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Caveness CF, Orvin AI, Ingram CW, Bouchard JL. Impact of restrictive urinalysis reflex to culture criteria at a large community hospital. Diagn Microbiol Infect Dis 2024; 108:116183. [PMID: 38309086 DOI: 10.1016/j.diagmicrobio.2024.116183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/30/2023] [Accepted: 01/09/2024] [Indexed: 02/05/2024]
Abstract
Treatment of asymptomatic bacteriuria (ASB) is a common, but often unnecessary, practice. Our objective was to determine the impact of restrictive urinalysis reflex to culture (UARC) criteria on rate of urine cultures (UC) ordered and ASB treatment. Criteria were modified from positive leukocyte esterase, positive nitrites, or white blood cells (WBC) >10 cells to only WBC >10 cells. This pre-post study evaluated UARCs ordered in the emergency department or inpatient units. The primary outcome was the proportion of reflex UCs prevented. Secondary outcomes included the frequency of repeat UARCs and stand-alone UCs, gram-negative rod (GNR) bacteremia, and ASB treatment. In the pre-intervention, there were 4761 UARCs compared to 5420 in the post-intervention; 37.9 % and 21.4 % reflexed to UCs, a 43.5 % reduction in UCs. The rate of repeat UARCs, stand-alone UCs, and GNR bacteremia in the pre- and post-interventions were similar. ASB treatment rate was numerically lower in the post-intervention.
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Affiliation(s)
| | - Alison I Orvin
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Christopher W Ingram
- Infection Control and Occupational Health, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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Duda-Madej A, Stecko J, Sobieraj J, Szymańska N, Kozłowska J. Naringenin and Its Derivatives-Health-Promoting Phytobiotic against Resistant Bacteria and Fungi in Humans. Antibiotics (Basel) 2022; 11:1628. [PMID: 36421272 PMCID: PMC9686724 DOI: 10.3390/antibiotics11111628] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/09/2022] [Accepted: 11/13/2022] [Indexed: 07/30/2023] Open
Abstract
Naringenin is a trihydroxyflavanone present in large amount in different citrus fruits, e.g., oranges, pomelos, grapefruits, but also in tomatoes, fenugreek and coffee. It has a wide range of pharmacological and biological effects beneficial to human health. Its antioxidant, anti-cancer, anti-inflammatory, antifungal and antimicrobial activity is frequently reported in scientific literature. In this review we presented the current state of knowledge on the antimicrobial activity of naringenin and its natural and synthetic derivatives as a phytobiotic against resistant Gram-positive and Gram-negative bacteria as well as fungi in humans. Most of the data reported here have been obtained from in vitro or in vivo studies. Over the past few years, due to the overuse of antibiotics, the occurrence of bacteria resistant to all available antibiotics has been growing. Therefore, the main focus here is on antibiotic resistant strains, which are a significant, worldwide problem in the treatment of infectious diseases. The situation is so alarming that the WHO has listed microbial resistance to drugs on the list of the 10 most important health problems facing humanity. In addition, based on scientific reports from recent years, we described the potential molecular mechanism of action of these bioflavonoids against pathogenic strains of microorganisms. As plant-derived substances have been pushed out of use with the beginning of the antibiotic era, we hope that this review will contribute to their return as alternative methods of preventing and treating infections in the epoch of drug resistance.
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Affiliation(s)
- Anna Duda-Madej
- Department of Microbiology, Faculty of Medicine, Wroclaw Medical University, Chałubińskiego 4, 50-368 Wrocław, Poland
| | - Jakub Stecko
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Jakub Sobieraj
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Natalia Szymańska
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Joanna Kozłowska
- Department of Food Chemistry and Biocatalysis, Faculty of Biotechnology and Food Science, Wrocław University of Environmental and Life Sciences, C.K. Norwida 25, 50-375 Wrocław, Poland
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Alghamdi A, Almajid M, Alalawi R, Alganame A, Alanazi S, Alghamdi G, Alharthi S, Alghamdi I. Evaluation of asymptomatic bacteruria management before and after antimicrobial stewardship program implementation: retrospective study. BMC Infect Dis 2021; 21:869. [PMID: 34433412 PMCID: PMC8386035 DOI: 10.1186/s12879-021-06460-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background The Infectious Diseases Society of America (IDSA) recommends against screening for and/or treating asymptomatic bacteriuria (ASB). This study aims to evaluate the inappropriate use of antibiotics in ASB before and after Antimicrobial Stewardship Program (ASP) implementation and advance towards its appropriate use. Method We performed a retrospective study of patients diagnosed with ASB from 2016 to 2019 at a tertiary hospital in Saudi Arabia. This study included hospitalized patients ≥ 18 years old who had a positive urine culture with no documented signs or symptoms of urinary tract infection We excluded pregnant women, solid organ transplant patients, patient on active chemotherapy, and patients about to undergo urological surgery. Results A total of 716 patients with a positive urine culture were screened. Among these, we identified 109 patients with ASB who were included in our study. The rate of inappropriate antibiotic use was 95% during the study period. The implementation of the ASP Program was associated with a significant reduction in the use of carbapenems (P = 0.04) and an increase in the use of cephalosporins (P = 0.01). However, overprescribing antimicrobial agents was a concern in both eras. Approximately 90% of the microorganisms identified were gram-negative bacteria. Of those, 38.7% were multidrug-resistant strains. Conclusion The urine culture order in ASB is considered relatively small number; however, it showed a high rate of the inappropriate use of antibiotics when there is an order of urine culture in both era. ASP ought to focus on targeting the ordering physician, promoting awareness and/or organizational interventions that appear to reduce the incidence of overtreatment.
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Affiliation(s)
- Ahlam Alghamdi
- Pharmacy Practice Department, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia. .,Pharmacy Practice Department, King Abdullah bin AbdulAziz University Hospital, Riyadh, Saudi Arabia.
| | - Majid Almajid
- Department of Pharmacy, Security Forces Hospital Program, Riyadh, Saudi Arabia
| | - Raneem Alalawi
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Amjad Alganame
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Shorooq Alanazi
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ghaida Alghamdi
- College of Medicine, Imam Mohammed Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Salman Alharthi
- Department of Pharmacy, Security Forces Hospital Program, Riyadh, Saudi Arabia
| | - Isra Alghamdi
- College of Medicine, Imam Mohammed Ibn Saud Islamic University, Riyadh, Saudi Arabia
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4
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Szymczak J, Trautner B. Support to scale antibiotic stewardship in long-term care homes: how much is enough? BMJ Qual Saf 2021; 31:79-82. [PMID: 34059558 DOI: 10.1136/bmjqs-2021-013073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Julia Szymczak
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
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Brown KA, Daneman N, Schwartz KL, Langford B, McGeer A, Quirk J, Diong C, Garber G. The Urine-culturing Cascade: Variation in Nursing Home Urine Culturing and Association With Antibiotic Use and Clostridiodes difficile Infection. Clin Infect Dis 2021; 70:1620-1627. [PMID: 31197362 DOI: 10.1093/cid/ciz482] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Antibiotic prescribing for a presumed urinary tract infection is often preceded by inappropriate urine culturing. We examined nursing home urine-culturing practices and their association with antibiotic use. METHODS We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering >90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (eg, nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates. RESULTS A total of 131 218 residents in 591 nursing homes were included; 7.9% of resident assessments had a urine culture in the prior 14 days; this proportion was highly variable across the 591 nursing homes (10th percentile = 3.4%, 90th percentile = 14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio [RR] per doubling of urine culturing, 1.21; 95% confidence interval [CI], 1.18-1.23), urinary antibiotic use (RR, 1.33; 95% CI, 1.28-1.38), and C. difficile infection (incidence rate ratio, 1.18; 95% CI, 1.07-1.31). CONCLUSIONS Nursing homes have highly divergent urine culturing rates; this variability is associated with higher antibiotic use and rates of C. difficile infection.
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Affiliation(s)
- Kevin Antoine Brown
- Public Health Ontario, Canada.,Institute for Clinical Evaluative Sciences, Canada.,Dalla Lana School of Public Health, University of Toronto, Canada
| | - Nick Daneman
- Public Health Ontario, Canada.,Institute for Clinical Evaluative Sciences, Canada.,Sunnybrook Research Institute, Division of Infectious Diseases, Canada.,The Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Canada.,Institute for Clinical Evaluative Sciences, Canada.,Dalla Lana School of Public Health, University of Toronto, Canada.,St Joseph's Health Centre, Canada
| | | | - Allison McGeer
- Dalla Lana School of Public Health, University of Toronto, Canada.,Mount Sinai Hospital, Toronto, Canada
| | | | | | - Gary Garber
- Public Health Ontario, Canada.,Ottawa Research Institute, Canada
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Incidence and Diagnostic Yield of Repeat Urine Culture in Hospitalized Patients: an Opportunity for Diagnostic Stewardship. J Clin Microbiol 2019; 57:JCM.00910-19. [PMID: 31391227 DOI: 10.1128/jcm.00910-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/25/2019] [Indexed: 11/20/2022] Open
Abstract
There is limited knowledge on the incidence, diagnostic yield, and cost associated with inappropriate repeat urine cultures. The factors that affect repeat urine culturing practices are not well understood. We conducted a retrospective study of adult inpatients who had ≥1 urine culture performed during their hospitalization between January 2015 and February 2018. We analyzed the proportion of inappropriate repeat urine cultures performed <48 h after the index culture. We defined an inappropriate repeat urine culture to be a repeat urine culture performed following a negative index culture or a repeat urine specimen obtained from the same urinary catheter. Overall, 28,141 urine cultures were performed on 21,306 patients. There were 2,060 (7.3%) urine cultures repeated in <48 h. Of these, 1,120 (54.4%) urine cultures were inappropriate. Predictors for inappropriate repeat urine cultures included collection of the initial urine sample for culture in the emergency department (adjusted odds ratio [aOR], 5.65; 95% confidence interval [CI], 4.70 to 6.78), male gender (aOR, 1.61; 95% CI, 1.42 to 1.84), congestive heart failure (aOR, 1.20; 95% CI, 1.03 to 1.38), and a longer hospital stay (aOR, 1.01 per day; 95% CI, 1.00 to 1.01). A patient with an index urine culture obtained from an indwelling catheter (aOR, 0.65; 95% CI, 0.53 to 0.80) was less likely to have an inappropriate repeat culture. Among 1,120 negative index urine cultures, only 4.7% of repeat cultures were positive for bacteriuria. The estimated laboratory charges for inappropriate repeat urine cultures were $16,800 over the study period. Among inpatients, over half of all urine cultures repeated in <48 h were inappropriate. This offers an opportunity for diagnostic stewardship and optimization of antimicrobial use.
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Hecker MT, Son AH, Murphy NN, Sethi AK, Wilson BM, Watkins RR, Donskey CJ. Impact of syndrome-specific antimicrobial stewardship interventions on use of and resistance to fluoroquinolones: An interrupted time series analysis. Am J Infect Control 2019; 47:869-875. [PMID: 30850252 DOI: 10.1016/j.ajic.2019.01.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile. METHODS We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care-associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis. RESULTS The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days -15.3, P < .01). The health care-associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P < .01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile. CONCLUSIONS Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.
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Affiliation(s)
- Michelle T Hecker
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, OH; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Andrea H Son
- Department of Pharmacy, MetroHealth Medical Center, Cleveland, OH
| | | | - Ajay K Sethi
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | | | - Curtis J Donskey
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH.
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Ung L, Bispo PJM, Shanbhag SS, Gilmore MS, Chodosh J. The persistent dilemma of microbial keratitis: Global burden, diagnosis, and antimicrobial resistance. Surv Ophthalmol 2019; 64:255-271. [PMID: 30590103 PMCID: PMC7021355 DOI: 10.1016/j.survophthal.2018.12.003] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 12/16/2018] [Accepted: 12/18/2018] [Indexed: 01/16/2023]
Abstract
Microbial keratitis is a potentially blinding condition that must be treated emergently to preserve vision. Although long recognized as a significant cause of corneal blindness, our understanding of its true global scale, associated burden of disease, and etiological patterns remains somewhat limited. Current epidemiological data suggest that microbial keratitis may be epidemic in parts of the world-particularly within South, South-East, and East Asia-and may exceed 2 million cases per year worldwide. Etiological patterns vary between economically developed and developing countries, with bacterial predominance in the former and fungal predominance in the latter. The key to effective management lies in timely diagnosis; however, the current gold standard of stain and culture remains time consuming and often yields no clinically useful results. For this reason, there are attempts to develop highly sensitive and accurate molecular diagnostic tools to provide rapid diagnosis, inform treatment decision making, and minimize the threat of antimicrobial resistance. We provide an overview of these key areas and of avenues for further research toward the goal of more effectively addressing the problem of microbial keratitis on both an individual and public health level.
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Affiliation(s)
- Lawson Ung
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Paulo J M Bispo
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA; Infectious Disease Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Swapna S Shanbhag
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA; Tej Kohli Cornea Institute, L. V. Prasad Eye Institute, Hyderabad, India
| | - Michael S Gilmore
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA; Infectious Disease Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA; Infectious Disease Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.
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9
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Reducing urinary catheter use using an electronic reminder system in hospitalized patients: A randomized stepped-wedge trial. Infect Control Hosp Epidemiol 2019; 40:427-431. [PMID: 30827283 DOI: 10.1017/ice.2019.31] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the effectiveness and ease of use of an electronic reminder device in reducing urinary catheterization duration. DESIGN A randomized controlled trial with a cross-sectional anonymous online survey and focus group. SETTING Ten wards in an Australian hospital. PARTICIPANTS All hospitalized patients with a urinary catheter. INTERVENTION An electronic reminder system, the CATH TAG, applied to urinary catheter bags to prompt removal of urinary catheters. OUTCOMES Catheterization duration and perceptions of nurses about the ease of use. METHODS A Cox proportional hazards model was used to assess the rate of removal of catheters. A phenomenological approach underpinned data collection and analysis methods associated with the focus group. RESULTS In total, 1,167 patients with a urinary catheter were included. The mean durations in control and intervention phases were 5.51 days (95% confidence interval [CI], 4.9-6.2) and 5.08 days (95% CI, 4.6-5.6), respectively. For patients who had a CATH TAG applied, the hazard ratio (HR) was 1.02 (95% CI, 0.91-1.14; P = .75). A subgroup analysis excluded patients in an intensive care unit (ICU), and the use of the CATH TAG was associated with a 23% decrease in the mean, from 5.00 days (95% CI, 4.44-5.56) to 3.84 days (95% CI, 3.47-4.21). Overall, 82 nurses completed a survey and 5 nurses participated in a focus group. Responses regarding the device were largely positive, and benefits for patient care were identified. CONCLUSION The CATH TAG did not reduce the duration of catheterization, but potential benefits in patients outside the ICU were identified. Electronic reminders may be useful to aid prompt removal of urinary catheters in the non-ICU hospital setting.
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Belfield K, Kalith S, Aimar K, Parkinson R, Bayston R. Micro-organisms attached to the lumens and balloons of indwelling urinary catheters and correlation with symptoms, antibiotic use and catheter specimen of urine results. J Med Microbiol 2019; 68:549-554. [PMID: 30806614 DOI: 10.1099/jmm.0.000946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
To determine micro-organisms attached to removed urethral catheters and relate this to patient-specific information. Indwelling urethral catheters were collected from patients at a UK teaching hospital. The balloon and lumen were sonicated, and micro-organisms were enumerated. Catheter specimen urine results were retrospectively reviewed. Escherichia coli and Enterococcus faecalis were the most common isolates from 61 catheters. 19.7% of patients received antibiotics and 25 % of those had a multi-drug-resistant (MDR) organism in the lumen. Only 2.04% of catheters from patients not receiving antibiotics had a MDR organism. All lumens were colonized irrespective of antibiotic use. Symptom presentation did not correlate with numbers of colonizing organisms or species. Despite heavy colonization, only 8/61 patients were symptomatic. Indwelling urinary catheters in place for ≥10 days were universally colonized and there was no correlation with symptom presentation. Symptom presentation remains the most important factor for defining catheter-associated urinary tract infection.
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Affiliation(s)
- Katherine Belfield
- Biomaterials-Related Infection Group, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sajitha Kalith
- Biomaterials-Related Infection Group, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kelsey Aimar
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Parkinson
- Urology Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Roger Bayston
- Biomaterials-Related Infection Group, School of Medicine, University of Nottingham, Nottingham, UK
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Zeng S, Zhang Z, Bai Y, Sun Y, Xu C. Antimicrobial agents for preventing urinary tract infections in adults undergoing cystoscopy. Cochrane Database Syst Rev 2019; 2:CD012305. [PMID: 30789676 PMCID: PMC6383548 DOI: 10.1002/14651858.cd012305.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cystoscopy is commonly performed for diagnostic purposes to inspect the interior lining of the bladder. One disadvantage of cystoscopy is the risk of symptomatic urinary tract infection (UTI) due to pre-existing colonization or by introduction of bacteria at the time of the procedure. However, the incidence of symptomatic UTI following cystoscopy is low. Currently, there is no consensus on whether antimicrobial agents should be used to prevent symptomatic UTI for cystoscopy. OBJECTIVES To assess the effects of antimicrobial agents compared with placebo or no treatment for prevention of UTI in adults undergoing cystoscopy. SEARCH METHODS We comprehensively searched electronic databases of the Cochrane Library, PubMed, Embase, LILACS, and CINAHL. We searched the WHO ICTRP and ClinicalTrials.gov for ongoing trials. We used no language or date restrictions in the electronic searches. We searched the reference lists of identified articles and contacted authors for related information. The last search of the electronic databases was 4 February 2019. SELECTION CRITERIA We included randomized controlled trials (RCTs) or quasi-RCTs that compared any prophylactic antibiotic versus placebo, no treatment, or other non-antibiotic prophylaxis in adults undergoing cystoscopy. There was no restriction on the dose, frequency, formulation, duration, or mode of administration of the antibiotics. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were systemic UTI, symptomatic UTI (composite of systemic and/or localized UTI), and serious adverse events. Secondary outcomes were minor adverse events, localized UTI, asymptomatic bacteriuria, and bacterial resistance. We assessed the quality of evidence using GRADE. MAIN RESULTS We included 20 RCTs and two quasi-RCTs with 7711 participants, all of which compared antibiotic prophylaxis with placebo or no treatment control. We found no studies comparing antibiotic prophylaxis with non-antibiotic prophylaxis.Primary outcomesSystemic UTI: antibiotic prophylaxis may have little or no effect on the risk of systemic UTI compared with placebo or no treatment (risk ratio (RR) 1.12, 95% confidence interval (CI) 0.38 to 3.32; 5 RCTs; 504 participants; low-quality evidence); this corresponds to two more people (95% CI 12 fewer to 46 more) per 1000 people developing a systemic UTI. We downgraded the quality of the evidence for study limitations and imprecision.Symptomatic UTI: antibiotic prophylaxis may reduce the risk of symptomatic UTI (RR 0.49, 95% CI 0.28 to 0.86; 11 RCTs; 5441 participants; low-quality evidence); this corresponds to 30 fewer people (95% CI 42 fewer to 8 fewer) per 1000 people developing a symptomatic UTI when provided with antibiotic prophylaxis. We downgraded the quality of the evidence for study limitations and potential publication bias.Serious adverse events: the studies reported no serious adverse events in either the intervention group or control group and no effect size could be calculated. Antibiotic prophylaxis may have little or no effect on serious adverse events (4 RCTs, 630 participants; very low-quality evidence), but we are very uncertain of this finding. We downgraded the quality of the evidence for study limitations and very serious imprecision.Secondary outcomesMinor adverse events: prophylactic antibiotics may have little or no effect on minor adverse events when compared with placebo or no treatment (RR 2.82, 95% CI 0.54 to 14.80; 4 RCTs; 630 participants; low-quality evidence). We downgraded the quality of the evidence for study limitations and imprecision.Localized UTI: prophylactic antibiotics may have little or no effect on the risk of localized UTI (RR 1.0, 95% CI 0.06 to 15.77; 1 RCT; 200 participants; very low-quality evidence), but we were very uncertain of this finding. We downgraded the quality of the evidence for study limitations and very serious imprecision.Bacterial resistance: prophylactic antibiotics may increase bacterial resistance (RR 1.73, 95% CI 1.04 to 2.87; 38 participants; 2 RCTs; very low-quality evidence), but we were uncertain of this finding. We downgraded the quality of the evidence for study limitations, indirectness, and imprecision.We were able to perform few secondary analyses; these did not suggest any subgroup effects. AUTHORS' CONCLUSIONS Antibiotic prophylaxis may reduce the risk of symptomatic UTI but not systemic UTIs. Serious and minor adverse events may not be increased with the use of antibiotic prophylaxis. The findings are informed by low- and very low-quality evidence ratings for all outcomes.
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Affiliation(s)
- Shuxiong Zeng
- Changhai Hospital, Second Military Medical UniversityDepartment of UrologyChanghai Road 168#Yangpu DistrictShanghaiChina200433
| | - Zhensheng Zhang
- Changhai Hospital, Second Military Medical UniversityDepartment of UrologyChanghai Road 168#Yangpu DistrictShanghaiChina200433
| | - Yu Bai
- Changhai Hospital, Second Military Medical UniversityDepartment of Gastroenterology/Center for Clinical Epidemiology & Evidence‐Based Medicine18th Floor168 Changhai RdShanghaiChina200433
| | - Yinghao Sun
- Changhai Hospital, Second Military Medical UniversityDepartment of UrologyChanghai Road 168#Yangpu DistrictShanghaiChina200433
| | - Chuanliang Xu
- Changhai Hospital, Second Military Medical UniversityDepartment of UrologyChanghai Road 168#Yangpu DistrictShanghaiChina200433
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12
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Long B, Koyfman A. The Emergency Department Diagnosis and Management of Urinary Tract Infection. Emerg Med Clin North Am 2018; 36:685-710. [PMID: 30296999 DOI: 10.1016/j.emc.2018.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Urinary tract infection (UTI) is a common infection seen in the emergency department. The spectrum of UTI includes simple versus complicated infection and lower versus upper UTI. No one history or examination finding is definitive for diagnosis. Testing often includes urinalysis and/or urine dipstick, and several pitfalls may occur in interpretation. Urine cultures should be obtained in complicated or upper UTIs but not simple and lower tract UTIs, unless a patient is pregnant. Imaging often is not required. Most patients with simple cystitis and pyelonephritis are treated as outpatients. A variety of potentially dangerous conditions may mimic UTI and pyelonephritis.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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13
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Treating asymptomatic bacteriuria before immunosuppressive therapy during multiple sclerosis: Should we do it? Mult Scler Relat Disord 2017; 18:161-163. [DOI: 10.1016/j.msard.2017.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 05/19/2017] [Accepted: 08/16/2017] [Indexed: 11/19/2022]
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Garcia R, Spitzer ED. Promoting appropriate urine culture management to improve health care outcomes and the accuracy of catheter-associated urinary tract infections. Am J Infect Control 2017; 45:1143-1153. [PMID: 28476493 DOI: 10.1016/j.ajic.2017.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 12/16/2022]
Abstract
Published literature indicates that the unjustified ordering or improper collection of urine for urinalysis or culture from either catheterized patients or those without indwelling devices, or misinterpretation of positive results, often leads to adverse health care events, including increased financial burdens, overreporting of mandated catheter-associated urinary tract infection events, overtreatment of patients with antimicrobial agents, selection of multidrug-resistant organisms, and Clostridium difficile infection. Moreover, national guidelines that provide evidence-based direction on core processes that form the basis for subsequent clinical therapy decisions or surveillance interpretations; that is, the appropriate ordering and collection of urine for laboratory testing and the treatment of patients with symptomatic urinary tract infection, are not widely known or lack adherence. This article provides published evidence on the influence of inappropriate ordering of urine specimens and subsequent treatment of asymptomatic bacteriuria and associated adverse effects; reviews research on bacterial contamination and preservation; and delineates best practices in the collection, handling, and testing of urine specimens for culture or for biochemical analysis in both catheterized and noncatheterized patients. The goal is to provide infection preventionists (IPs) with a cohesive evidence-based framework that will assist them in facilitating the implementation of a urine culture management program that reduces patient harms, enhances the accuracy of catheter-associated urinary tract infection surveillance, improves antibiotic stewardship, and reduces costs.
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Vochozka M, Maroušková A, Šuleř P. Moral Polemics of Far-Reaching Economic Consequences of Antibiotics Overuse. SCIENCE AND ENGINEERING ETHICS 2017; 23:1035-1040. [PMID: 27896609 DOI: 10.1007/s11948-016-9834-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/17/2016] [Indexed: 06/06/2023]
Abstract
The unethical overuse of antibiotics to seek to achieve a shortening of the treatment period raises the cost of health services and poses a threat to humanity due to the gradual development of antibiotic resistance. Other consequences of our modern passion for antibiotics have appeared. Small concentrations of antibiotic residues in sewage waters slow down the metabolism of anaerobic microorganism thereby reducing the overall performance of the anaerobic fermentation used to detoxify and digest sewage and other collected organic wastes. Reduced biogas yields represents a serious threat to the energy self-sufficiency of some waste-water treatment plants, so it might change them from energy producers into energy consumers. Morally justifiable production of renewable energy from bio-waste is also threatened by antibiotic residues that remain in the bio-waste.
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Affiliation(s)
- Marek Vochozka
- The Institute of Technology and Business in České Budějovice, Okružní 517/10, 370 01, Ceske Budejovice, Czech Republic.
| | - Anna Maroušková
- The Institute of Technology and Business in České Budějovice, Okružní 517/10, 370 01, Ceske Budejovice, Czech Republic
| | - Petr Šuleř
- Faculty of Management and Informatics, University of Žilina, Univerzitná 8215/1, 010 26, Zilina, Slovakia
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Davenport M, Mach KE, Shortliffe LMD, Banaei N, Wang TH, Liao JC. New and developing diagnostic technologies for urinary tract infections. Nat Rev Urol 2017; 14:296-310. [PMID: 28248946 PMCID: PMC5473291 DOI: 10.1038/nrurol.2017.20] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Timely and accurate identification and determination of the antimicrobial susceptibility of uropathogens is central to the management of UTIs. Urine dipsticks are fast and amenable to point-of-care testing, but do not have adequate diagnostic accuracy or provide microbiological diagnosis. Urine culture with antimicrobial susceptibility testing takes 2-3 days and requires a clinical laboratory. The common use of empirical antibiotics has contributed to the rise of multidrug-resistant organisms, reducing treatment options and increasing costs. In addition to improved antimicrobial stewardship and the development of new antimicrobials, novel diagnostics are needed for timely microbial identification and determination of antimicrobial susceptibilities. New diagnostic platforms, including nucleic acid tests and mass spectrometry, have been approved for clinical use and have improved the speed and accuracy of pathogen identification from primary cultures. Optimization for direct urine testing would reduce the time to diagnosis, yet these technologies do not provide comprehensive information on antimicrobial susceptibility. Emerging technologies including biosensors, microfluidics, and other integrated platforms could improve UTI diagnosis via direct pathogen detection from urine samples, rapid antimicrobial susceptibility testing, and point-of-care testing. Successful development and implementation of these technologies has the potential to usher in an era of precision medicine to improve patient care and public health.
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Affiliation(s)
- Michael Davenport
- Department of Urology, Stanford University School of Medicine, 300 Pasteur Drive S-287, Stanford, California 94305 USA
| | - Kathleen E Mach
- Department of Urology, Stanford University School of Medicine, 300 Pasteur Drive S-287, Stanford, California 94305 USA
| | - Linda M Dairiki Shortliffe
- Department of Urology, Stanford University School of Medicine, 300 Pasteur Drive S-287, Stanford, California 94305 USA
| | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, 3375 Hillview Avenue, Palo Alto, California 94304 USA
| | - Tza-Huei Wang
- Departments of Mechanical and Biomedical Engineering, Johns Hopkins University, 3400 N. Charles Street, Baltimore, Maryland 21218, USA
| | - Joseph C Liao
- Department of Urology, Stanford University School of Medicine, 300 Pasteur Drive S-287, Stanford, California 94305 USA
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, California 94304 USA
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Al Nasser W, El-Saed A, Al-Jardani A, Althaqafi A, Alansari H, Alsalman J, Maskari ZA, El Gammal A, Al-Abri SS, Balkhy HH. Rates of catheter-associated urinary tract infection in tertiary care hospitals in 3 Arabian Gulf countries: A 6-year surveillance study. Am J Infect Control 2016; 44:1589-1594. [PMID: 27692786 DOI: 10.1016/j.ajic.2016.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND The true burden of catheter-associated urinary tract infections (CAUTIs) remains largely unknown because of a lack of national and regional surveillance reports in Gulf Cooperation Council (GCC) countries. The purpose of this study was to estimate location-specific CAUTI rates in the GCC region and to compare them with published reports from the U.S. National Healthcare Safety Network (NHSN) and the International Nosocomial Infection Control Consortium (INICC). METHODS CAUTI rates and urinary catheter utilization between 2008 and 2013 were calculated using NHSN methodology pooled from 6 hospitals in 3 GCC countries: Saudi Arabia, Oman, and Bahrain. The standardized infection ratios of the CAUTIs were compared with published reports of the NHSN and INICC. RESULTS A total of 286 CAUTI events were diagnosed during 6 years of surveillance, covering 89,254 catheter days and 113,807 patient days. The overall CAUTI rate was 3.2 per 1,000 catheter days (95% confidence interval, 2.8-3.6), with an overall urinary catheter utilization of 0.78. The CAUTI rates showed a wide variability between participating hospitals, with approximately 80% reduction during the study. The overall compliance with the urinary catheter bundle implementation during the second half of the study was 65%. The risk of CAUTI in GCC hospitals was 35% higher than the NHSN hospitals, but 37% lower than the INICC hospitals. CONCLUSIONS CAUTI rates pooled from a sample of GCC hospitals are quite different from rates in both developing and developed countries.
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Affiliation(s)
- Wafa Al Nasser
- Infection Prevention and Control, Imam Abdulrahman bin Faisal Hospital, Dammam, Saudi Arabia
| | - Aiman El-Saed
- Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; Gulf Cooperation Council States and World Health Organization Collaborating Center for Infection Prevention & Control, Riyadh, Saudi Arabia; Community Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Amina Al-Jardani
- Gulf Cooperation Council States and World Health Organization Collaborating Center for Infection Prevention & Control, Riyadh, Saudi Arabia; Infection Prevention and Control, Royal Hospital, Muscat, Oman
| | - Abdulhakeem Althaqafi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Infection Prevention and Control, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Huda Alansari
- Infection Prevention and Control, Salmaniya Medical Complex, Manama, Bahrain
| | - Jameela Alsalman
- Gulf Cooperation Council States and World Health Organization Collaborating Center for Infection Prevention & Control, Riyadh, Saudi Arabia; Infection Prevention and Control, Salmaniya Medical Complex, Manama, Bahrain
| | | | - Ayman El Gammal
- Infection Prevention and Control, King Abdulaziz Hospital, Al hassa, Saudi Arabia
| | - Seif S Al-Abri
- Gulf Cooperation Council States and World Health Organization Collaborating Center for Infection Prevention & Control, Riyadh, Saudi Arabia; Infection Prevention and Control, Royal Hospital, Muscat, Oman
| | - Hanan H Balkhy
- Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; Gulf Cooperation Council States and World Health Organization Collaborating Center for Infection Prevention & Control, Riyadh, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit With an Emphasis on "Stewardship of Culturing". Infect Control Hosp Epidemiol 2016; 38:186-188. [PMID: 27852357 DOI: 10.1017/ice.2016.266] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications. OBJECTIVE To implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture. METHODS A project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared. RESULTS The CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014. CONCLUSIONS Effectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts. Infect Control Hosp Epidemiol 2017;38:186-188.
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19
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Zeng S, Zhang Z, Bai Y, Sun Y, Xu C. Antimicrobial agents for preventing urinary tract infections in patients undergoing cystoscopy. Hippokratia 2016. [DOI: 10.1002/14651858.cd012305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Shuxiong Zeng
- Changhai Hospital, Second Military Medical University; Department of Urology; Changhai Hospital, Changhai Road 168#, Yangpu District, Shanghai China Shanghai Shanghai China 200433
| | - Zhensheng Zhang
- Changhai Hospital, Second Military Medical University; Department of Urology; Changhai Hospital, Changhai Road 168#, Yangpu District, Shanghai China Shanghai Shanghai China 200433
| | - Yu Bai
- Changhai Hospital, Second Military Medical University; Department of Gastroenterology/Center for Clinical Epidemiology & Evidence-Based Medicine; 18th Floor 168 Changhai Rd Shanghai China 200433
| | - Yinghao Sun
- Changhai Hospital, Second Military Medical University; Department of Urology; Changhai Hospital, Changhai Road 168#, Yangpu District, Shanghai China Shanghai Shanghai China 200433
| | - Chuanliang Xu
- Changhai Hospital, Second Military Medical University; Department of Urology; Changhai Hospital, Changhai Road 168#, Yangpu District, Shanghai China Shanghai Shanghai China 200433
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20
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Lingenfelter E, Drapkin Z, Fritz K, Youngquist S, Madsen T, Fix M. ED pharmacist monitoring of provider antibiotic selection aids appropriate treatment for outpatient UTI. Am J Emerg Med 2016; 34:1600-3. [PMID: 27306262 DOI: 10.1016/j.ajem.2016.05.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 05/25/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE We sought to determine whether an emergency department (ED) pharmacist could aid in the monitoring and correction of inappropriate empiric antibiotic selection for urinary tract infections in an outpatient ED population. METHODS Urine cultures with greater than 100 000 CFU/mL bacteria from the University of Utah Emergency Department over 1 year (October 2011-Sept 2012) were identified using our electronic medical record system. Per ED protocol, an ED pharmacist reviews all cultures and performs a chart review of patient symptoms, diagnosis, and discharge antibiotics to determine whether the treatment was appropriate. A retrospective review of this process was performed to identify how often inappropriate treatment was recognized and intervened on by an ED pharmacist. RESULTS Of the 180 cultures included, a total of 42 (23%) of empiric discharge treatments were considered inappropriate and required intervention. In 35 (83%) of 42 patients, the ED pharmacist was able to contact the patient and make appropriate changes; the remaining 7 patients were unable to be contacted, and no change could be made in their treatment. CONCLUSION A chart review of all urine cultures with greater than 100 000 CFU/mL performed by an ED pharmacist helped identify inappropriate treatment in 23% of patients discharged to home with the diagnosis of urinary tract infection. Of these patients who had received inappropriate treatment, an ED pharmacist was able to intervene in 83% of cases. These data highlight the role of ED pharmacists in improving patient care after discharge.
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Affiliation(s)
- Erin Lingenfelter
- Inpatient Pharmacy Services, University of Utah, Salt Lake City, UT, USA
| | - Zachary Drapkin
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kelly Fritz
- Inpatient Pharmacy Services, University of Utah, Salt Lake City, UT, USA
| | - Scott Youngquist
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Troy Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Megan Fix
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
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21
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Kiyatkin D, Bessman E, McKenzie R. Impact of antibiotic choices made in the emergency department on appropriateness of antibiotic treatment of urinary tract infections in hospitalized patients. J Hosp Med 2016; 11:181-4. [PMID: 26559929 DOI: 10.1002/jhm.2508] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 10/01/2015] [Accepted: 10/06/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Overuse of antibiotics to treat urinary tract infections (UTIs) is common in hospitalized patients and may begin in the emergency department (ED). METHODS For a 4-week period we reviewed medical records of all patients admitted to the hospital who initiated treatment for a UTI in the ED. RESULTS According to study criteria, initiation of antibiotics was inappropriate for 55 of 94 patients (59% [95% confidence interval {CI}, 48%-69%]), and continuation after admission was inappropriate for 54 of 80 patients (68% [95% CI, 57%-78%]). CONCLUSION Failure to reevaluate the need for antibiotics initiated in the ED to treat UTIs may lead to overuse of antibiotics in hospitalized patients.
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Affiliation(s)
- Dmitry Kiyatkin
- Collaborative Inpatient Medical Service, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Edward Bessman
- Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Robin McKenzie
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Treatment for Positive Urine Cultures in Hospitalized Adults: A Survey of Prevalence and Risk Factors in 3 Medical Centers. Infect Control Hosp Epidemiol 2015; 37:319-26. [PMID: 26607408 DOI: 10.1017/ice.2015.281] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Antibiotic treatment for asymptomatic bacteriuria (ASB) is prevalent but often contrary to published guidelines. OBJECTIVE To evaluate risk factors for treatment of ASB. DESIGN Retrospective observational study. SETTING A tertiary academic hospital, county hospital, and community hospital. PATIENTS Hospitalized adults with bacteriuria. METHODS Patients without documented symptoms of urinary tract infection per Infectious Diseases Society of America (IDSA) criteria were classified as ASB. We examined ASB treatment risk factors as well as broad-spectrum antibiotic usage and quantified diagnostic concordance between IDSA and National Healthcare Safety Network criteria. RESULTS Among 300 patients with bacteriuria, ASB was present in 71% by IDSA criteria. By National Healthcare Safety Network criteria, 71% of patients had ASB; within-patient diagnostic concordance with IDSA was moderate (kappa, 0.52). After excluding those given antibiotics for nonurinary indications, antibiotics were given to 38% (62/164) with ASB. Factors significantly associated with ASB treatment were elevated urine white cell count (65 vs 24 white blood cells per high-powered field, P<.01), hospital identity (hospital C vs A, odds ratio, 0.34 [95% CI, 0.14-0.80], P =.01), presence of leukocyte esterase (5.48 [2.35-12.79], P<.01), presence of nitrites (2.45 [1.11-5.41], P=.03), and Escherichia coli on culture (2.4 [1.2-4.7], P=.01). Of patients treated for ASB, broad-spectrum antibiotics were used in 84%. CONCLUSIONS ASB treatment was prevalent across settings and contributed to broad-spectrum antibiotic use. Associating abnormal urinalysis results with the need for antibiotic treatment regardless of symptoms may drive unnecessary antibiotic use.
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Abstract
Overuse of urinalysis in older adults to investigate vague changes in condition such as confusion, lethargy, and anorexia, has led to overtreatment of asymptomatic bacteriuria and associated antibiotic resistance.
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Affiliation(s)
- Joan M Nelson
- Joan M. Nelson University of Colorado at Anshutz Medical Campus College of Nursing, Aurora, Colo. Elliot Good is an adult-geriatric NP at Physician Housecalls, Wheat Ridge, Colo
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Zalmanovici Trestioreanu A, Lador A, Sauerbrun‐Cutler M, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev 2015; 4:CD009534. [PMID: 25851268 PMCID: PMC8407041 DOI: 10.1002/14651858.cd009534.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
| | - Adi Lador
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | | | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
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Herr HW. The Risk of Urinary Tract Infection after Flexible Cystoscopy in Patients with Bladder Tumor Who Did Not Receive Prophylactic Antibiotics. J Urol 2015; 193:548-51. [DOI: 10.1016/j.juro.2014.07.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Harry W. Herr
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York
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26
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Gandhi T, Flanders SA, Markovitz E, Saint S, Kaul DR. Importance of Urinary Tract Infection to Antibiotic Use Among Hospitalized Patients. Infect Control Hosp Epidemiol 2015; 30:193-5. [DOI: 10.1086/593951] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Many patients with asymptomatic bacteriuria receive extended courses of broad-spectrum antibiotics. Antibiotic use was analyzed in patients admitted to the hospital with urinary tract infection. Strategies to optimize antibiotic use for such patients are discussed and include implementing a process whereby a urine culture is automatically performed if a urinalysis result suggests infection.
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27
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Fakih MG, Krein SL, Edson B, Watson SR, Battles JB, Saint S. Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm. Am J Infect Control 2014; 42:S223-9. [PMID: 25239714 DOI: 10.1016/j.ajic.2014.03.355] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 10/24/2022]
Abstract
Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The "On the CUSP: Stop CAUTI" initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.
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Pallin DJ, Ronan C, Montazeri K, Wai K, Gold A, Parmar S, Schuur JD. Urinalysis in acute care of adults: pitfalls in testing and interpreting results. Open Forum Infect Dis 2014; 1:ofu019. [PMID: 25734092 PMCID: PMC4324184 DOI: 10.1093/ofid/ofu019] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/10/2014] [Indexed: 12/04/2022] Open
Abstract
Background. Rapid urine tests for infection (urinalysis, dipstick) have low up-front costs. However, many false positives occur, with important downstream consequences, including unnecessary antibiotics. We studied indications, collection technique, and results of urinalyses in acute care. Methods. This research was a prospective observational study of a convenience sample of emergency department (ED) patients who had urinalysis performed between June 1, 2012 and February 15, 2013 at an urban teaching hospital. Analyses were conducted via t tests, χ2 tests, and multivariable logistic regression. Results. Of 195 cases included in the study, the median age was 56 and 70% of participants were female. There were specific symptoms or signs of urinary tract infection (UTI) in 74 cases (38%; 95% confidence interval [CI], 31%–45%), nonspecific symptoms or signs in 83 cases (43%; 95% CI, 36%–50%), and no symptoms or signs of UTI in 38 cases (19%; 95% CI, 14%–25%). The median age was 51 (specific symptoms), 58 (nonspecific symptoms), and 61 (no symptoms), respectively (P = .005). Of 137 patients who produced the specimen without assistance, 78 (57%; 95% CI, 48%–65%) received no instructions on urine collection. Correct midstream clean-catch technique was used in 8 of 137 cases (6%). Presence of symptoms or signs was not associated with a new antibiotic prescription, but positive urinalysis (OR, 4.9; 95% CI, 1.7–14) and positive urine culture (OR, 3.6; 95% CI, 1.1–12) were. Of 36 patients receiving antibiotics, 10 (28%; 95% CI, 13%–43%) had no symptoms or nonspecific symptoms. Conclusion. In this sample at an urban teaching hospital ED, urine testing was not driven by symptoms. Improving practice may lower costs, improve efficiency of care, decrease unnecessary data that can distract providers and impair patient safety, decrease misdiagnosis, and decrease unnecessary antibiotics.
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Affiliation(s)
- Daniel J Pallin
- Department of Emergency Medicine , Brigham and Women's Hospital , Boston, Massachusetts
| | - Clare Ronan
- Department of Emergency Medicine , Brigham and Women's Hospital , Boston, Massachusetts
| | - Kamaneh Montazeri
- Department of Emergency Medicine , Brigham and Women's Hospital , Boston, Massachusetts
| | - Katherine Wai
- Department of Emergency Medicine , Brigham and Women's Hospital , Boston, Massachusetts
| | - Allen Gold
- Department of Emergency Medicine , Brigham and Women's Hospital , Boston, Massachusetts
| | - Siddharth Parmar
- Department of Emergency Medicine , Brigham and Women's Hospital , Boston, Massachusetts
| | - Jeremiah D Schuur
- Department of Emergency Medicine , Brigham and Women's Hospital , Boston, Massachusetts
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29
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Dull RB, Friedman SK, Risoldi ZM, Rice EC, Starlin RC, Destache CJ. Antimicrobial treatment of asymptomatic bacteriuria in noncatheterized adults: a systematic review. Pharmacotherapy 2014; 34:941-60. [PMID: 24807583 DOI: 10.1002/phar.1437] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Ryan B Dull
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
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Duncan RA. Prosthetic joint replacement: should orthopedists check urine because it's there? Clin Infect Dis 2014; 59:48-50. [PMID: 24723277 DOI: 10.1093/cid/ciu243] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Robert A Duncan
- Center for Infectious Diseases and Prevention, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Coman T, Troché G, Semoun O, Pangon B, Mignon F, Jacq G, Merceron S, Abbosh N, Laurent V, Guezennec P, Henry-Lagarrigue M, Revault-d'Allonnes L, Ben-Mokhtar H, Audibert J, Bruneel F, Resche-Rigon M, Bedos JP, Legriel S. Diagnostic accuracy of urinary dipstick to exclude catheter-associated urinary tract infection in ICU patients: a reappraisal. Infection 2014; 42:661-8. [PMID: 24647770 DOI: 10.1007/s15010-014-0612-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 03/03/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We wanted to assess the diagnostic accuracy of urinary dipstick testing in excluding catheter-associated urinary tract infection (CAUTI) in intensive care unit (ICU) patients with fever or hypothermia. METHODS This was a prospective observational cohort study in a medical-surgical ICU. Patients with new-onset fever >38.3 °C or hypothermia <36 °C at least 48 h after urinary catheter insertion were included over a 2-year period. At each episode, a urinary dipstick test and a urine culture were performed as the criterion standard. Extensive microbiological investigations for extra-urinary infections were performed also. The performances of various urinary dipstick result combinations in ruling out CAUTI were compared based on the likelihood ratios (LR+ and LR-). RESULTS Symptomatic CAUTI was diagnosed in 31 (24.4 %) of the 127 included patients (195 episodes of fever or hypothermia). LR+ was best for combined leukocyte esterase-positive and nitrite-positive dipstick results (overall population: 14.91; 95 % confidence interval [95 % CI], 5.53-40.19; patients without urinary symptoms: 15.63; 95 % CI, 5.76-42.39). LR- was best for either leukocyte esterase-positive or nitrite-positive dipstick results (overall population: 0.41; 95 % CI, 0.57-0.65; patients without urinary symptoms, 0.36; 95 % CI, 0.21-0.60). CONCLUSIONS Urinary dipstick testing at the bedside does not help to rule out symptomatic CAUTI in medical or surgical ICU patients with fever or hypothermia.
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Affiliation(s)
- T Coman
- Intensive Care Unit, Centre Hospitalier de Versailles, 177 Rue de Versailles, 78150, Le Chesnay cedex (78), France
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Dayts O. Evidence-based protocol: diagnosis and treatment of catheter-associated urinary tract infection within adult neurocritical care patient population. Nurs Clin North Am 2013; 49:29-43. [PMID: 24485184 DOI: 10.1016/j.cnur.2013.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Evidence exists that patients requiring neurologic ICU admission have concomitant immunosuppression that makes them more prone to acquiring nosocomial infections. The risk of infection is highest in the acute phase after stroke, which may be attributed to stroke-induced immunodepression syndrome. Significant numbers of patients are being diagnosed inappropriately with catheter-associated urinary tract infection, for which they receive treatment that is not recommended. Protocol-based care enables providers to translate evidence into practice.
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Affiliation(s)
- Olga Dayts
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37212, USA.
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Trautner BW, Grigoryan L. Approach to a positive urine culture in a patient without urinary symptoms. Infect Dis Clin North Am 2013; 28:15-31. [PMID: 24484572 DOI: 10.1016/j.idc.2013.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Asymptomatic bacteriuria (ASB) is a condition in which bacteria are present in a noncontaminated urine sample collected from a patient without signs or symptoms related to the urinary tract. ASB must be distinguished from symptomatic urinary tract infection (UTI) by the absence of signs and symptoms compatible with UTI or by clinical determination that a nonurinary cause accounts for the patient's symptoms. The overall purpose of this review is to promote an awareness of ASB as a distinct condition from UTI and to empower clinicians to withhold antibiotics in situations in which antimicrobial treatment of bacteriuria is not indicated.
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Affiliation(s)
- Barbara W Trautner
- Department of Medicine, Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA; Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby, Houston, TX 77098, USA
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Clinician practice and the National Healthcare Safety Network definition for the diagnosis of catheter-associated urinary tract infection. Am J Infect Control 2013; 41:1173-7. [PMID: 24011555 DOI: 10.1016/j.ajic.2013.05.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/10/2013] [Accepted: 05/10/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND The National Healthcare Safety Network (NHSN) definition for catheter-associated urinary tract infection (CAUTI) is used to evaluate improvements in CAUTI prevention efforts. We assessed whether clinician practice was reflective of the NHSN definition. METHODS We evaluated all adult inpatients hospitalized between July 2010 and June 2011, with a first positive urine culture > 48 hours of admission obtained while catheterized or within 48 hours of catheter discontinuation. Data comprised patients' signs, symptoms, and diagnostic tests; clinician's diagnosis; and the impression of the infectious diseases (ID) consultant. The clinician's practice was compared with the NHSN definition and the ID consultant's impression. RESULTS Antibiotics were initiated by clinicians to treat CAUTI in 216 of 387 (55.8%) cases, with 119 of 387 (30.7%) fitting the NHSN CAUTI definition, and 63 of 211 (29.9%) considered by ID to have a CAUTI. The sensitivity, specificity, and positive and negative predictive values of a clinician diagnosis of CAUTI were 62.2%, 47%, 34.3%, and 73.7% when compared with NHSN CAUTI definition (n = 387) and 100%, 57.4%, 50%, and 100% when compared with the ID consultant evaluation (n = 211), respectively. The positive predictive value of the NHSN CAUTI definition was 35.1% when compared with the ID consultant's impression (n = 211). CONCLUSION NHSN CAUTI definition did not reflect clinician or ID consultant practices. Our findings reflect the differences between surveillance definitions and clinical practice.
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Herr HW. Should antibiotics be given prior to outpatient cystoscopy? A plea to urologists to practice antibiotic stewardship. Eur Urol 2013; 65:839-42. [PMID: 24012206 DOI: 10.1016/j.eururo.2013.08.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 08/21/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antimicrobial resistance is a major health problem, caused primarily by overuse of antibiotics in clinical situations in which they are not necessary. Practice guidelines recommend that antibiotics be given before outpatient cystoscopy to prevent symptomatic urinary tract infection (UTI). OBJECTIVE To determine the frequency of febrile UTI after outpatient flexible cystoscopy in antibiotic-naive bladder tumor patients. DESIGN, SETTING, AND PARTICIPANTS A total of 2010 consecutive outpatients with bladder tumors were entered into a prospective registry study. All patients underwent cystoscopy after they submitted a voided urine sample for culture. Significant bacteriuria was defined as >10(4) colony-forming units per milliliter with a single organism. Patients were stratified for known risk factors for UTI. INTERVENTION Patients underwent flexible cystoscopy and received no antibiotics immediately before or after cystoscopy. They were followed for 30 d for onset of febrile UTI. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The end point was incidence of febrile UTI within 30 d of cystoscopy. Febrile UTI was defined as temperature >38°C and dysuria, or having received antibiotics from an outside physician for urinary symptoms. RESULTS AND LIMITATIONS Of the 2010 patient cystoscopies, 489 (24%) had asymptomatic bacteriuria, and 1521 (76%) had sterile urine. Thirty-nine patients (1.9%) developed febrile UTI ≤30 d after cystoscopy-4.5% in colonized patients and 1.1% in uninfected patients (p=0.02). All UTIs resolved in ≤12-24h with oral antibiotics. None of the patients was admitted for bacterial sepsis. Limitations of the study are that it is a single-surgeon experience in one institution, and results may not apply to other patient populations. CONCLUSIONS Antibacterial therapy before outpatient flexible cystoscopy does not appear necessary in bladder tumor patients who have no clinical signs or symptoms of acute UTI, including asymptomatic bacteriuria. Antibiotic stewardship is the responsibility of all urologists.
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Affiliation(s)
- Harry W Herr
- Department of Urology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Gutiérrez-Gutiérrez G, Sereno M, García Vaquero C, Miralles A. Levofloxacin-induced Myasthenic Crisis. J Emerg Med 2013; 45:260-1. [DOI: 10.1016/j.jemermed.2012.09.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/01/2012] [Accepted: 09/18/2012] [Indexed: 10/27/2022]
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Marschall J, Piccirillo ML, Foxman B, Zhang L, Warren DK, Henderson JP. Patient characteristics but not virulence factors discriminate between asymptomatic and symptomatic E. coli bacteriuria in the hospital. BMC Infect Dis 2013; 13:213. [PMID: 23663267 PMCID: PMC3658957 DOI: 10.1186/1471-2334-13-213] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 05/02/2013] [Indexed: 01/26/2023] Open
Abstract
Background Escherichia coli is a common cause of asymptomatic and symptomatic bacteriuria in hospitalized patients. Asymptomatic bacteriuria (ASB) is frequently treated with antibiotics without a clear indication. Our goal was to determine patient and pathogen factors suggestive of ASB. Methods We conducted a 12-month prospective cohort study of adult inpatients with E. coli bacteriuria seen at a tertiary care hospital in St. Louis, Missouri, USA. Urine cultures were taken at the discretion of treating physicians. Bacterial isolates were tested for 14 putative virulence genes using high-throughput dot-blot hybridization. Results The median age of the 287 study patients was 65 (19–101) years; 78% were female. Seventy percent had community-acquired bacteriuria. One-hundred ten (38.3%) patients had ASB and 177 (61.7%) had symptomatic urinary tract infection (sUTI). Asymptomatic patients were more likely than symptomatic patients to have congestive heart failure (p = 0.03), a history of myocardial infarction (p = 0.01), chronic pulmonary disease (p = 0.045), peripheral vascular disease (p = 0.04), and dementia (p = 0.03). Patients with sUTI were more likely to be neutropenic at the time of bacteriuria (p = 0.046). Chronic pulmonary disease [OR 2.1 (95% CI 1.04, 4.1)] and dementia [OR 2.4 (95% CI 1.02, 5.8)] were independent predictors for asymptomatic bacteriuria. Absence of pyuria was not predictive of ASB. None of the individual virulence genes tested were associated with ASB nor was the total number of genes. Conclusions Asymptomatic E. coli bacteriuria in hospitalized patients was frequent and more common in patients with dementia and chronic pulmonary disease. Bacterial virulence factors could not discriminate symptomatic from asymptomatic bacteriurias. Asymptomatic E. coli bacteriuria cannot be predicted by virulence screening.
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Affiliation(s)
- Jonas Marschall
- Division of Infectious Diseases, Washington University School of Medicine, St, Louis, MO 63110, USA.
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Trautner BW, Bhimani RD, Amspoker AB, Hysong SJ, Garza A, Kelly PA, Payne VL, Naik AD. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013; 13:48. [PMID: 23587259 PMCID: PMC3664217 DOI: 10.1186/1472-6947-13-48] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 04/04/2013] [Indexed: 11/17/2022] Open
Abstract
Background Overtreatment of catheter-associated bacteriuria is a quality and safety problem, despite the availability of evidence-based guidelines. Little is known about how guidelines-based knowledge is integrated into clinicians’ mental models for diagnosing catheter-associated urinary tract infection (CA-UTI). The objectives of this research were to better understand clinicians’ mental models for CA-UTI, and to develop and validate an algorithm to improve diagnostic accuracy for CA-UTI. Methods We conducted two phases of this research project. In phase one, 10 clinicians assessed and diagnosed four patient cases of catheter associated bacteriuria (n= 40 total cases). We assessed the clinical cues used when diagnosing these cases to determine if the mental models were IDSA guideline compliant. In phase two, we developed a diagnostic algorithm derived from the IDSA guidelines. IDSA guideline authors and non-expert clinicians evaluated the algorithm for content and face validity. In order to determine if diagnostic accuracy improved using the algorithm, we had experts and non-experts diagnose 71 cases of bacteriuria. Results Only 21 (53%) diagnoses made by clinicians without the algorithm were guidelines-concordant with fair inter-rater reliability between clinicians (Fleiss’ kappa = 0.35, 95% Confidence Intervals (CIs) = 0.21 and 0.50). Evidence suggests that clinicians’ mental models are inappropriately constructed in that clinicians endorsed guidelines-discordant cues as influential in their decision-making: pyuria, systemic leukocytosis, organism type and number, weakness, and elderly or frail patient. Using the algorithm, inter-rater reliability between the expert and each non-expert was substantial (Cohen’s kappa = 0.72, 95% CIs = 0.52 and 0.93 between the expert and non-expert #1 and 0.80, 95% CIs = 0.61 and 0.99 between the expert and non-expert #2). Conclusions Diagnostic errors occur when clinicians’ mental models for catheter-associated bacteriuria include cues that are guidelines-discordant for CA-UTI. The understanding we gained of clinicians’ mental models, especially diagnostic errors, and the algorithm developed to address these errors will inform interventions to improve the accuracy and reliability of CA-UTI diagnoses.
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Affiliation(s)
- Barbara W Trautner
- Houston Health Services Research and Development Center of Excellence, Michael E, DeBakey VA Medical Center, Houston, TX, USA
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Chiu J, Thompson GW, Austin TW, Hussain Z, John M, Bombassaro AM, Connelly SE, Elsayed S. Antibiotic prescribing practices for catheter urine culture results. Can J Hosp Pharm 2013; 66:13-20. [PMID: 23467594 DOI: 10.4212/cjhp.v66i1.1207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The literature suggests that positive results of catheter urine cultures frequently lead to unnecessary antimicrobial prescribing, which therefore represents an important target for stewardship. OBJECTIVE To assess the appropriateness of antibiotic prescribing in response to the results of urine cultures from patients with indwelling urinary catheters. METHODS This retrospective study was conducted at a tertiary care centre and involved adults with indwelling urinary catheters from whom urine specimens were obtained for culture. Patients with positive or negative culture results were identified from microbiology laboratory reports. The medical records of consecutive patients were screened to select a sample of 80 inpatients (40 per group). Abstracted patient histories were independently evaluated by an expert panel of 3 infectious diseases consultants blinded to the decisions of prescribers and of fellow panelists. The primary end point was concordance of each patient's treatment decision (with respect to the indication) between the expert panel (based on majority agreement, i.e., at least 2 of the 3 expert panelists) and the prescriber. The secondary end points were unnecessary days of therapy and selected outcomes over a predefined period after urine was obtained for culture. RESULTS A total of 591 charts were screened to generate the targeted number of patients. Baseline demographic characteristics were comparable for the 2 groups, except antibiotic exposure before urine collection was significantly more frequent for the group with negative culture results. The treatment decision was concordant in 40% (16/40) of the patients with a positive culture result and 85% (34/40) of those with a negative culture result (p < 0.001). The most common reason for discordance was administration of antibiotics when not indicated (23 of 24 patients with a positive result and 5 of 6 patients with a negative result), which accounted for 165 and 32 unnecessary days of therapy per 1000 inpatient-days, respectively (p < 0.001). Adverse effects occurred in 2 of the 23 patients with a positive result who received antibiotics that were not indicated. CONCLUSIONS Appropriateness of antibiotic prescribing, as measured by concordance of decisions between the expert panel and prescribers, was more common among patients with negative urine culture results than among those with positive results. However, there is an opportunity to improve prescribing for both groups through antimicrobial stewardship initiatives. Unnecessary days of therapy and adverse effects were more common in patients with a positive culture result.
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Affiliation(s)
- Jonathan Chiu
- , BScPhm, was at the time of this study, a Pharmacy Resident, Pharmacy Services, London Health Sciences Centre, London, Ontario. He is now a Critical Care Pharmacist in the Pharmacy Department, The Credit Valley Hospital and Trillium Health Centre, Mississauga, Ontario
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Press MJ, Metlay JP. Catheter-associated urinary tract infection: does changing the definition change quality? Infect Control Hosp Epidemiol 2013; 34:313-5. [PMID: 23388369 DOI: 10.1086/669525] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The Centers for Disease Control and Prevention (CDC) recently narrowed its definition of catheter-associated urinary tract infection (CAUTI) to exclude asymptomatic bacteriuria. Although CAUTI rates decreased after the definition was changed, rates of related measures remained relatively stagnant, which indicates that longitudinal measurements of CAUTI may be misleading and that the change in definition did not itself impact care.
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Affiliation(s)
- Matthew J Press
- Department of Public Health, Weill Cornell Medical College, New York, New York 10065, USA.
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Yacoub R, Akl NK. Urinary tract infections and asymptomatic bacteriuria in renal transplant recipients. J Glob Infect Dis 2012; 3:383-9. [PMID: 22224004 PMCID: PMC3249996 DOI: 10.4103/0974-777x.91064] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Asymptomatic bacteriuria and urinary tract infection are common complications after kidney transplantation. In this population, if urinary tract infection occurred in the first six months post procedure, it carries a grave impact on both graft and patient survival. Renal transplant recipients with urinary tract infection are often clinically asymptomatic as a consequence of immunosuppression. Urinary tract infection, however, may progress to acute pyelonephritis, bacteremia and the full blown picture of urosepsis. PubMed and Cochrane databases were searched. The purpose of this review is to discuss the screening and treatment of urinary tract infection and asymptomatic bacteriuria in renal transplant recipients and to evaluate the guidelines on the basis of a review of published evidence.
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Affiliation(s)
- Rabi Yacoub
- Department of Internal Medicine, University at Buffalo, David K. Miller Building, 462 Grider ST. Buffalo, NY, USA
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Ibrahim OM, Polk RE. Benchmarking antimicrobial drug use in hospitals. Expert Rev Anti Infect Ther 2012; 10:445-57. [PMID: 22512754 DOI: 10.1586/eri.12.18] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Measuring and monitoring antibiotic use in hospitals is believed to be an important component of the strategies available to antimicrobial stewardship programs to address acquired antimicrobial resistance. Recent efforts to organize large numbers of hospitals into networks allow for interhospital comparisons of a variety of healthcare processes and outcomes, a process often called 'benchmarking'. For comparisons of antimicrobial use to be valid, usage figures must be risk-adjusted to account for differences in patient mix and hospital characteristics. The purpose of this review is to describe recent methods to benchmark antimicrobial drug use and to critically assess the potential advantages and the remaining challenges. While many methodological challenges remain, and the clinical outcomes resulting from benchmarking programs have yet to be determined, recent developments suggest that benchmarking antimicrobial drug use will become an important component of antimicrobial stewardship program activities.
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Affiliation(s)
- Omar M Ibrahim
- Department of Pharmacotherapy and Outcome Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
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Chowdhury F, Sarkar K, Branche A, Kim J, Dwek P, Nangit A, Tompkins D, Visconti E. Preventing the inappropriate treatment of asymptomatic bacteriuria at a community teaching hospital. J Community Hosp Intern Med Perspect 2012; 2:17814. [PMID: 23882368 PMCID: PMC3714060 DOI: 10.3402/jchimp.v2i2.17814] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 06/11/2012] [Accepted: 06/13/2012] [Indexed: 11/14/2022] Open
Abstract
The goal of this study was to assess the overtreatment of asymptomatic bacteriuria (ASB) in hospitalized patients, calculate the total costs of inappropriate treatment, and determine if a multi-faceted educational intervention was effective in reducing the overtreatment of ASB in a resource-limited community hospital. The study encompassed three phases: a retrospective pre-intervention assessment of the baseline cost and treatment of ASB, the implementation of a multi-faceted educational intervention, and a prospective post-intervention assessment of the efficacy of the intervention. A positive urine culture was defined by bacterial counts ≥10(5) cfu/mL. In the pre-intervention group, 64 (83%) of 109 patients were asymptomatic: 30 (47%) were treated. In the post-intervention group, 13 (17%) of 55 patients were asymptomatic: 2 (15%) were treated, (p=0.04). Fewer urine cultures were collected during the post-intervention period than the pre-intervention period (3,127 and 3,419, respectively) (p<0.001). The total cost of inappropriately treating ASB in the pre-intervention group was $1200 compared to $600 in the post-intervention group. The results demonstrated a significant decrease in the inappropriate treatment of ASB and the associated costs.
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Affiliation(s)
- Farhana Chowdhury
- Department of Internal Medicine, Lutheran Medical Center, New York, NY, USA
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Herr HW. Intravesical Bacillus Calmette-Guérin Outcomes in Patients With Bladder Cancer and Asymptomatic Bacteriuria. J Urol 2012; 187:435-7. [DOI: 10.1016/j.juro.2011.10.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Harry W. Herr
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York
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Marschall J, Ota KN, Henderson JP, Warren DK. Not all nosocomial Escherichia coli bacteriurias are catheter associated. Infect Control Hosp Epidemiol 2011; 32:1140-2. [PMID: 22011547 DOI: 10.1086/662587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jonas Marschall
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Abstract
Each year around one million urinary catheters are inserted in NHS hospitals. In around 60% of cases prophylactic antibiotics are prescribed prior to removal. This practice aims to reduce infection risks, but is not supported by evidence. Inappropriate prescribing increases antibiotic resistance, already a serious and worsening problem, and exposes patients to the hazards of antibiotic prescribing. This practice also costs an estimated £1.35-£2.7 million pounds annually. Nurses at all levels can have a huge influence on catherterization rates and catheter management. This can reduce the risks of harm and infection and improve quality of care.
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Positive urine cultures: A major cause of inappropriate antimicrobial use in hospitals? CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 20:107-11. [PMID: 21119801 DOI: 10.1155/2009/702545] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
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.
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O’Dell KK. Pharmacologic Management of Asymptomatic Bacteriuria and Urinary Tract Infections in Women. J Midwifery Womens Health 2011; 56:248-65. [DOI: 10.1111/j.1542-2011.2011.00063.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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