers who had changed smoking status (no smoking/any smoking) between consecutive pregnancies (n = 27 246 pregnancy-pairs) were analyzed as one cluster and compared with non-smokers.

RESULTS

Smokers had UTIs more often compared with the non-smokers. The association was even stronger among those who continued to smoke (aOR 1.60, 95% CI 1.51-1.70) than among those who smoked only during the first trimester (aOR 1.27, 95% CI 1.18-1.37) compared with non-smokers. In pregnancy-pair analysis, smoking was associated with upper UTIs during pregnancy (OR 1.49, 95% CI 1.05-2.12) compared with non-smokers, but after the adjustments this association was attenuated (aOR 1.27, 95% CI 0.88-1.82). No association in lower UTIs was observed in the pregnancy-pair design.

CONCLUSIONS

Maternal smoking was associated with a higher prevalence of UTIs during pregnancy in the standard comparison. The observed association was fully attenuated in the pregnancy-pair analysis, in which smoking was dichotomized. This study suggests that the association between maternal smoking during pregnancy and adverse maternal health effects might be more complex than previously thought.

Antibiotic Resistance Profile of Common Uropathogens during COVID-19 Pandemic: Hospital based Epidemiologic Study.. [DOI: 10.21203/rs.3.rs-2092345/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Antimicrobial resistance has a direct impact on the ability to treat common infections, and this was worsened during the COVID-19 pandemic. Worldwide surveillance studies are lacking and resistance rates vary spatially, so frequent local surveillance reports are required to guide antimicrobial stewardship efforts. This study aims to report our common local uropathogens and their antibiogram profiles in our community during the COVID era. Methods: A retrospective study included patients referred to our urology units with urine culture and sensitivity. All bacterial strains were identified, and their antibiotic susceptibilities were tested. Results: Out of 2581 urine culture results recruited, 30% showed microbiological proof of infection. The majority, 486 (63.4%), were isolated from females. The most frequent isolates were Escherichia coli (44.4%) and S. aureus (17.8%). The resistance rates ranged from 26.9 to 76.9%. Piperacillin-tazobactam antibiotic had the lowest resistance rate. The multi-drug resistance pattern was recorded in 181 (23.9%) of the isolates; 159/597 (26.6%) Gram-negative and 22/160 (13.8%) Gram-positive isolates. Conclusions: Alarming rates of antimicrobial resistance were detected, which stresses the significance of following infection control policies and establishing national antimicrobial stewardship standards.

Prevalence, etiology and antibiotic resistance patterns of community-acquired urinary tract infections in Dhaka, Bangladesh

Urinary tract infection (UTI) accounts for a significant morbidity and mortality across the world and is a leading cause for antibiotic prescriptions in the community especially in developing countries. Empirical choice of antibiotics for treatment of UTI is often discordant with the drug susceptibility of the etiologic agent. This study aimed to estimate the prevalence of community-acquired UTI caused by antibiotic resistant organisms. This was a cross-sectional study where urine samples were prospectively collected from 4,500 patients at the icddr,b diagnostic clinic in Dhaka, Bangladesh during 2016–2018. Urine samples were analyzed by standard culture method and the isolated bacteria were tested for antibiotic susceptibility by using disc diffusion method and VITEK-2. Descriptive statistics were used to estimate the prevalence of community acquired UTI (CA-UTI) by different age groups, sex, and etiology of infection. Relationship between the etiology of CA-UTI and age and sex of patients was analyzed using binary logistic regression analysis. Seasonal trends in the prevalence of CA-UTI, multi-drug resistant (MDR) pathogens and MDR Escherichia coli were also analyzed. Around 81% of patients were adults (≥18y). Of 3,200 (71%) urine samples with bacterial growth, 920 (29%) had a bacterial count of ≥1.0x10⁵ CFU/ml indicating UTI. Women were more likely to have UTI compared to males (OR: 1.48, CI: 1.24–1.76). E. coli (51.6%) was the predominant causative pathogen followed by Streptococcus spp. (15.7%), Klebsiella spp. (12.1%), Enterococcus spp. (6.4%), Pseudomonas spp. (4.4%), coagulase-negative Staphylococcus spp. (2.0%), and other pathogens (7.8%). Both E. coli and Klebsiella spp. were predominantly resistant to penicillin (85%, 95%, respectively) followed by macrolide (70%, 76%), third-generation cephalosporins (69%, 58%), fluoroquinolones (69%, 53%) and carbapenem (5%, 9%). Around 65% of patients tested positive for multi-drug resistant (MDR) uropathogens. A higher number of male patients tested positive for MDR pathogens compared to the female patients (p = 0.015). Overall, 71% of Gram-negative and 46% of Gram-positive bacteria were MDR. The burden of community-acquired UTI caused by MDR organisms was high among the study population. The findings of the study will guide clinicians to be more selective about their antibiotic choice for empirical treatment of UTI and alleviate misuse/overuse of antibiotics in the community.

Pyelonephritis in Pregnancy From the Lens of an Underserved Community

In pregnancy, early signs and symptoms of urinary tract infection, including cystitis or pyelonephritis, may overlap with pregnancy symptoms, making early detection challenging. Compounding this challenge is when it presents itself in resource-poor settings for several factors, including poverty, poor access to healthcare care, inadequate diagnostic facilities, low availability of insurance, education, and cultural limitations. In this case report, we present a case of a 33-year-old G3P2 with pyelonephritis in pregnancy that was compounded by issues related to access to care in resource-limited settings. Although this case was handled in a resource-poor country, fighting to improve access to better health care, the term "underserved" is not exclusive to such a place. Therefore, we reviewed some basic guidelines for managing pyelonephritis in pregnancy and the obstacles in most underprivileged populations.

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.

D-mannose for preventing and treating urinary tract infections

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

A Meta-Analysis on Clinical Outcomes of Ceftolozane versus Piperacillin in Combination with Tazobactam in Patients with Complicated Urinary Tract Infections

Objective

To evaluate efficacy and adverse events of ceftolozane/tazobactam in complicated UTI including acute pyelonephritis.

Method

Databases that include PubMed, Embase, Scopus, and TRIP were searched. All randomized controlled trials and cohort studies were considered for the study. Statistical analysis was done using a fixed effects model, and results were expressed in proportion for dichotomous data and risk ratio for continuous data with 95% confidence intervals (CI).

Results

A clinical cure of ceftolozane/tazobactam was found to be 92% with 95% CI of 90-94 while that of piperacillin/tazobactam was only 78% (95% CI, 74-82) in patients with complicated UTI. Microbiological eradication was still higher in the ceftolozane/tazobactam group (83%, 95% CI 81-88) when compared with piperacillin/tazobactam (63% 95% CI, 58.77-65.2). Ceftolozane/tazobactam was more effective in the treatment of complicated urinary tract infections other than acute pyelonephritis as compared to piperacillin/tazobactam (RR = 1.21, 95% CI, 1.07-1.23). Serious adverse events were found comparable in both groups (RR = 1.15, 95% CI, 0.64-2.09).

Conclusion

The analysis showed that ceftolozane/tazobactam has better clinical outcomes including cure rates and low resistance for the treatment of complicated urinary tract infection.

pH Responsive Antibacterial Hydrogel Utilizing Catechol-Boronate Complexation Chemistry

Bacteria such as Methicillin-resistant Staphylococcus aureus (MRSA) causes acidic microenvironment during infection. A biomaterial that exhibits tunable antimicrobial property in a pH dependent manner is potentially attractive. Herein, we presented a novel antibacterial hydrogel consisting of pH responsive and reversible catechol-boronate linkage formed between intrinsically bactericidal chlorinated catechol (catechol-Cl) and phenylboronic acid. Fourier transformed infrared spectroscopy (FTIR), oscillatory rheometry, and Johnson Kendall Roberts (JKR) contact mechanics testing confirmed the formation and dissociation of the complex in a pH dependent manner. When the hydrogel was treated with an acidic buffer (pH 3), the hydrogel exhibited excellent antimicrobial property against multiple strains of Gram-positive and negative bacteria including MRSA (up to 4 log₁₀ reduction from 10⁸ colony forming units/mL). At an acidic pH, catechol-Cl was unbound from the phenylboronic acid and available for killing bacteria. Conversely, when the hydrogel was treated with a basic buffer (pH 8.5), the hydrogel lost its antimicrobial property but also became non-cytotoxic. At a basic pH, the formation of catechol-boronate complex effectively reduce the exposure of the cytotoxic catechol-Cl to the surrounding. When further incubating the hydrogel in an acidic pH, the reversible complex dissociated to re-expose catechol-Cl and the hydrogel recovered its antibacterial property. Overall, the combination of catechol-Cl and phenylboronic acid provide a new strategy for designing hydrogels with pH responsive antibacterial activity and reduced cytotoxicity.

Asymptomatic Bacteriuria: Prevalence, Diagnosis, Management, and Current Antimicrobial Stewardship Implementations

Asymptomatic bacteriuria is a common clinical condition that often leads to unnecessary treatment. It has been shown that incidence of asymptomatic bacteriuria increases with age and are more prominent in women than men. In older women, the incidence of asymptomatic bacteriuria is recorded to be more than 15%. This number increased up to 50% for those who reside in long-term care facilities. In most scenarios, asymptomatic bacteriuria does not lead to urinary tract infections, and therefore, antibiotic treatment of asymptomatic bacteriuria has not been shown to improve patient outcomes. In 2019, the Infectious Disease Society of America (IDSA) updated its asymptomatic bacteriuria management guidelines, which emphasized on the risks and benefits of treating the condition. Women who are pregnant should be screened for asymptomatic bacteriuria in the first trimester and treated, if positive. Individuals who are undergoing endoscopic urologic procedures should be screened and treated appropriately for asymptomatic bacteriuria as well. Treating asymptomatic bacteriuria in individuals with diabetes, neutropenia, spinal cord injuries, indwelling urinary catheters, and so on has not been found to improve clinical outcomes. Furthermore, unnecessary treatment is often associated with unwanted consequences including but not limited to increased antimicrobial resistance, Clostridioides difficile infection, and increased health care cost. As a result, multiple antibiotic stewardship programs around the US have implemented protocols to appropriately reduce unnecessary treatment of asymptomatic bacteriuria. It is important to appropriately screen and treat asymptomatic bacteriuria only when there is evidence of potential benefit.

Bacterial Colonization in Double J Stent and Bacteriuria in Post-Renal Transplant Patients

Background and objective

Urinary tract infections (UTI) in kidney transplant recipients can cause significant morbidity and negatively impact both, graft and patient survival. Ureteric stenting in renal transplantation is aimed at reducing the risks of complications like ureteric leak and stenosis. Ureteric stents are not without their potential complications which may include UTI. We aimed to compare urine bacteriology and bacterial colonization of DJ stent following kidney transplantation, and to establish antimicrobial susceptibility to guide the choice of empirical antibiotics in the event of UTI in post-transplant patients with DJ stent.

Materials and methods

This was a prospective study carried out over a year period (February 2020 to January 2021). Eighty post-renal transplant patients with indwelling ureteral stents were recruited for the study. An early morning midstream urine sample was taken for analysis from consenting patients that met the inclusion criteria. All stents were removed via rigid cystoscopy and the distal end of the stent (4cm) was cut off and put in a sterile bottle for microbiological analysis. Sensitivity and resistance were tested against a panel of 19 antibiotics on all microbial isolates. Results were considered statistically significant when p < 0.05.

Results

The mean age of the patients was 47.9+ 12.1 years. Male patients were 60 (75%) while 20 (25%) were females. Fifty-one (52%) patients had hypertension while 25 (26%) had diabetes mellitus. Hypertension and diabetes were noted in 20 (21%) patients while only one patient (1%) had HCV. Prior to renal transplantation, patients had negative urine cultures. The majority of the patients (76, 95%) had their stent retrieved after 4 weeks, 2 (2.5%) of them had stents retrieved after 2 weeks, and 2 (2.5%) had stents retrieved after 8 weeks. There was a significant association between the duration of stent and stent colonization (p=0.031).

No organism was cultured in both the urine and stent in 13 (14.4%) patients. Nine (10%) had positive stent culture with a negative urine culture while 5 (5.6%) had positive urine culture with a negative stent culture. The same organism was noted in both urine and stent in 58 (64.4%) of patients while different organisms were cultured in 5 (5.6%) of the patients. Escherichia coli was the most common organism cultured in the urine of 38 (65.5%) patients and 36 (58.1%) stents, respectively.

The sensitivity pattern shows that the organisms were more susceptible to nitrofurantoin and gentamicin, and resistant to tetracycline and ceftriaxone. Tigecycline showed good susceptibility and poor resistance.

Conclusion

This study shows that stent colonization was slightly higher than urine bacteriology, with both demonstrating similar microbiological patterns. Selection of the initial empiric treatment should be based on local epidemiological data. Initial therapy should be de-escalated to the most narrow-spectrum antibiotics to complete the course of therapy once culture and sensitivity data is available. Antibiotics stewardship will help in reducing the trend of MDR pathogens.