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Kranz J, Bartoletti R, Bruyère F, Cai T, Geerlings S, Köves B, Schubert S, Pilatz A, Veeratterapillay R, Wagenlehner FME, Bausch K, Devlies W, Horváth J, Leitner L, Mantica G, Mezei T, Smith EJ, Bonkat G. European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines. Eur Urol 2024; 86:27-41. [PMID: 38714379 DOI: 10.1016/j.eururo.2024.03.035] [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: 03/12/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND AND OBJECTIVE Urological infections significantly impact the wellbeing and quality of life of individuals owing to their widespread occurrence and diverse clinical manifestations. The objective of the guidelines panel was to provide evidence-based guidance on the diagnosis, treatment, and prevention of urinary tract infections (UTIs) and male accessory-gland infections, while addressing crucial public health aspects related to infection control and antimicrobial stewardship. METHODS For the 2024 guidelines on urological infections, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences. KEY FINDINGS AND LIMITATIONS Key recommendations emphasise the importance of a thorough medical history and physical examination for patients with urological infections. The guidelines stress the role of antimicrobial stewardship to combat the rising threat of antimicrobial resistance, providing recommendations for antibiotic selection, dosing, and duration on the basis of the latest evidence. CONCLUSIONS AND CLINICAL IMPLICATIONS This overview of the 2024 EAU guidelines offers valuable insights into managing urological infections and are designed for effective integration into clinical practice. PATIENT SUMMARY The European Association of Urology has issued an updated guideline on urological infections. The guidelines provide recommendations for diagnosis, treatment, and prevention, with a particular focus on minimising antibiotic use because of the increasing global threat of antimicrobial resistance.
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Affiliation(s)
- Jennifer Kranz
- Department of Urology and Pediatric Urology, RWTH Aachen University, Aachen, Germany; Department of Urology and Kidney Transplantation, Martin-Luther-University, Halle, Germany.
| | - Riccardo Bartoletti
- Department of Translational Research and New Technologies, University of Pisa, Pisa, Italy
| | - Franck Bruyère
- Department of Urology, CHRU Bretonneau, Tours, France; Université Francois Rabelais, PRES Centre Val de Loire, Tours, France
| | - Tommaso Cai
- Department of Urology, Santa Chiara, Regional Hospital, Trento, Italy
| | - Suzanne Geerlings
- Department of Internal Medicine, Amsterdam Institute for Infection and Immunity, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Bela Köves
- Department of Urology, University of Szeged, Szeged, Hungary
| | - Sören Schubert
- Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Adrian Pilatz
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany
| | | | - Florian M E Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Kathrin Bausch
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wout Devlies
- Department of Urology, UZ Leuven, Leuven, Belgium
| | - József Horváth
- BKMK SZTE ÁOK Okt. Kh. Urológiai Osztálya, Kecskemét, Hungary
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Tunde Mezei
- Department of Urology, Telemark Hospital, Skien, Norway
| | - Emma J Smith
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Gernot Bonkat
- alta Uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University of Basel, Basel, Switzerland
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White AT, Vaughn VM, Petty LA, Gandhi TN, Horowitz JK, Flanders SA, Bernstein SJ, Hofer TP, Ratz D, McLaughlin ES, Nielsen D, Czilok T, Minock J, Gupta A. Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections. Clin Infect Dis 2024; 78:1403-1411. [PMID: 38298158 PMCID: PMC11175682 DOI: 10.1093/cid/ciae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/28/2023] [Accepted: 01/26/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services. METHODS Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability. RESULTS Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24 483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through (a) face validity by hospital users, the TEPs, and patient focus group, (b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and (c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, P < .001), supporting usability. CONCLUSIONS We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI.
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Affiliation(s)
- Andrea T White
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Timothy P Hofer
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth S McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Daniel Nielsen
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tawny Czilok
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer Minock
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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3
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Lazarus JE, Gupta K. Recurrent UTI in Women-Risk Factors and Management. Infect Dis Clin North Am 2024; 38:325-341. [PMID: 38599896 DOI: 10.1016/j.idc.2024.03.010] [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] [Indexed: 04/12/2024]
Abstract
Urinary tract infections (UTIs) are common in women; more than 50% of women will be diagnosed with a UTI in her lifetime. Many of these women will go on to develop recurrent UTI. Nevertheless, evidence-based prevention of recurrent UTI is under-utilized. Here, the authors provide detailed practical advice on UTI prevention with a thorough review of the evidence. Non-antibiotic prevention measures discussed include increased fluid intake, vaginal estrogen therapy, methenamine, and cranberry. Antibiotic prophyalxis for carefully selected patients is also discussed.
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Affiliation(s)
- Jacob E Lazarus
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, GRJ 512C, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Kalpana Gupta
- Harvard Medical School, Boston, MA, USA; Veterans Affairs Boston Healthcare System, 1400 VFW Parkway, Executive Suite, West Roxbury, MA 02132, USA; Boston University School of Medicine, Boston, MA, USA.
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Naber KG, Alidjanov JF, Fünfstück R, Strohmaier WL, Kranz J, Cai T, Pilatz A, Wagenlehner FM. Therapeutic strategies for uncomplicated cystitis in women. GMS INFECTIOUS DISEASES 2024; 12:Doc01. [PMID: 38764941 PMCID: PMC11099625 DOI: 10.3205/id000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
Uncomplicated cystitis is affecting many women of all ages and has a great impact on the quality of life, especially in women suffering from recurrent, uncomplicated cystitis. By far the most frequent uropathogen, E. coli, may have acquired increasing resistance against a variety of oral antibiotics, which may differ between countries and regions. Therefore, local resistance data are important to be considered. On the other hand, non-antibiotic therapy has also become an option which should be discussed and offered to the patient. In patients suffering from recurrent uncomplicated cystitis, individual risk factors and possible behavioral changes should first be taken into account. Non-antimicrobial prophylactic strategies shown to be successful in well-designed clinical studies are the next options. Long term antibiotic prophylaxis, however, should only be considered as a last option. For some of those patients self-diagnosis and self-treatment may be suitable, e.g. by using a recognized questionnaire.
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Affiliation(s)
- Kurt G. Naber
- Department of Urology, Technical University of Munich, Germany
| | | | | | - Walter L. Strohmaier
- Medical School Regiomed, Coburg, Germany
- Julius Maximilian University, Wuerzburg, Germany
- University of Split, Croatia
| | - Jennifer Kranz
- Department of Urology and Pediatric Urology, University Medical Center RWTH Aachen, Germany
- Department of Urology and Kidney Transplantation, Martin Luther University, Halle (Saale), Germany
| | - Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
| | - Adrian Pilatz
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Germany
| | - Florian M. Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University of Giessen, Germany
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Ayoub E, Kutchukian S, Bigot P, Dinh A, Gondran-Tellier B, Robin H, Françot M, de Vergie S, Rigaud J, Chapuis M, Brureau L, Jousseaume C, Karray O, Kosseifi FT, Borojeni S, Descazeaud A, Asare HJ, Gaullier M, Poussot B, Tricard T, Baboudjian M, Lechevallier É, Delpech PO, Ducousso H, Bernardeau S, Bruyère F, Vallée M. Asymptomatic bacteriuria prior to partial and radical nephrectomy: To screen or not to screen? Results from the national and multicenter TOCUS database. World J Urol 2024; 42:179. [PMID: 38507063 DOI: 10.1007/s00345-024-04853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/06/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION In the era of increased bacterial resistance, the main strategy is to reduce the prescription of antibiotics when possible. Nowadays, it is highly recommended to screen for asymptomatic bacteriuria (ABU), prior to urological surgery with potential mucosal breach or urine exposure. Screening and treating urinary colonization is a strategy widely adopted before radical and partial nephrectomy but without any evidence. Our main end point in this study is to analyze the relationship between preoperative urine culture and the risk of postoperative febrile urinary tract infection (UTI) or surgical-site infection (SSI) in partial or radical nephrectomy patients. METHODS We conducted a multicenter retrospective cohort study between January 2016 and January 2023 in 11 French tertiary referral hospitals (TOCUS database). We collected the data for 269 patients including several pre-, intra-, and post-operative variables that could potentially increase the risk of postoperative UTI and SSI including preoperative urinary culture results. RESULTS The incidence rate of postoperative UTI and SSI was 8.9% in our study. After conducting a logistic multivariate analysis, a propensity score matching analysis, and a subgroup analysis, we found no significant correlation between the urine culture and the postoperative UTI risk [OR = 1.2 (0.5-2.7) (p = 0.7)]. Only the postoperative non-infectious complications were related to a higher risk of postoperative UTI [OR = 12 (4-37), p < 0.001)]. CONCLUSION Our research shows that screening and treating for ABU prior to radical or partial nephrectomy seems to be unnecessary to prevent postoperative UTI and SSI.
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Affiliation(s)
- Elias Ayoub
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France.
| | - Stessy Kutchukian
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Pierre Bigot
- Département d'urologie Centre Hospitalier Universitaire, Angers, France
| | - Aurélien Dinh
- Service de maladies infectieuses, Centre Hospitalier Universitaire, R. Poincaré, APHP, GarchesUniversité Versailles Paris Saclay, IHU PROMETHEUS, Paris, France
- Membre du comité d'infectiologie de l'Association Française d'Urologie (CIAFU), Paris, France
| | - Bastien Gondran-Tellier
- Département d'urologie Centre Hospitalier Universitaire, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Humphrey Robin
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Marc Françot
- Département d'urologie Centre Hospitalier Universitaire, Nantes, France
| | | | - Jérôme Rigaud
- Département d'urologie Centre Hospitalier Universitaire, Nantes, France
| | - Mathilde Chapuis
- Département d'urologie Centre Hospitalier Universitaire, Guadeloupe, France
| | - Laurent Brureau
- Département d'urologie Centre Hospitalier Universitaire, Guadeloupe, France
| | - Camille Jousseaume
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Omar Karray
- Département d'urologie Centre Hospitalier, Pontoise, France
| | - Fares T Kosseifi
- Département d'urologie Centre Hospitalier Universitaire, Paris Saint Joseph, France
| | - Shahed Borojeni
- Département d'urologie Centre Hospitalier Universitaire, Paris Saint Joseph, France
| | | | - Harrison-Junior Asare
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Maxime Gaullier
- Département d'urologie Centre Hospitalier Universitaire, Strasbourg, France
| | - Baptiste Poussot
- Département d'urologie Centre Hospitalier Universitaire, Strasbourg, France
| | - Thibault Tricard
- Département d'urologie Centre Hospitalier Universitaire, Strasbourg, France
| | - Michael Baboudjian
- Département d'urologie Centre Hospitalier Universitaire, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Éric Lechevallier
- Département d'urologie Centre Hospitalier Universitaire, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Pierre-Olivier Delpech
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Héloïse Ducousso
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Simon Bernardeau
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Franck Bruyère
- Membre du comité d'infectiologie de l'Association Française d'Urologie (CIAFU), Paris, France
- Département d'urologie Centre Hospitalier Universitaire, Tours, France
| | - Maxime Vallée
- Département d'urologie et de transplantation rénale, Centre Hospitalier Universitaire, 2 rue de la Milétrie, 86000, Poitiers, France
- Membre du comité d'infectiologie de l'Association Française d'Urologie (CIAFU), Paris, France
- Université de Poitiers, unité INSERM U1070, PHAR2, 86000, Poitiers, France
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Cuningham W, Perera S, Coulter S, Wang Z, Tong SYC, Wozniak TM. Repurposing antibiotic resistance surveillance data to support treatment of recurrent infections in a remote setting. Sci Rep 2024; 14:2414. [PMID: 38287025 PMCID: PMC10825221 DOI: 10.1038/s41598-023-50008-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 12/14/2023] [Indexed: 01/31/2024] Open
Abstract
In northern Australia, a region with limited access to healthcare and a substantial population living remotely, antibiotic resistance adds to the complexity of treating infections. Focussing on Escherichia coli urinary tract infections (UTIs) and Staphylococcus aureus skin & soft tissue infections (SSTIs) captured by a northern Australian antibiotic resistance surveillance system, we used logistic regression to investigate predictors of a subsequent resistant isolate during the same infection episode. We also investigated predictors of recurrent infection. Our analysis included 98,651 E. coli isolates and 121,755 S. aureus isolates from 70,851 patients between January 2007 and June 2020. Following an initially susceptible E. coli UTI, subsequent recovery of a cefazolin (8%) or ampicillin (13%) -resistant isolate during the same infection episode was more common than a ceftriaxone-resistant isolate (2%). For an initially susceptible S. aureus SSTI, subsequent recovery of a methicillin-resistant isolate (8%) was more common than a trimethoprim-sulfamethoxazole-resistant isolate (2%). For UTIs and SSTIs, prior infection with a resistant pathogen was a strong predictor of both recurrent infection and resistance in future infection episodes. This multi-centre study demonstrates an association between antibiotic resistance and an increased likelihood of recurrent infection. Particularly in remote areas, a patient's past antibiograms should guide current treatment choices since recurrent infection will most likely be at least as resistant as previous infection episodes. Using population-level surveillance data in this way can also help clinicians decide if they should switch antibiotics for patients with ongoing symptoms, while waiting for diagnostic results.
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Affiliation(s)
- Will Cuningham
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, SW17 0RE, UK.
| | | | - Sonali Coulter
- Medication Services Queensland, Prevention Division, Department of Health, Brisbane, QLD, Australia
| | - Zhiqiang Wang
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Steven Y C Tong
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Teresa M Wozniak
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
- Australian e-Health Research Centre CSIRO, Brisbane, QLD, Australia.
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7
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Durkin MJ, Schmitz V, Hsueh K, Troubh Z, Politi MC. Older adults' and caregivers' perceptions about urinary tract infection and asymptomatic bacteriuria guidelines: a qualitative exploration. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e224. [PMID: 38156231 PMCID: PMC10753467 DOI: 10.1017/ash.2023.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Abstract
Objective To explore older adults' and caregivers' knowledge and perceptions of guidelines for appropriate antibiotics use for bacteria in the urine. Design Semi-structured qualitative interviews. Setting Infectious disease clinics, community senior living facilities, memory care clinics, and general public. Participants Patients 65 years or older diagnosed with a urinary tract infection (UTI) in the past two years, or caregivers of such patients. Methods We conducted interviews between March and July 2023. We developed an interview guide based on the COM-B (capability, opportunity, motivation-behavior) behavior change framework. We thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques. Results Thirty participants (21 patients, 9 caregivers) enrolled. Most participants understood UTI symptoms such as pain during urination and frequent urination. However, communication with multiple clinicians, misinformation, and unclear symptoms that overlapped with other health issues clouded their understanding of asymptomatic bacteriuria (ASB) and UTIs. Some participants worried that clinicians would be dismissive of symptoms if they suggested a diagnosis of ASB without prescribing antibiotics. Many participants felt that the benefits of taking antibiotics for ASB outweighed harms, though some mentioned fears of personal antibiotic resistance if taking unnecessary antibiotics. No participants mentioned the public health impact of potential antibiotic resistance. Most participants trusted information from clinicians over brochures or websites but wanted to review information after clinical conversations. Conclusion Clinician-focused interventions to reduce antibiotic use for ASB should also address patient concerns during clinical visits, and provide standardized high-quality educational materials at the end of the visit.
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Affiliation(s)
- Michael J. Durkin
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Viktoria Schmitz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin Hsueh
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Zoe Troubh
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Melnick D, Talley AK, Gupta VK, Critchley IA, Eckburg PB, Hamed KA, Bhatt N, Moore G, Austin D, Rubino CM, Bhavnani SM, Ambrose PG. Impact of antibiotic pharmacokinetics in urine on recurrent bacteriuria following treatment of complicated urinary tract infections. Antimicrob Agents Chemother 2023; 67:e0053523. [PMID: 37768311 PMCID: PMC10583661 DOI: 10.1128/aac.00535-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/16/2023] [Indexed: 09/29/2023] Open
Abstract
The clinical relevance of bacteriuria following antibiotic treatment of complicated urinary tract infections in clinical trials remains controversial. We evaluated the impact of urine pharmacokinetics on the timing of recurrent bacteriuria in a recently completed trial that compared oral tebipenem pivoxil hydrobromide to intravenous ertapenem. The urinary clearance and urine dwell time of ertapenem were prolonged relative to tebipenem and were associated with a temporal difference in the repopulation of bladder urine with bacteria following treatment, potentially confounding the assessment of efficacy.
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Affiliation(s)
- David Melnick
- Spero Therapeutics, Inc., Cambridge, Massachusetts, USA
| | | | | | | | | | | | | | - Gary Moore
- Moore Computing Services, Inc., Little Rock, Arkansas, USA
| | | | | | - Sujata M. Bhavnani
- Institute for Clinical Pharmacodynamics, Inc., Schenectady, New York, USA
| | - Paul G. Ambrose
- Institute for Clinical Pharmacodynamics, Inc., Schenectady, New York, USA
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9
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Abbott IJ, Peel TN, Cairns KA, Stewardson AJ. Antibiotic management of urinary tract infections in the post-antibiotic era: a narrative review highlighting diagnostic and antimicrobial stewardship. Clin Microbiol Infect 2023; 29:1254-1266. [PMID: 35640839 DOI: 10.1016/j.cmi.2022.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/03/2022] [Accepted: 05/11/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND As one of the most common indications for antimicrobial prescription in the community, the management of urinary tract infections (UTIs) is both complicated by, and a driver of, antimicrobial resistance. OBJECTIVES To highlight the key clinical decisions involved in the diagnosis and treatment of UTIs in adult women, focusing on clinical effectiveness and both diagnostic and antimicrobial stewardship as we approach the post-antimicrobial era. SOURCES Literature reviewed via directed PubMed searches and manual searching of the reference list for included studies to identify key references to respond to the objectives. A strict time limit was not applied. We prioritised recent publications, randomised trials, and systematic reviews (with or without meta-analyses) where available. Searches were limited to English language articles. A formal quality assessment was not performed; however, the strengths and limitations of each paper were reviewed by the authors throughout the preparation of this manuscript. CONTENT We discuss the management of UTIs in ambulatory adult women, with particular focus on uncomplicated infections. We address the diagnosis of UTIs, including the following: definition and categorisation; bedside assessments and point-of-care tests; and the indications for, and use of, laboratory tests. We then discuss the treatment of UTIs, including the following: indications for treatment, antimicrobial sparing approaches, key considerations when selecting a specific antimicrobial agent, specific treatment scenarios, and duration of treatment. We finally outline emerging areas of interest in this field. IMPLICATIONS The steady increase in antimicrobial resistance among common uropathogens has had a substantial affect on the management of UTIs. Regarding both diagnosis and treatment, the clinician must consider both the patient (clinical effectiveness and adverse effects, including collateral damage) and the community more broadly (population-level antimicrobial selection pressure).
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia; Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Nguyen HM, Flerchinger S, Smith JR, Felcher AH, Turley M, Mcnamara M. Diagnostic and antibiotic stewardship lessons: an outpatient assessment of symptomatic reflex urinalysis ordering accuracy using an electronic best-practice alert. J Antimicrob Chemother 2023; 78:2283-2290. [PMID: 37492974 DOI: 10.1093/jac/dkad233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND It is not well known how reliably clinicians order reflex urinalysis to microscopy and culture (rUA-cx) for outpatient urinary tract infection (UTI) workup. Antibiotic appropriateness cannot be fully appreciated until the prevalence of UTIs and asymptomatic bacteriuria (ASB) are realized. OBJECTIVE This quality improvement study has two major aims, first to determine UTI symptom accuracy for rUA-cx ordering and second, to confirm UTI and ASB cases by integrating rUA-cx and cascaded urinalysis results. Antibiotic utilization and diagnostic coding were secondarily linked to UTIs and ASB. METHODS An electronic best-practice alert informed the ordering of two rUA-cx options: symptomatic- rUA-cx specifically for dysuria, frequency, urgency, costovertebral pain, suprapubic pain or fever versus non-specific-rUA-cx for vague complaints. UTI symptoms were verified by chart review. Confirmed UTI was defined as a significant culture with UTI symptoms and ASB as a significant culture without UTI symptoms. RESULTS rUA-cx (2065) were prospectively collected over 6 months from female patients at risk for uncomplicated UTIs. Symptomatic-rUA-cx and non-specific-rUA-cx were associated with UTI symptoms for 53% (809/1527) and 20% (107/538), respectively. Overall, 44% (916/2065) of all rUA-cx had UTI symptoms. rUA-cx were overordered by a factor of 9 (2065/225) for every confirmed UTI. The UTI-to-ASB relative ratio was 2.6 (225/86). Regarding UTI-relevant antibiotics, 39% (214/553) were appropriately associated with UTI whereas only 22% (74/339) of inappropriate antibiotics were captured by the ASB definition, underestimating the problem 4-fold. CONCLUSIONS UTI and ASB remain challenging to categorize despite a meticulous method that applied acceptable criteria.
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Affiliation(s)
- Hien M Nguyen
- Department of Infectious Diseases, Northwest Permanente, Portland, Oregon, USA
| | | | - Jeffrey R Smith
- Kaiser Permanente Northwest Region Laboratories, Portland, Oregon, USA
- The Permanente Federation, Convergent Medical Terminology, Oakland, California, USA
| | - Andrew H Felcher
- Department of Hospital Medicine, Northwest Permanente, Portland, Oregon, USA
| | | | - Michael Mcnamara
- Department of Medical Informatics, Northwest Permanente, Portland, Oregon, USA
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11
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Tverring J, Månsson E, Andrews V, Ljungquist O. Pivmecillinam with Amoxicillin/Clavulanic acid as step down oral therapy in febrile Urinary Tract Infections caused by ESBL-producing Enterobacterales (PACUTI). Trials 2023; 24:568. [PMID: 37660037 PMCID: PMC10474767 DOI: 10.1186/s13063-023-07542-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/25/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Oral treatment alternatives for febrile urinary tract infections are limited in the era of increasing antimicrobial resistance. We aim to evaluate if the combination of pivmecillinam and amoxicillin/clavulanic acid is non-inferior to current alternatives for step-down therapy in adult patients with febrile urinary tract infection. METHODS We plan to perform an investigator-initiated non-inferiority trial. Adult hospitalised patients treated with 1-5 days of intravenous antibiotics for acute febrile urinary tract infection caused by extended spectrum beta-lactamase (ESBL) producing Enterobacterales will be randomised 1:1 to either control (7-10 days of either oral ciprofloxacin 500 mg twice daily or oral trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily or intravenous ertapenem 1 g once daily, depending on sex, drug allergy, glomerular filtration rate and susceptibility testing) or intervention (10 days of pivmecillinam 400 mg three times daily and amoxicillin/clavulanic acid 500/125 mg three times daily). The primary outcome will be clinical cure 10 days (+/- 2 days) after antibiotic treatment completion. Clinical cure is defined as being alive with absence of fever and return to non-infected baseline of urinary tract symptoms without additional antibiotic treatment or re-hospitalisation (for urinary tract infection) based on a centralised allocation-blinded structured telephone interview. We plan to recruit 330 patients to achieve 90% power based on a sample size simulation analysis using a two-group comparison, one-sided alpha of 2.5%, an absolute non-inferiority margin of 10% and expecting 93% clinical cure rate and 10% loss to follow-up. The primary endpoint will be analysed using generalised estimated equations and reported as risk difference for both intention-to-treat and per protocol populations. Patients are planned to be recruited from at least 10 centres in Sweden from 2023 to 2026. DISCUSSION If the combination of pivmecillinam and amoxicillin/clavulanic acid is found to be non-inferior to the control drugs there are potential benefits in terms of tolerability, frequency of interactions, outpatient treatment, side effects, nosocomial infections and drive for further antimicrobial resistance compared to existing drugs. TRIAL REGISTRATION NCT05224401. Registered on February 4, 2022.
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Affiliation(s)
- Jonas Tverring
- Department of Clinical Sciences Helsingborg (AKVH), Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Infectious Diseases, Helsingborg Hospital, Region Skåne, Helsingborg, Sweden.
| | - Emeli Månsson
- Department of Infectious Diseases and Centre of Clinical Research, Västmanland Hospital, Västerås, Sweden
| | - Vigith Andrews
- Department of Clinical Microbiology, Lund University Hospital, Lund, Sweden
| | - Oskar Ljungquist
- Department of Clinical Sciences Helsingborg (AKVH), Faculty of Medicine, Lund University, Lund, Sweden
- Department of Infectious Diseases, Helsingborg Hospital, Region Skåne, Helsingborg, Sweden
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12
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Belk MG, Hammond OD, Seales CC, Edwards JD, Steuber TD. Effect of microbiology comment nudging on antibiotic use in asymptomatic bacteriuria: A before-and-after quasi-experimental study. Infect Control Hosp Epidemiol 2023; 44:1391-1395. [PMID: 36924157 PMCID: PMC10507501 DOI: 10.1017/ice.2022.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To describe the effect of a microbiology comment nudge on antibiotic use for asymptomatic bacteriuria (ASB). DESIGN Single-center, before-and-after, quasi-experimental study. SETTING Community-based, public, not-for-profit teaching hospital in the southeastern United States. PARTICIPANTS Adult inpatients with a positive urine culture and the absence of urinary tract infection signs and symptoms. INTERVENTION Implementation of a microbiology comment nudge on urine cultures. RESULTS In total, 204 patients were included in the study. Antibiotics were less likely to be continued beyond 72 hours in the postimplementation group: 57 (55%) of 104 versus 38 (38%) of 100 (P = .016). They were less likely to have antibiotics continued beyond 48 hours: 60 (58%) of 104 versus 43 (43%) of 100 (P = .036). They were also less likely to have antibiotics prescribed at discharge 35 (34%) of 104 versus 20 (20%) of 100 (P = .028). In addition, they had fewer total antibiotic days of therapy: 4 (IQR, 1-6) versus 1 (IQR, 0-6) (P = .022). CONCLUSION Microbiology comment nudging may contribute to less antibiotic utilization in patients with ASB.
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Affiliation(s)
- Madeline G. Belk
- Huntsville Hospital, Department of Pharmacy, Huntsville, Alabama
| | | | | | | | - Taylor D. Steuber
- Huntsville Hospital, Department of Pharmacy, Huntsville, Alabama
- Auburn University Harrison School of Pharmacy, Pharmacy Practice, Huntsville, Alabama
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13
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Piggott KL, Trimble J, Leis JA. Reducing unnecessary urine culture testing in residents of long term care facilities. BMJ 2023; 382:e075566. [PMID: 37558239 PMCID: PMC10466199 DOI: 10.1136/bmj-2023-075566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
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14
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Butler DS, Wagenlehner F, Höller M, Abramov-Sommariva D, Steindl H, Naber KG. Phytotherapy (BNO 1045) of Acute Lower Uncomplicated Urinary Tract Infection in Women Normalizes Local Host Responses. Urol Int 2023; 107:778-784. [PMID: 37544300 PMCID: PMC10614491 DOI: 10.1159/000531206] [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: 12/14/2022] [Accepted: 05/13/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Acute lower uncomplicated urinary tract infection (uUTI) affects a large proportion of women. Increased antimicrobial resistance has created an urgent need for novel therapeutics and the phytotherapeutic drug BNO 1045 (Canephron® N) has previously been shown to be noninferior to standard antimicrobial stewardship. This sub-analysis from a randomized, double-blind, controlled phase III noninferiority clinical trial using BNO 1045 versus fosfomycin to treat uUTI aimed to determine how urine cytokine levels are altered by the two different treatments. METHODS Urine samples from a predefined subset of women diagnosed with uUTI (18-70 years) and treated with BNO 1045 (n = 58) or fosfomycin (n = 69) were analyzed for urine levels of IL-6 and IL-8, using analyte-to-creatinine ratios. RESULTS BNO 1045 treatment showed similar effects to fosfomycin treatment in reducing both urine IL-6 and IL-8 levels. Mean IL-6 and IL-8 levels were markedly reduced in all patients regardless of treatment. BNO 1045 treatment decreased urine IL-8 significantly (p = 0.0142) and showed a trend toward reduction of urine IL-6 (p = 0.0551). Fosfomycin treatment reduced both IL-6 and IL-8 levels significantly (p = 0.0038, <0.0001 respectively). CONCLUSION BNO 1045 is, in addition to reducing symptoms, comparable to fosfomycin treatment in reducing the local inflammatory response associated with uUTI.
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Affiliation(s)
- Daniel S.C. Butler
- Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Florian Wagenlehner
- Clinic of Urology, Pediatric Urology and Andrology, Justus-Liebig University, Giessen, Germany
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15
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Frost DW, Vaisman A. The Use of Urinalysis and Urine Culture in Diagnosis: The Role of Uncertainty Tolerance. Am J Med 2023; 136:729-731. [PMID: 37004955 DOI: 10.1016/j.amjmed.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 04/04/2023]
Affiliation(s)
- David W Frost
- Division of General Internal Medicine, University of Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Department of Medicine.
| | - Alon Vaisman
- University Health Network, Toronto, Ontario, Canada; Department of Medicine; Division of Infectious Diseases, University of Toronto, Ontario, Canada
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16
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Miller T, Lange D, Kizhakkedathu JN, Yu K, Felix D, Samejima S, Shackleton C, Malik RN, Sachdeva R, Walter M, Krassioukov AV. The Microbiological Burden of Short-Term Catheter Reuse in Individuals with Spinal Cord Injury: A Prospective Study. Biomedicines 2023; 11:1929. [PMID: 37509568 PMCID: PMC10377649 DOI: 10.3390/biomedicines11071929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Despite the risk of developing catheter-associated urinary tract infections (CAUTI), catheter reuse is common among people with spinal cord injury (SCI). This study examined the microbiological burden and catheter surface changes associated with short-term reuse. Ten individuals with chronic SCI reused their catheters over 3 days. Urine and catheter swab cultures were collected daily for analysis. Scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS) analyses were used to assess catheter surface changes. Catheter swab cultures showed no growth after 48 h (47.8%), skin flora (28.9%), mixed flora (17.8%), or bacterial growth (5.5%). Asymptomatic bacteriuria was found for most participants at baseline (n = 9) and all at follow-up (n = 10). Urine samples contained Escherichia coli (58%), Klebsiella pneumoniae (30%), Enterococcus faecalis (26%), Acinetobacter calcoaceticus-baumannii (10%), Pseudomonas aeruginosa (6%) or Proteus vulgaris (2%). Most urine cultures showed resistance to one or more antibiotics (62%). SEM images demonstrated structural damage, biofilm and/or bacteria on all reused catheter surfaces. XPS analyses also confirmed the deposition of bacterial biofilm on reused catheters. Catheter surface changes and the presence of antibiotic-resistant bacteria were evident following short-term reuse, which may increase susceptibility to CAUTI in individuals with SCI despite asymptomatic bacteriuria.
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Affiliation(s)
- Tiev Miller
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Dirk Lange
- Department of Urologic Sciences, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- The Stone Centre at Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Jayachandran N Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Centre for Blood Research, Life Science Institute, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- The School of Biomedical Engineering, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Kai Yu
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Centre for Blood Research, Life Science Institute, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Demian Felix
- Department of Urologic Sciences, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- The Stone Centre at Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Soshi Samejima
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Claire Shackleton
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Raza N Malik
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Rahul Sachdeva
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Matthias Walter
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Department of Urology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC V5Z 2G9, Canada
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17
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Almas S, Carpenter RE, Rowan C, Tamrakar VK, Bishop J, Sharma R. Advantage of precision metagenomics for urinary tract infection diagnostics. Front Cell Infect Microbiol 2023; 13:1221289. [PMID: 37469596 PMCID: PMC10352793 DOI: 10.3389/fcimb.2023.1221289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023] Open
Abstract
Background Urinary tract infections (UTIs) remain a diagnostic challenge and often promote antibiotic overuse. Despite urine culture being the gold standard for UTI diagnosis, some uropathogens may lead to false-negative or inconclusive results. Although PCR testing is fast and highly sensitive, its diagnostic yield is limited to targeted microorganisms. Metagenomic next-generation sequencing (mNGS) is a hypothesis-free approach with potential of deciphering the urobiome. However, clinically relevant information is often buried in the enormous amount of sequencing data. Methods Precision metagenomics (PM) is a hybridization capture-based method with potential of enhanced discovery power and better diagnostic yield without diluting clinically relevant information. We collected 47 urine samples of clinically suspected UTI and in parallel tested each sample by microbial culture, PCR, and PM; then, we comparatively analyzed the results. Next, we phenotypically classified the cumulative microbial population using the Explify® data analysis platform for potential pathogenicity. Results Results revealed 100% positive predictive agreement (PPA) with culture results, which identified only 13 different microorganisms, compared to 19 and 62 organisms identified by PCR and PM, respectively. All identified organisms were classified into phenotypic groups (0-3) with increasing pathogenic potential and clinical relevance. This PM can simultaneously quantify and phenotypically classify the organisms readily through bioinformatic platforms like Explify®, essentially providing dissected and quantitative results for timely and accurate empiric UTI treatment. Conclusion PM offers potential for building effective diagnostic models beyond usual care testing in complex UTI diseases. Future studies should assess the impact of PM-guided UTI management on clinical outcomes.
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Affiliation(s)
- Sadia Almas
- Department of Research, Advanta Genetics, Tyler, TX, United States
| | - Rob E. Carpenter
- Department of Research, Advanta Genetics, Tyler, TX, United States
- Soules College of Business, University of Texas at Tyler, Tyler, TX, United States
| | - Chase Rowan
- Department of Research, Advanta Genetics, Tyler, TX, United States
| | - Vaibhav K. Tamrakar
- Divison of Communicable Diseases, ICMR-National Institute of Research in Tribal Health, Jabalpur, India
- Department of Research, RetroBioTech LLC, Coppell, TX, United States
| | - Joseph Bishop
- Department of Research, Advanta Genetics, Tyler, TX, United States
| | - Rahul Sharma
- Department of Research, Advanta Genetics, Tyler, TX, United States
- Department of Research, RetroBioTech LLC, Coppell, TX, United States
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18
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Mak Q, Greig J, Ahmed K, Khan S, Dasgupta P, Malde S, Raison N. Competitive Inoculation as an Effective Prophylaxis Against Recurrent Urinary Tract Infections: A Systematic Review. Int Neurourol J 2023; 27:79-87. [PMID: 37401018 DOI: 10.5213/inj.2346052.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/09/2023] [Indexed: 07/05/2023] Open
Abstract
Urinary tract infection (UTI) is a common condition defined as the presence of bacteria within the urine above a certain threshold (usually >100,000 m/L). The lifetime risk in women is estimated to be 50%, of whom 25% will develop recurrence within 6 months. Unfortunately, the use of antibiotics to treat and manage recurrent UTI (rUTI) is a growing problem, due to the burden of growing antibiotic resistance on public health. As such, new approaches to manage rUTI are being investigated and developed. Competitive inoculation via instillation of Escherichia coli 83972 or HU2117 in the bladder is a new prophylactic non-antimicrobial therapy for rUTIs. It utilizes the principle of the protective nature of asymptomatic bacteriuria to prevent recurrence of symptomatic UTIs. However, the effectiveness and safety of this technique remains unclear. This systematic review examined the current outcomes data on competitive inoculation as an effective and safe treatment for rUTI prophylaxis. Based on a limited number of studies, current evidence suggests that competitive inoculation is an effective and safe prophylactic measure against UTIs in a select group of patients with incomplete bladder emptying. However, administration of the technology is both resource and time intensive, and there is strong data demonstrating low successful colonisation rates. Competitive inoculation is an alternative to antibiotics only to rUTI patients with incomplete bladder emptying. There is no evidence to suggest that the technology would be suitable for other subsets of rUTI patients. Further randomized controlled trials should be conducted to improve the evidence base before drawing conclusions for clinical practice, and ideas to improve colonisation rates and simplify the administration process should be explored.
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Affiliation(s)
- Quentin Mak
- GKT School of Medical Education, King's College London, London, UK
| | - Julian Greig
- GKT School of Medical Education, King's College London, London, UK
| | - Kamran Ahmed
- MRC Centre for Transplantation, Guy's Hospital, King's College London, London, UK
- Khalifa University, Abu Dhabi, United Arab Emirates
| | - Shamim Khan
- Department of Urology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Prokar Dasgupta
- MRC Centre for Transplantation, Guy's Hospital, King's College London, London, UK
- Department of Urology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Sachin Malde
- Department of Urology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Raison
- MRC Centre for Transplantation, Guy's Hospital, King's College London, London, UK
- Department of Urology, Guys and St Thomas' NHS Foundation Trust, London, UK
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19
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Edwards G, Seeley A, Carter A, Patrick Smith M, Cross ELA, Hughes K, Van den Bruel A, Llewelyn MJ, Verbakel JY, Hayward G. What is the Diagnostic Accuracy of Novel Urine Biomarkers for Urinary Tract Infection? Biomark Insights 2023; 18:11772719221144459. [PMID: 36761839 PMCID: PMC9902898 DOI: 10.1177/11772719221144459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/31/2022] [Indexed: 01/26/2023] Open
Abstract
Background Urinary tract infection (UTI) affects half of women at least once in their lifetime. Current diagnosis involves urinary dipstick and urine culture, yet both methods have modest diagnostic accuracy, and cannot support decision-making in patient populations with high prevalence of asymptomatic bacteriuria, such as older adults. Detecting biomarkers of host response in the urine of hosts has the potential to improve diagnosis. Objectives To synthesise the evidence of the diagnostic accuracy of novel biomarkers for UTI, and of their ability to differentiate UTI from asymptomatic bacteriuria. Design A systematic review. Data Sources and Methods We searched MEDLINE, EMBASE, CINAHL and Web of Science for studies of novel biomarkers for the diagnosis of UTI. We excluded studies assessing biomarkers included in urine dipsticks as these have been well described previously. We included studies of adult patients (≥16 years) with a suspected or confirmed urinary tract infection using microscopy and culture as the reference standard. We excluded studies using clinical signs and symptoms, or urine dipstick only as a reference standard. Quality appraisal was performed using QUADAS-2. We summarised our data using point estimates and data accuracy statistics. Results We included 37 studies on 4009 adults measuring 66 biomarkers. Study quality was limited by case-control design and study size; only 4 included studies had a prospective cohort design. IL-6 and IL-8 were the most studied biomarkers. We found plausible evidence to suggest that IL-8, IL-6, GRO-a, sTNF-1, sTNF-2 and MCR may benefit from more rigorous evaluation of their potential diagnostic value for UTI. Conclusions There is insufficient evidence to recommend the use of any novel biomarker for UTI diagnosis at present. Further evaluation of the more promising candidates, is needed before they can be recommended for clinical use.
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Affiliation(s)
- George Edwards
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK,George Edwards, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK.
| | - Anna Seeley
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Adam Carter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Maia Patrick Smith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth LA Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - Kathryn Hughes
- PRIME Centre Wales, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Ann Van den Bruel
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - Jan Y Verbakel
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK,EPI-Centre, Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - Gail Hayward
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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20
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Gołębiewska JE, Krawczyk B, Wysocka M, Dudziak A, Dębska-Ślizień A. Asymptomatic Bacteriuria in Kidney Transplant Recipients-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020198. [PMID: 36837399 PMCID: PMC9958684 DOI: 10.3390/medicina59020198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Urinary tract infections (UTIs) are the most prevalent complications in kidney transplant (KTx) recipients. The most frequent finding in this group of patients is asymptomatic bacteriuria (ASB). Here, we provide an overview of the available evidence regarding ASB in KTx recipients, including its etiopathology, clinical impact and management. There is a growing body of evidence from clinical trials that screening for and treating ASB is not beneficial in most KTx recipients. However, there are insufficient data to recommend or discourage the use of a "screen-and-treat strategy" for ASB during the first 1-2 months post-transplant or in the case of an indwelling urinary catheter. Despite its frequency, ASB after KTx is still an understudied phenomenon.
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Affiliation(s)
- Justyna E. Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
- Correspondence:
| | - Beata Krawczyk
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, 80-233 Gdańsk, Poland
| | - Magdalena Wysocka
- Digital Experimental Cancer Medicine Team, Cancer Biomarker Centre, CRUK Manchester Institute, University of Manchester, Manchester M13 9PL, UK
| | - Aleksandra Dudziak
- Microbiology Laboratory, University Clinical Center, 80-952 Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
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21
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Watson RA. Enlisting Probiotics to Combat Recurrent Urinary Tract Infections in Women-A Military Strategy for Meeting the Challenge. Antibiotics (Basel) 2023; 12:antibiotics12010167. [PMID: 36671368 PMCID: PMC9854529 DOI: 10.3390/antibiotics12010167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
For decades, the potential role of probiotics in the prevention and treatment of recurrent urinary tract infections has been extensively studied. However, achieving an effective problem-solving strategy has thus far proven elusive. Perhaps adopting a military paradigm might expedite our assault on chronic, recurring bacteriuria in women. What is needed is a targeted strategy with specific attention to (1) the enemy: the case-specific uropathogen; (2) the battlefield: the extraordinarily complex interplay of factors within the bladder, unique to a given patient, which interface with profoundly important influences from the gut biome, as well as the vaginal biota; (3) the weapon: an antimicrobial probiotic with demonstrated activity against that specific uropathogen; (4) a new strategy: taking these complexities into account, we posit a key role for the instillation of case-specific lactobacilli directly into the bladder of the designated patient. This newly proposed, targeted intervention might be termed "Probiotic Intravesical Organic Therapy-PIVOT"; and (5) the long campaign: reaching clinically proven success may entail a long campaign. However, already, on many fronts, the elements necessary for victory recently seem to be falling into place.
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22
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Hojat LS, Saade EA, Hernandez AV, Donskey CJ, Deshpande A. Can Electronic Clinical Decision Support Systems Improve the Diagnosis of Urinary Tract Infections? A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2022; 10:ofac691. [PMID: 36632418 PMCID: PMC9830539 DOI: 10.1093/ofid/ofac691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Background Urinary tract infection (UTI) is a commonly misdiagnosed infectious syndrome. Diagnostic stewardship interventions can reduce rates of asymptomatic bacteriuria treatment but are often labor intensive, and thus an automated means of reducing unnecessary urine testing is preferred. In this systematic review and meta-analysis, we sought to identify studies describing interventions utilizing clinical decision support (CDS) to optimize UTI diagnosis and to characterize the effectiveness of these interventions. Methods We conducted a comprehensive electronic search and manual reference list review for peer-reviewed articles published before July 2, 2021. Publications describing an intervention intending to enhance UTI diagnosis via CDS were included. The primary outcome was urine culture test rate. Results The electronic search identified 5013 studies for screening. After screening and full-text review, 9 studies met criteria for inclusion, and a manual reference list review identified 5 additional studies, yielding a total of 14 studies included in the systematic review. The most common CDS intervention was urinalysis with reflex to urine culture based on prespecified urinalysis parameters. All 9 studies that provided statistical comparisons reported a decreased urine culture rate postintervention, 8 of which were statistically significant. A meta-analysis including 4 studies identified a pooled urine culture incidence rate ratio of 0.56 (95% confidence interval, .52-.60) favoring the postintervention versus preintervention group. Conclusions In this systematic review and meta-analysis, CDS appeared to be effective in decreasing urine culture rates. Prospective trials are needed to confirm these findings and to evaluate their impact on antimicrobial prescribing, patient-relevant outcomes, and potential adverse effects.
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Affiliation(s)
- Leila S Hojat
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Elie A Saade
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA,Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Curtis J Donskey
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, Ohio, USA,Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans’ Affairs Medical Center, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Center for Value Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA,Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Phenotypic Assessment of Clinical Escherichia coli Isolates as an Indicator for Uropathogenic Potential. mSystems 2022; 7:e0082722. [PMID: 36445110 PMCID: PMC9765037 DOI: 10.1128/msystems.00827-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
For women in the United States, urinary tract infections (UTIs) are the most frequent diagnosis in emergency departments, comprising 21.3% of total visits. Uropathogenic Escherichia coli (UPEC) causes ~80% of uncomplicated UTIs. To combat this public health issue, it is vital to characterize UPEC strains as well as to differentiate them from commensal strains to reduce the overuse of antibiotics. It has been challenging to determine a consistent genetic signature that clearly distinguishes UPEC from other E. coli strains. Therefore, we examined whether phenotypic data could be predictive of uropathogenic potential. We screened 13 clinical strains of UPEC, isolated from cases of uncomplicated UTI in young otherwise healthy women, in a series of microbiological phenotypic assays using UPEC prototype strain CFT073 and nonpathogenic E. coli strain MG1655 K-12 as controls. Phenotypes included adherence, iron acquisition, biofilm formation, human serum resistance, motility, and stress resistance. By use of a well-established experimental mouse model of UTI, these data were able to predict the severity of the bacterial burden in both the urine and bladders. Multiple linear regression using three different phenotypic assays, i.e., growth in minimal medium, siderophore production, and type 1 fimbrial expression, was predictive of bladder colonization (adjusted R2 = 0.6411). Growth in ex vivo human urine, hemagglutination of red blood cells, and motility modeled urine colonization (adjusted R2 = 0.4821). These results showcase the utility of phenotypic characterization to predict the severity of infection that these strains may cause. We predict that these methods will also be applicable to other complex, genetically redundant, pathogens. IMPORTANCE Urinary tract infections are the second leading infectious disease worldwide, occurring in over half of the female population during their lifetime. Most infections are caused by uropathogenic Escherichia coli (UPEC) strains. These strains can establish a reservoir in the gut, in which they do not cause disease but, upon introduction to the urinary tract, can infect the host and elicit pathogenesis. Clinically, it would be beneficial to screen patient E. coli strains to understand their pathogenic potential, which may lead to the administration of prophylactic antibiotic treatment for those with increased risk. Others have proposed the use of PCR-based genetic screening methods to detect UPEC strains and differentiate them from other E. coli pathotypes; however, this method has not yielded a consistent uropathogenic genetic signature. Here, we used phenotypic characteristics such as growth rate, siderophore production, and expression of fimbriae to better predict uropathogenic potential.
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Antonio MEE, Cassandra BGC, Emiliano RJD, Guadalupe OLM, Lilian REA, Teresa TGM, Mario GG, Ivan RCG, Mercedes RV, Alfredo CW, Rafael RA, Lilian GBA, Manuel AGJ. Treatment of asymptomatic bacteriuria in the first 2 months after kidney transplant: A controlled clinical trial. Transpl Infect Dis 2022; 24:e13934. [PMID: 35980169 DOI: 10.1111/tid.13934] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of urinary tract infections (UTIs) in the first 2 months postrenal transplantation (pRT) is very high. We evaluate the efficacy of asymptomatic bacteriuria (AB) screening and treatment on the incidence of UTI in the first 2 months pRT METHODS: We conducted a randomized controlled clinical trial. A urine culture was obtained in all patients on the day of the bladder catheter removal, on week three, and before removal of the ureteral catheter. The intervention group received treatment for AB. The control group did not receive treatment. The primary outcomes were the cumulative incidence of UTI and/or graft pyelonephritis and the time to the first episode of UTI and/or graft pyelonephritis RESULTS: Eighty patients were randomized, 40 in each group, and the median follow-up was 63 days (IQR 54-70). The average age was 29.8 years and 33.7% (n = 27) were women. The incidences of UTI (n = 10, 25 % vs. n = 4, 10%, p = .07) and pyelonephritis (n = 6, 15% vs. n = 1, 2.5%, p = .04) were greater in the intervention group, as also shown in the survival analysis: UTI (HR2.8, 95% CI 0.8-9.1, p = .07) and pyelonephritis (HR 6.5, 95% CI 0.8-54.7, p = .08), respectively. The most commonly isolated bacterium was Escherichia coli (n = 28, 59.5%), and over half were E. coli with extended-spectrum beta-lactamases (n = 15). A major limitation was not obtaining the calculated sample size due to a delay in patient recruitment resulting from the COVID-19 pandemic CONCLUSION: Treatment of AB in the first 2 months pRT does not decrease the incidence of UTI or graft pyelonephritis and may actually increase their frequency. Routine treatment of AB during the first months after renal transplantation should not be a standard procedure.
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Affiliation(s)
| | | | | | | | | | | | - Gonzalez Gamez Mario
- Department of Internal Medicine, Hospital Centenario Miguel Hidalgo, Aguascalientes, Mexico
| | | | | | - Chew Wong Alfredo
- Department of Nephrology, Hospital Centenario Miguel Hidalgo, Aguascalientes, Mexico
| | - Reyes Acevedo Rafael
- Department of Transplantation, Hospital Centenario Miguel Hidalgo, Aguascalientes, Mexico
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Asymptomatic Bacteriuria: a Contemporary Review. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00675-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Recurrent UTI: Questions and Answers on Clinical Practice. URO 2022. [DOI: 10.3390/uro2040029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Recurrent urinary tract infection (rUTI) management is still a challenge due to the lack of a standard approach and due to the burden of diseases both on personal and societal aspects. Consultations for rUTIs in everyday clinical practice range from 1% to 6% of all medical visits with high social and personal associated costs, such as prescriptions, hospital expenses, days of sick leave due to the disease, and the treatment of related comorbidities. Recurrent UTIs are, then, associated with anxiety and depression due to treatment failures and symptomatic recurrences. Often urologists are asked to give practical recommendations to patients regarding the everyday management of recurrent UTIs. Here, we aim to give to the physicians managing UTI some helpful suggestions for their everyday clinical practice, on the basis of the recent evidence.
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Cai T, Tamanini I, Collini L, Brugnolli A, Migno S, Mereu L, Tateo S, Pilatz A, Rizzo M, Liguori G, Bonkat G, Wagenlehner FME, Bjerklund Johansen TE. Management of Recurrent Cystitis in Women: When Prompt Identification of Risk Factors Might Make a Difference. Eur Urol Focus 2022; 8:1476-1482. [PMID: 35135727 DOI: 10.1016/j.euf.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/19/2021] [Accepted: 01/20/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Management of recurrent urinary tract infection (rUTI) is still challenging. A better understanding of the natural history of rUTI could help us reduce antibiotic use and improve antibiotic stewardship. OBJECTIVE To describe the effect of risk identification, stratification, and counseling on the natural course of the disease in women with rUTI. DESIGN, SETTING, AND PARTICIPANTS A total of 373 women affected by recurrent cystitis were enrolled in this longitudinal cohort study between December 2014 and December 2019. A systematic and standardized identification of risk factors was performed. INTERVENTION As intervention, risk factors were treated or removed where possible. Patients with nonremovable risk factors were included in the control group. All patients were scheduled for follow-up visits every 6 mo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The main outcome measures were the rate of symptomatic recurrences and improvement in questionnaire results from baseline to the end of the follow-up period. Reduction of antibiotic usage was regarded as a secondary outcome measure. RESULTS AND LIMITATIONS Finally, 353 women were analyzed: 196 in the study group and 157 in the control group. At the end of the follow-up period, a statistically significant reduction in the symptomatic recurrence rate was found between the two groups (0.9 ± 0.2 and 2.6 ± 0.5; p < 0.001), as well as in quality of life and anxiety according to mean questionnaire results: quality of life (0.88 ± 0.06 and 0.63 ± 0.09; p < 0.001) and Spielberger State-Trait Anxiety Inventory-Form Y (32.7 ± 9.3 and 47.5 ± 14.3; p < 0.001). The use of antibiotics was significantly lower in the study group: 4410 versus 9821 (p < 0.001). A limitation to consider is the lack of a randomized design for the active approach in the high-risk group. CONCLUSIONS Identification, counseling, and removal of risk factors, where possible, are able to change the natural history of rUTI, by reducing the number of symptomatic episodes and antibiotic use and improving quality of life. PATIENT SUMMARY In this report, we analyzed a large cohort of women affected by recurrent urinary tract infections and followed for a long time period. We found that risk factor identification and counseling may change the natural history of recurrent urinary tract infections, concluding that this approach is able to reduce the number of symptomatic episodes, reduce antibiotic usage, and improve patients' quality of life.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Irene Tamanini
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
| | - Lucia Collini
- Department of Microbiology, Santa Chiara Regional Hospital, Trento, Italy
| | - Anna Brugnolli
- Centre of Higher Education for Health Sciences, Trento, Italy
| | - Serena Migno
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, Trento, Italy
| | - Liliana Mereu
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, Trento, Italy
| | - Saverio Tateo
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, Trento, Italy
| | - Adrian Pilatz
- Clinic for Urology, Pediatric Urology and Andrology, University Hospital Giessen and Marburg GmbH, Justus Liebig University, Giessen, Germany
| | - Michele Rizzo
- Department of Urology, University of Trieste, Trieste, Italy
| | | | - Gernot Bonkat
- alta uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University of Basel, Basel, Switzerland
| | - Florian M E Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, University Hospital Giessen and Marburg GmbH, Justus Liebig University, Giessen, Germany
| | - Truls E Bjerklund Johansen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Urology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Aarhus, Aarhus, Denmark
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28
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Cash MC, Hile G, Johnson J, Stone T, Smith J, Ohl C, Luther V, Beardsley J. Sustained impact of an antibiotic stewardship initiative targeting asymptomatic bacteriuria and pyuria in the emergency department. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e148. [PMID: 36483350 PMCID: PMC9726488 DOI: 10.1017/ash.2022.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To determine whether a multifaceted initiative resulted in maintained reduction in inappropriate treatment of asymptomatic pyuria (ASP) or bacteriuria (ASB) in the emergency department (ED). DESIGN Single-center, retrospective study. METHODS Beginning in December 2015, a series of interventions were implemented to decrease the inappropriate treatment of ASP or ASB in the ED. Patients discharged from the ED from August to October 2015 (preintervention period), from December 2016 to February 2017 (postintervention period 1), and from November 2019 to January 2020 (postintervention period 2) were included if they had pyuria and/or bacteriuria without urinary symptoms. The primary outcome was the proportion of patients prescribed antibiotics within 72 hours of discharge from the ED. The secondary outcome was the number of patients returning to the ED with symptomatic UTI within 30 days of discharge. RESULTS We detected a significant decrease in the proportion of patients with ASP or ASB who were inappropriately treated when comparing the preintervention group and post-intervention group 1 (100% vs 32.4%; P < .001). This reduced frequency of inappropriate treatment was noted 3 years after the intervention, with 28% of patients receiving treatment for ASP or ASB in postintervention group 2. (P was not significant fin the comparison with postintervention group 1.) Among the 3 groups analyzed, we detected no difference in the numbers of patients returning to the ED with a symptomatic UTI within 30 days of ED discharge regardless of whether patients received antibiotics. CONCLUSIONS A multifaceted intervention resulted in a significant decrease in inappropriate use of antibiotics for ASP and/or ASB that was maintained 3 years after implementation.
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Affiliation(s)
- Mary Catherine Cash
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Garrett Hile
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - James Johnson
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tyler Stone
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jessica Smith
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Chris Ohl
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Vera Luther
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Beardsley
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Ten Doesschate T, Kuiper S, van Nieuwkoop C, Hassing RJ, Ketels T, van Mens SP, van den Bijllaardt W, van der Bij AK, Geerlings SE, Koster A, Koldewijn EL, Branger J, Hoepelman AIM, van Werkhoven CH, Bonten MJM. Fosfomycin Vs Ciprofloxacin as Oral Step-Down Treatment for Escherichia coli Febrile Urinary Tract Infections in Women: A Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial. Clin Infect Dis 2022; 75:221-229. [PMID: 34791074 PMCID: PMC8689999 DOI: 10.1093/cid/ciab934] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We aimed to determine the noninferiority of fosfomycin compared to ciprofloxacin as an oral step-down treatment for Escherichia coli febrile urinary tract infections (fUTIs) in women. METHODS This was a double-blind, randomized, controlled trial in 15 Dutch hospitals. Adult women who were receiving 2-5 days of empirical intravenous antimicrobials for E. coli fUTI were assigned to step-down treatment with once-daily 3g fosfomycin or twice-daily 0.5g ciprofloxacin for 10 days of total antibiotic treatment. For the primary end point, clinical cure at days 6-10 post-end of treatment (PET), a noninferiority margin of 10% was chosen. The trial was registered on Trialregister.nl (NTR6449). RESULTS After enrollment of 97 patients between 2017 and 2020, the trial ended prematurely because of the coronavirus disease 2019 pandemic. The primary end point was met in 36 of 48 patients (75.0%) assigned to fosfomycin and 30 of 46 patients (65.2%) assigned to ciprofloxacin (risk difference [RD], 9.6%; 95% confidence interval [CI]: -8.8% to 28.0%). In patients assigned to fosfomycin and ciprofloxacin, microbiological cure at days 6-10 PET occurred in 29 of 37 (78.4%) and 33 of 35 (94.3%; RD, -16.2%; 95% CI: -32.7 to -0.0%). Any gastrointestinal adverse event was reported in 25 of 48 (52.1%) and 14 of 46 (30.4%) patients (RD, 20.8%; 95% CI: 1.6% to 40.0%), respectively. CONCLUSIONS Fosfomycin is noninferior to ciprofloxacin as oral step-down treatment for fUTI caused by E. coli in women. Fosfomycin use is associated with more gastrointestinal events. CLINICAL TRIAL REGISTRATION Trial NL6275 (NTR6449).
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Affiliation(s)
- Thijs Ten Doesschate
- Department of Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sander Kuiper
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands.,Department of Infectious Diseases, Leiden University Medical Center, The Hague, The Netherlands
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Robert Jan Hassing
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Tom Ketels
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Suzan P van Mens
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Akke K van der Bij
- Department of Medical Microbiology, Diakonessenhuis, Utrecht, The Netherlands
| | - Suzanne E Geerlings
- Department of Infectious Diseases, University of Amsterdam, Amsterdam, The Netherlands
| | - Ad Koster
- Department of Internal Medicine, Viecuri Medical Center, Venlo, The Netherlands
| | - Evert L Koldewijn
- Department of Urology, Catharina Hospital, Eindhoven, The Netherlandsand
| | - Judith Branger
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
| | - Andy I M Hoepelman
- Department of Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cornelis H van Werkhoven
- Department of Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc J M Bonten
- Department of Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Balasubramanian S, Wang X, Sahil S, Cheng AL, Sutkin G, Shepherd JP. Risk factors for the development of acute pyelonephritis in women with a positive urine culture. Neurourol Urodyn 2022; 41:1582-1589. [PMID: 35788978 DOI: 10.1002/nau.25005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/23/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In treating lower urinary tract symptoms (LUTS), the risk of overtreatment with antibiotics must be reconciled with the risk of an untreated urinary tract infection (UTI) progressing to acute pyelonephritis (APN). Using Cerner HealthFacts, a longitudinal clinical informatics database, we aimed to determine risk factors associated with the development of APN from UTI in an effort to guide the initiation of empiric antibiotics. METHODS We queried the Cerner HealthFacts database for women over age 18 with a positive urine culture. Any patient with an International Classification of Disease (ICD) code indicating chronic pyelonephritis was excluded. Development of APN within 30 days of the positive culture, specified by ICD coding, was our primary outcome. Patient and facility factors were assessed as potential risk factors for the development of APN using multivariable regression. RESULTS Out of 58 344 women with a positive urine culture, 3.9% (2296) developed APN. Mean patient age was 54.4 ± 25.3 years. Overall, 12 variables were predictive for APN and 11 variables were protective against APN. Presence of obstructive and reflux uropathies (OR 4.58), presentation to an acute care facility (OR 3.19), urinary retention (OR 2.30), history of UTI (OR 2.19), and renal comorbidities (OR 2.07) conferred the highest odds of APN development. The most protective variable against APN development was cognitive impairment (OR 0.49). CONCLUSIONS Identified risk factors associated with APN development may aid decisions regarding empiric antibiotic initiation for patients presenting with LUTS while awaiting urine culture results. The relationship between cognitive impairment and progression to APN deserves further study.
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Affiliation(s)
- Shiva Balasubramanian
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Xi Wang
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Suman Sahil
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - An-Lin Cheng
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Gary Sutkin
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Jonathan P Shepherd
- Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Connecticut, USA
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Jordano Q. A vueltas con la bacteriuria. Med Clin (Barc) 2022; 159:437-439. [DOI: 10.1016/j.medcli.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
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Penney JA, Rodday AM, Sebastiani P, Snydman DR, Doron SI. Impact of provider-selected indication requirement on urine test utilization and positivity. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e103. [PMID: 36483372 PMCID: PMC9726588 DOI: 10.1017/ash.2022.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate the impact of the addition of an indication specification requirement to isolated urine-culture ordering on testing utilization. DESIGN Retrospective study utilizing interrupted time series analysis with negative binomial regression. The preintervention period was October 1, 2018-November 11, 2019, and the postintervention period was November 12, 2019-October 31, 2020. The primary outcome was isolated culture rate per 1,000 patient days. Secondary outcomes were the proportion of all urine tests ordered as isolated urine culture and culture positivity. An exploratory analysis assessed the appropriateness of selected testing indications. SETTING A 415-bed, urban, academic medical center. PATIENTS Adult patients with urine testing performed during hospital admission. In total, 1,494 unique isolated urine-culture orders were included in the analysis. INTERVENTIONS On November 12, 2019, the laboratory order interface was changed to require the ordering provider to select an indication for isolated urine culture. RESULTS Isolated urine-culture rates did not significantly change after the intervention (11.2-7.8 cultures per 1,000 patient days; P = .17) nor did culture positivity (26.9% vs 26.8%). Most ordering providers left the indication for testing blank, and of those charts reviewed, 67% did not have a documented condition for which isolated urine culture was the most appropriate initial test. CONCLUSIONS The addition of an order-specification requirement for isolated urine-culture testing did not significantly affect ordering practices. The test remains overused as the initial diagnostic evaluation for a suspected urinary tract infection. Further provider education and continued changes in provider workflow are needed to achieve lasting change in practice.
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Affiliation(s)
- Jessica A. Penney
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Paola Sebastiani
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - David R. Snydman
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
| | - Shira I. Doron
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
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Mellhammar L, Elén S, Ehrhard S, Bouma H, Ninck L, Muntjewerff E, Wünsch D, Bloos F, Malmström E, Linder A. New, Useful Criteria for Assessing the Evidence of Infection in Sepsis Research. Crit Care Explor 2022; 4:e0697. [PMID: 35620771 PMCID: PMC9116943 DOI: 10.1097/cce.0000000000000697] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The Sepsis-3 definition states the clinical criteria for sepsis but lacks clear definitions of the underlying infection. To address the lack of applicable definitions of infection for sepsis research, we propose new criteria, termed the Linder-Mellhammar criteria of infection (LMCI). The aim of this study was to validate these new infection criteria. DESIGN A multicenter cohort study of patients with suspected infection who were admitted to emergency departments or ICUs. Data were collected from medical records and from study investigators. SETTING Four academic hospitals in Sweden, Switzerland, the Netherlands, and Germany. PATIENTS A total of 934 adult patients with suspected infection or suspected sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Agreement of infection site classification was measured using the LMCI with Cohen κ coefficient, compared with the Calandra and Cohen definitions of infection and diagnosis on hospital discharge as references. In one of the cohorts, comparisons were also made to adjudications by an expert panel. A subset of patients was assessed for interobserver agreement. MEASUREMENTS AND MAIN RESULTS The precision of the LMCI varied according to the applied reference. LMCI performed better than the Calandra and Cohen definitions (κ = 0.62 [95% CI, 0.59-0.65] vs κ = 0.43 [95% CI, 0.39-0.47], respectively) and the diagnosis on hospital discharge (κ = 0.57 [95% CI, 0.53-0.61] vs κ = 0.43 [95% CI, 0.39-0.47], respectively). The interobserver agreement for the LMCI was evaluated in 91 patients, with agreement in 77%, κ = 0.72 (95% CI, 0.60-0.85). When tested with adjudication as the gold standard, the LMCI still outperformed the Calandra and Cohen definitions (κ = 0.65 [95% CI, 0.60-0.70] vs κ = 0.29 [95% CI, 0.24-0.33], respectively). CONCLUSIONS The LMCI is useful criterion of infection that is intended for sepsis research, in and outside of the ICU. Useful criteria for infection have the potential to facilitate more comparable sepsis research and exclude sepsis mimics from clinical studies, thus improving and simplifying sepsis research.
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Affiliation(s)
- Lisa Mellhammar
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Sixten Elén
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Simone Ehrhard
- Department of Emergency Medicine, Inselpital, University Hospital University of Bern, Bern, Bern, Switzerland
| | - Hjalmar Bouma
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Lorenz Ninck
- Department of Emergency Medicine, Inselpital, University Hospital University of Bern, Bern, Bern, Switzerland
| | - Eva Muntjewerff
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Daniel Wünsch
- Department of Anesthesiology and Intensive Care Therapy, University Hospital, Jena, Germany
| | - Frank Bloos
- Department of Anesthesiology and Intensive Care Therapy, University Hospital, Jena, Germany
| | - Erik Malmström
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
- Emergency Medicine, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Adam Linder
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
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Screening Biomarkers and Constructing a Predictive Model for Symptomatic Urinary Tract Infection and Asymptomatic Bacteriuria in Patients Undergoing Cutaneous Ureterostomy: A Metagenomic Next-Generation Sequencing Study. DISEASE MARKERS 2022; 2022:7056517. [PMID: 35531475 PMCID: PMC9072028 DOI: 10.1155/2022/7056517] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/02/2022] [Indexed: 11/17/2022]
Abstract
Objectives. To investigate the clinical diagnostic value of differential flora as biomarkers in patients with symptomatic urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) undergoing cutaneous ureterostomy based on metagenomic next-generation sequencing and construct predictive models to provide a scientific reference for clinical diagnosis and treatment. Material and Methods. According to standard procedures, samples were taken from each patient for routine tests (urine, ureteral stent, and skin swab around the stoma). Cytokine levels in the blood were also detected. Urinary microflora were measured by mNGS, and potential biomarkers for distinguishing UTI and ASB were identified by differential flora. Finally, we generated the predictive models for ASB and UTI using the Lasso method and cytokine levels. Results. Urine culture was performed for 50 patients with cutaneous ureterostomy; 44 of these patients developed bacteriuria. The incidence of symptomatic bacteriuria was 54.55%. Biomarker analysis showed that Propionimicrobium lymphophilum, Staphylococcus haemolyticus, Stenotrophomonas maltophilia, Ralstonia insidiosa, and Aspergillus sydowii all had good predictive performance and were combined in a single model. The predictive model exhibited good prediction performance (area under the curve
,
,
, and
). We also identified a significant negative correlation between the weight sum of the abundance for these five characteristic pathogens (Sum_weighted_Reads) and levels of the cytokine IL-6 and IL-1β (
). Conclusion. mNGS had a higher positive detection rate for pathogens in urine samples. The selected differential bacteria can be used as biomarkers of ASB and UTI, and the prediction model has good predictive performance. Analysis also showed that the occurrence of symptoms was related to individual immunity. Combined with the Sum_weighted_Reads cutoff and cytokine levels (IL-6 and IL-1β) of differential flora, it was possible to judge the severity of symptoms in cutaneous ureterostomy patients with bacteriuria and provide new insights for the treatment and intervention of ASB and UTI.
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Daggamseh A, Dickinson A, Campain N, Longshaw A, Maccormick A, Miller C. Effect of asymptomatic bacteriuria on readmissions and rate of urosepsis after ureterorenoscopy for urolithiasis. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158211073444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: This study aims to assess whether the rate of readmissions after ureterorenoscopy (URS) is dependent on results of urine microscopy, culture and sensitivity (MC&S) or nitrite dipstick test performed before the procedure. Patients and Methods: All patients attending for ureteroscopy for stone disease over 12 months were included and had urine dipstick performed immediately prior to the surgery with mid-stream urine (MSU) sample sent for culture. Asymptomatic bacteriuria (ABU) was not treated before ureteroscopy. All included patients received standard antibiotic prophylaxis. Readmissions within 30 days of the procedure were evaluated. Results: A total 120 ureteroscopies were included, of which 20% had ABU. Eight patients (6.67%) were readmitted due to all procedure-related complications; among them, five (4.17%) were readmitted with urinary tract infection (UTI). Readmission rates with UTIs were similar for patients with sterile urine and those who had untreated ABU. Of those patients who were readmitted with UTI, all had a negative nitrite result on preoperative urine dipstick specimens. Most patients (54.17%) who had ABU also had a negative urinary nitrite test. Conclusions: Screening and routine treatment of ABU before ureteroscopy for urolithiasis may be unnecessary provided patients have standard antibiotic prophylaxis. Moreover, urine nitrite testing before ureteroscopy may not be a useful screening test for ABU before ureteroscopy. Level of evidence: 2
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Affiliation(s)
- Abdallah Daggamseh
- Urology Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, UK
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36
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Naber KG, Tirán-Saucedo J, Wagenlehner FME. Psychosocial burden of recurrent uncomplicated urinary tract infections. GMS INFECTIOUS DISEASES 2022; 10:Doc01. [PMID: 35463815 PMCID: PMC9006425 DOI: 10.3205/id000078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: Urinary tract infections (UTI) are a leading cause of bacterial infections in women. Despite acute treatment, 30-50% of women who have a UTI will experience a recurrence within 6-12 months. In this review, the focus will be on the personal psychosocial impacts of recurrent UTI. Methods: A PubMed/MEDLINE literature search was carried out from 2000 to 2020 in order to identify any recent high-quality meta-analyses or systematic reviews on these topics. Results: One systematic review was found appropriate for this manuscript. Concerning impact on quality of life (QoL) and daily activities, a reduced quality of both intimate and social relationships, self-esteem, and capacity for work was found due to recurrent UTI. Social function was substantially more reduced than physical function. In one study, the greatest reduction overall was in mental role functioning, whereas in another study, mental health reductions were not substantially greater than those of physical health. About one third of women suffered from UTI very often or often after sexual intercourse, and more than half of the patients stated that sexual relations were negatively influenced by UTI. Data from the GESPRIT study suggest that prophylaxis for recurrent UTI is underutilized, because less than 40% of the study population were offered prophylaxis after experiencing three UTI per year, despite all surveyed participants being willing to undertake at least one of the prophylactic measures listed in the survey. Conclusions: Little data on the psychosocial impact of recurrent UTI are available. Therefore, future studies must also incorporate QoL assessments as key outcome measures.
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Affiliation(s)
- Kurt G. Naber
- Department of Urology, Technical University of Munich, Germany,*To whom correspondence should be addressed: Kurt G. Naber, Department of Urology, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Str. 22, 81675 Munich, Germany, E-mail:
| | - José Tirán-Saucedo
- IMIGO/Instituto Mexicano de Infectología Ginecología y Obstetricia, Obstetrics and Gynaecology/Infectious Diseases, Monterrey, México
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Kenneally C, Murphy CP, Sleator RD, Culligan EP. The Urinary Microbiome and Biological Therapeutics: Novel Therapies For Urinary Tract Infections. Microbiol Res 2022; 259:127010. [DOI: 10.1016/j.micres.2022.127010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/12/2022]
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Sawhney S, Johnson C, Shupe A, Fine J, Dantas G, Burnham CAD, Yarbrough ML. Assessment of the Urinary Microbiota of MSM Using Urine Culturomics Reveals a Diverse Microbial Environment. Clin Chem 2021; 68:192-203. [PMID: 34969116 PMCID: PMC8872801 DOI: 10.1093/clinchem/hvab199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/27/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND The urinary tract is not sterile and is populated by microbial communities that influence urinary health. Men who have sex with men (MSM) are understudied yet have increased risk factors for genitourinary infections. Our objective was to interrogate the composition of MSM urinary microbiota. METHODS Midstream urine specimens (n = 129) were collected from MSM (n = 63) and men seen for routine care (clinical cohort, n = 30). Demographics and sexual/medical history were documented. Specimens underwent culture using standard-of-care and enhanced methods designed to isolate fastidious and anaerobic microorganisms. Isolates were identified by MALDI-TOF mass spectrometry or 16S rRNA gene sequencing. RESULTS The MSM cohort was younger (mean (SD), 35.4 (11.26) years) compared to the clinical cohort (62.7 (15.95) years). Organism recovery was significantly increased using enhanced vs standard culture for the MSM (mean of 9.1 vs 0.6 species/sample [P < 0.001]) and clinical (7.8 vs 0.9 species/sample [P < 0.001]) cohorts. The microbial composition of MSM urine specimens was dominated by Gram-positive and anaerobic microbes and clustered distinctly from that of clinical urine specimens. Composition of microbial species recovered within the same subject was dynamic between urine specimens but more similar relative to inter-individual comparisons. Principal coordinate analysis showed no correlation between urinary microbiota composition and age, recent antibiotic use, sexually transmitted infection/HIV status, or sexual practices. CONCLUSIONS Enhanced culture recovered a large diversity of microbial species from MSM urine specimens, especially taxa typically associated with mucosal surfaces. These findings may increase understanding of urologic disease in MSM and improve diagnostic methods for detection of genitourinary infections.
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Affiliation(s)
- Sanjam Sawhney
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO.,Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Caitlin Johnson
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Angela Shupe
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Jeremy Fine
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO.,Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA,Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO.,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO
| | - Carey-Ann D. Burnham
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Melanie L. Yarbrough
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA,Send correspondence to: Melanie Yarbrough, PhD, 660 S. Euclid Ave, St. Louis, MO 63110, Phone: (314) 362-2669, Fax: (314) 362-8465,
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Montelongo Hernandez C, Putonti C, Wolfe AJ. Characterizing Plasmids in Bacteria Species Relevant to Urinary Health. Microbiol Spectr 2021; 9:e0094221. [PMID: 34937183 PMCID: PMC8694116 DOI: 10.1128/spectrum.00942-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/25/2021] [Indexed: 12/21/2022] Open
Abstract
The urinary tract has a microbial community (the urinary microbiota or urobiota) that has been associated with human health. Whole genome sequencing of bacteria is a powerful tool, allowing investigation of the genomic content of the urobiota, also called the urinary microbiome (urobiome). Bacterial plasmids are a significant component of the urobiome yet are understudied. Because plasmids can be vectors and reservoirs for clinically relevant traits, they are important for urobiota dynamics and thus may have relevance to urinary health. In this project, we sought plasmids in 11 clinically relevant urinary species: Aerococcus urinae, Corynebacterium amycolatum, Enterococcus faecalis, Escherichia coli, Gardnerella vaginalis, Klebsiella pneumoniae, Lactobacillus gasseri, Lactobacillus jensenii, Staphylococcus epidermidis, Streptococcus anginosus, and Streptococcus mitis. We found evidence of plasmids in E. faecalis, E. coli, K. pneumoniae, S. epidermidis, and S. anginosus but insufficient evidence in other species sequenced thus far. Some identified plasmidic assemblies were predicted to have putative virulence and/or antibiotic resistance genes, although the majority of their annotated coding regions were of unknown predicted function. In this study, we report on plasmids from urinary species as a first step to understanding the role of plasmids in the bacterial urobiota. IMPORTANCE The microbial community of the urinary tract (urobiota) has been associated with human health. Whole genome sequencing of bacteria permits examination of urobiota genomes, including plasmids. Because plasmids are vectors and reservoirs for clinically relevant traits, they are important for urobiota dynamics and thus may have relevance to urinary health. Currently, urobiota plasmids are understudied. Here, we sought plasmids in 11 clinically relevant urinary species. We found evidence of plasmids in E. faecalis, E. coli, K. pneumoniae, S. epidermidis, and S. anginosus but insufficient evidence in the other 6 species. We identified putative virulence and/or antibiotic resistance genes in some of the plasmidic assemblies, but most of their annotated coding regions were of unknown function. This is a first step to understanding the role of plasmids in the bacterial urobiota.
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Affiliation(s)
- Cesar Montelongo Hernandez
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Catherine Putonti
- Bioinformatics Program, Loyola University Chicago, Chicago, Illinois, USA
- Department of Biology, Loyola University Chicago, Chicago, Illinois, USA
| | - Alan J. Wolfe
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
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Zhou S, Nagel JL, Kaye KS, LaPlante KL, Albin OR, Pogue JM. Antimicrobial Stewardship and the Infection Control Practitioner: A Natural Alliance. Infect Dis Clin North Am 2021; 35:771-787. [PMID: 34362543 DOI: 10.1016/j.idc.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Antibiotic overuse and misuse has contributed to rising rates of multidrug-resistant organisms and Clostridioides difficile. Decreasing antibiotic misuse has become a national public health priority. This review outlines the goals of antimicrobial stewardship, essential members of the program, implementation strategies, approaches to measuring the program's impact, and steps needed to build a program. Highlighted is the alliance between antimicrobial stewardship programs and infection prevention programs in their efforts to improve antibiotic use, improve diagnostic stewardship for C difficile and asymptomatic bacteriuria, and decrease health care-associated infections and the spread of multidrug-resistant organisms.
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Affiliation(s)
- Shiwei Zhou
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, F4171A University Hospital South, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109, USA
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, 5510A MSRB 1, SPC 5680, 1150 West Medical Center Drive, Ann Arbor, MI 48109-5680, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Veterans Affairs Medical Center (151), Building 7, 830 Chalkstone Avenue, Providence, RI 02908, USA; College of Pharmacy, University of Rhode Island, University of Rhode Island College of Pharmacy, Suite 255A-C, 7 Greenhouse Road Suite, Kingston, RI 02881, USA; Department of Health Services Policy & Practice, Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, RI, USA; Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Owen R Albin
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University Hospital South F4009, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109, USA.
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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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Hoey CSFK, Friend E, Meakin LB, Chanoit GP. Long-term outcome of female dogs treated for intramural ectopic ureters with cystoscopic-guided laser ablation. Vet Surg 2021; 50:1449-1462. [PMID: 34350607 DOI: 10.1111/vsu.13702] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 05/13/2021] [Accepted: 07/22/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report the complications and long-term outcome of female dogs with intramural ectopic ureter(s) (iEU) undergoing cystoscopic-guided laser ablation (CLA) and determine the effect of post-CLA neutering on urinary continence. STUDY DESIGN Retrospective clinical study. ANIMALS OR SAMPLE POPULATION Thirty-four client-owned dogs. METHODS Medical records of female dogs that had iEU-CLA were reviewed. A 10-point continence score was assigned before, immediately after, and at a minimum of 12 months postprocedure via owner telephone contact. Neutering status prior to and postprocedure was recorded. RESULTS Continence scores increased in all dogs after CLA (p < .0001, mean duration of follow-up: 63.9 ± 5.7 months) with an increase of the median score from 2 (preprocedure) to 10 (postprocedure). A urethral tear occurred in 2/34 dogs immediately after the procedure, successfully managed conservatively. Mild hematuria was present in 2/34, lasting less than 48 h. Postoperative urinary tract infections were documented in 6/34 dogs. Two dogs died of urinary-related issues at 1 and 5 months after CLA. Complete and near-complete urinary continence (scores 9 and 10/10) was achieved in 26/32 dogs including 3 dogs requiring medical (2) or surgical interventions (1). Post-CLA neutering did not affect continence scores (p = .44). CONCLUSION A large proportion of dogs regained and maintained full continence after CLA alone. Subsequent medical or surgical therapy allowed further improvements when needed. Post-CLA neutering did not negatively impact urinary continence score. CLINICAL SIGNIFICANCE The beneficial effect of iEU-CLA in female dogs is long standing and not affected by postprocedural neutering.
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Affiliation(s)
| | - Ed Friend
- Langford Vets, University of Bristol, Bristol, UK
| | - Lee B Meakin
- Langford Vets, University of Bristol, Bristol, UK
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Langford BJ, Brown KA, Diong C, Marchand-Austin A, Adomako K, Saedi A, Schwartz KL, Johnstone J, MacFadden DR, Matukas LM, Patel SN, Garber G, Daneman N. The Benefits and Harms of Antibiotic Prophylaxis for Urinary Tract Infection in Older Adults. Clin Infect Dis 2021; 73:e782-e791. [PMID: 33595621 DOI: 10.1093/cid/ciab116] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The role of antibiotics in preventing urinary tract infection (UTI) in older adults is unknown. We sought to quantify the benefits and risks of antibiotic prophylaxis among older adults. METHODS We conducted a matched cohort study comparing older adults (≥66 years) receiving antibiotic prophylaxis, defined as antibiotic treatment for ≥30 days starting within 30 days of a positive culture, with patients with positive urine cultures who received antibiotic treatment but did not receive prophylaxis. We matched each prophylaxis recipient to 10 nonrecipients based on organism, number of positive cultures, and propensity score. Outcomes included (1) emergency department (ED) visit or hospitalization for UTI, sepsis, or bloodstream infection within 1 year; (2) acquisition of antibiotic resistance in urinary tract pathogens; and (3) antibiotic-related complications. RESULTS Overall, 4.7% (151/3190) of UTI prophylaxis patients and 3.6% (n = 1092/30 542) of controls required an ED visit or hospitalization for UTI, sepsis, or bloodstream infection (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.12-1.57). Acquisition of antibiotic resistance to any urinary antibiotic (HR, 1.31; 95% CI, 1.18-1.44) and to the specific prophylaxis agent (HR, 2.01; 95% CI, 1.80-2.24) was higher in patients receiving prophylaxis. While the overall risk of antibiotic-related complications was similar between groups (HR, 1.08; 95% CI, .94-1.22), the risk of Clostridioidesdifficile and general medication adverse events was higher in prophylaxis recipients (HR [95% CI], 1.56 [1.05-2.23] and 1.62 [1.11-2.29], respectively). CONCLUSIONS Among older adults with UTI, the harms of long-term antibiotic prophylaxis may outweigh their benefits.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Kevin A Brown
- Public Health Ontario, ICES, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | | | | | | | - Kevin L Schwartz
- Public Health Ontario, ICES, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Jennie Johnstone
- Public Health Ontario, Sinai Health, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Larissa M Matukas
- Unity Health Toronto, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Samir N Patel
- Public Health Ontario, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Gary Garber
- Public Health Ontario, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Sunnybrook Health Sciences Center, ICES, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Álvarez-Artero E, Campo-Nuñez A, García-García I, García-Bravo M, Cores-Calvo O, Galindo-Pérez I, Pendones-Ulerio J, López-Bernus A, Belhassen-García M, Pardo-Lledías J. Infección urinaria por enterococos: Factores de riesgo y mortalidad. Estudio observacional. Rev Clin Esp 2021. [DOI: 10.1016/j.rce.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Alidjanov JF, Overesch A, Abramov-Sommariva D, Hoeller M, Steindl H, Wagenlehner FM, Naber KG. Acute Cystitis Symptom Score questionnaire for measuring patient-reported outcomes in women with acute uncomplicated cystitis: Clinical validation as part of a phase III trial comparing antibiotic and nonantibiotic therapy. Investig Clin Urol 2021; 61:498-507. [PMID: 32869564 PMCID: PMC7458871 DOI: 10.4111/icu.20200060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The Acute Cystitis Symptom Score (ACSS) used in a clinical trial comparing the phytodrug Canephron®N (BNO 1045) with an antibacterial agent (fosfomycin trometamol [FT]) in the treatment of acute uncomplicated cystitis (AC) in women was evaluated as a patient-reported outcome measure in a post hoc analysis. MATERIALS AND METHODS This double-blind, randomized, multicenter, phase III noninferiority trial was performed in 51 centers in Europe. The ACSS questionnaire was used to assess severity and course of symptoms. RESULTS The post hoc analysis included 325 patients treated with BNO 1045 and 332 patients treated with FT (total of 657 patients). The mean sum-scores of the ACSS-typical domain were comparable between groups on day 1 (BNO 1045: 10.2; FT: 10.1), and then decreased on day 4 (BNO 1045: 5.1; FT: 4.5), at end of treatment on day 8 (BNO 1045: 2.1; FT: 2.1), and at late follow-up on day 38 (BNO 1045: 0.8; FT: 0.9). Predefined thresholds using the scoring system of the ACSS could be established and validated to define "clinical cure." CONCLUSIONS Evaluating not only antibacterial but also nonantibacterial agents indicated for the treatment of AC in women, clinical criteria for diagnostics, and measures of patient-reported outcomes are more important as main objectives than microbiological criteria. In this post hoc evaluation, we showed that the ACSS questionnaire, validated in several languages, has the potential to be used as a suitable instrument for diagnostics and patient-reported outcomes in well-designed, international, clinical studies investigating different treatment modalities of uncomplicated urinary tract infections.
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Affiliation(s)
- Jakhongir F Alidjanov
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig University, Giessen, Germany
| | | | | | | | | | - Florian M Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig University, Giessen, Germany
| | - Kurt G Naber
- Department of Urology, Technical University of Munich, Munich, Germany.
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Álvarez-Artero E, Campo-Nuñez A, García-García I, García-Bravo M, Cores-Calvo O, Galindo-Pérez I, Pendones-Ulerio J, López-Bernus A, Belhassen-García M, Pardo-Lledías J. Urinary tract infection caused by Enterococcus spp.: Risk factors and mortality. An observational study. Rev Clin Esp 2021; 221:375-383. [PMID: 34074626 DOI: 10.1016/j.rceng.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Urinary tract infections (UTIs) are frequently caused by Enterococcus spp. This work aims to define the risk factors associated with UTIs caused by Enterococci and to determine its overall mortality and predictive risk factors. MATERIALS AND METHODS A retrospective study was conducted on bacteremic UTIs caused by Enterococcus spp. among inpatients. We compared 106 inpatients with bacteremic UTIs caused by Enterococcus spp. vs. a random sample of 100 inpatients with bacteremic UTIs caused by other enterobacteria. RESULTS A total of 106 inpatients with UTIs caused by Enterococcus spp. were analyzed, 51 of whom had concomitant positive blood cultures. Distribution by species was 83% E. faecalis and 17% E. faecium. The mean Charlson Comorbidity Index score was 5.9±2.9. Upon comparing bacteremic UTIs caused by Enterococcus spp. vs. bacteremic UTIs caused by others enterobacteria, we found the following independent predictors of bacteremic UTI by Enterococcus: male sex, obstructive uropathy, nosocomial infection, cancers of the urinary system, and previous antimicrobial treatment. Overall, inpatient mortality was 16.5% and was associated with a higher Sequential Organ Failure Assessment (SOFA) score (>4); severe comorbidities such as immunosuppression, malignant hemopathy, and nephrostomy; and Enterococcus faecium species and its pattern of resistance to ampicillin or vancomycin (p<0.05). Appropriate empiric antibiotic therapy was not associated with a better prognosis (p>0.05). CONCLUSIONS Enterococcus spp. is a frequent cause of complicated UTI in patients with risk factors. High mortality secondary to a severe clinical condition and high comorbidity may be sufficient for justifying the implementation of empiric treatment of at-risk patients.
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Affiliation(s)
- E Álvarez-Artero
- Servicio de Medicina Interna, Hospital Rio Carrión, Complejo Asistencial Universitario de Palencia (CAUPA), Palencia, Spain
| | - A Campo-Nuñez
- Servicio de Medicina Interna, Hospital Rio Carrión, Complejo Asistencial Universitario de Palencia (CAUPA), Palencia, Spain
| | - I García-García
- Servicio de Microbiología, Complejo Asistencial Universitario de Salamanca (CAUSA), Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain; Centro de Investigación en Enfermedades Tropicales de la Universidad de Salamanca (CIETUS), Universidad de Salamanca, Salamanca, Spain
| | - M García-Bravo
- Servicio de Medicina Interna, Hospital Rio Carrión, Complejo Asistencial Universitario de Palencia (CAUPA), Palencia, Spain
| | - O Cores-Calvo
- Servicio de Microbiología, Complejo Asistencial Universitario de Salamanca (CAUSA), Salamanca, Spain
| | - I Galindo-Pérez
- Centro de Atención Primaria, Puente San Miguel, Santander, Spain
| | - J Pendones-Ulerio
- Servicio de Microbiología, Complejo Asistencial Universitario de Salamanca (CAUSA), Salamanca, Spain
| | - A López-Bernus
- Servicio de Medicina Interna, Sección de Enfermedades Infecciosas, CAUSA, IBSAL, CIETUS, Universidad de Salamanca, Salamanca, Spain
| | - M Belhassen-García
- Servicio de Medicina Interna, Sección de Enfermedades Infecciosas, CAUSA, IBSAL, CIETUS, Universidad de Salamanca, Salamanca, Spain.
| | - J Pardo-Lledías
- Servicio de Medicina Interna, Hospital Universitario Marqués de Valdecilla (HUMV), Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
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Cai T. Recurrent uncomplicated urinary tract infections: definitions and risk factors. GMS INFECTIOUS DISEASES 2021; 9:Doc03. [PMID: 34113535 PMCID: PMC8167371 DOI: 10.3205/id000072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: Recurrent uncomplicated urinary tract infections (UTI) have a high impact on patients’ quality of life and high direct and indirect costs for public health. Therefore, optimal management should be of high priority. Methods: Current international guidelines were reviewed, and a systematic literature search was performed in Medline, Cochrane, and Embase. Results: Several risks factors have been identified and used in everyday clinical practice to plan the correct strategy for recurrence prevention. Among all factors, the most important are: sexual intercourse, spermicide use, having a new sex partner, having a mother with a history of UTI, having had UTI during childhood, and asymptomatic bacteriuria treatment. Moreover, other risk factors such as reduced fluid intake, habitual and post-coital delayed urination, wiping from back to front after defecation, douching and wearing occlusive underwear, as well as irregular bowel function should be taken into account. Conclusions: Recurrent UTI show a high impact on clinical practice. Risk factors are generally related to both virulence of pathogens and patient’s behavior or condition. A recently developed nomogram can assist in identifying women at high risk of symptomatic recurrence that can be suitable candidates for a prophylactic strategy.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Hospital, Trento, Italy
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Cai T, Konstantinidis C, Ward S. A non-pharmacological approach to the treatment of urinary tract infections: case reports with Utipro ® Plus. Drugs Context 2021; 10:dic-2021-2-2. [PMID: 34104200 PMCID: PMC8152786 DOI: 10.7573/dic.2021-2-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/13/2021] [Indexed: 12/27/2022] Open
Abstract
Recurrent urinary tract infections (UTIs) can profoundly impair patients’ quality of life and carry a substantial health resource burden. Although antibiotics are the mainstay of treatment, interest is growing in identifying antibiotic-sparing alternatives. Utipro® Plus is a medical device that acts as a mechanical barrier to protect the intestinal lumen against the adherence and invasion of uropathogenic strains of Escherichia coli. It is intended for the control and prevention of UTIs caused by E. coli and other Gram-negative uropathogens. Using illustrative case reports, this review documents outcomes in three women with recurrent UTIs who were treated with Utipro® Plus in clinical practice.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Sam Ward
- Clinic Saint Jean, Brussels, Belgium
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Trautner BW, Morgan DJ. Imprecision Medicine: Challenges in Diagnosis, Treatment, and Measuring Quality for Catheter-Associated Urinary Tract Infection. Clin Infect Dis 2021; 71:e520-e522. [PMID: 32324234 DOI: 10.1093/cid/ciaa467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/21/2020] [Indexed: 01/19/2023] Open
Abstract
We question the reliability of the vague symptoms that most commonly define catheter-associated urinary tract infection (CAUTI) and encourage further examination of whether the current CAUTI definition reflects a true infection. While diagnosing CAUTI using the current surveillance definition, physicians may be missing a number of nonurinary etiologies for fever, prematurely diagnosing urinary tract infection, and prescribing unnecessary antibiotics. We believe it is time to reconsider the quality metric of CAUTI. By doing so, we can improve antibiotic use and quality of patient care.
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Affiliation(s)
- Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel J Morgan
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA.,Division of Genomic Epidemiology and Clinical Outcomes, Department of Epidemiology and Public Health, University of Maryland, Baltimore, Baltimore, Maryland, USA
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Hooton TM, Roberts PL, Stapleton AE. Asymptomatic Bacteriuria and Pyuria in Premenopausal Women. Clin Infect Dis 2021; 72:1332-1338. [PMID: 32179902 PMCID: PMC8075033 DOI: 10.1093/cid/ciaa274] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/14/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Asymptomatic bacteriuria and pyuria in healthy women often trigger inappropriate antimicrobial treatment, but there is a paucity of data on their prevalence and persistence. METHODS To evaluate the prevalence and persistence of asymptomatic bacteriuria and pyuria in women at high risk of recurrent urinary tract infection, we conducted an observational cohort study in 104 healthy premenopausal women with a history of recurrent urinary tract infection with daily assessments of bacteriuria, pyuria, and urinary symptoms over a 3-month period. RESULTS The mean age of participants was 22 years, and 74% were white. Asymptomatic bacteriuria events (urine cultures with colony count ≥105 CFU/mL of a uropathogen on days with no symptomatic urinary tract infection diagnosed) occurred in 45 (45%) women on 159 (2.5%) of 6283 days. Asymptomatic bacteriuria events were most commonly caused by Escherichia coli, which was present on 1.4% of days, with a median duration of 1 day (range, 1-10). Pyuria occurred in 70 (78%) of 90 evaluable participants on at least 1 day and 25% of all days on which no symptomatic urinary tract infection was diagnosed. The positive predictive value of pyuria for E. coli asymptomatic bacteriuria was 4%. CONCLUSIONS In this population of healthy women at high risk of recurrent urinary tract infection, asymptomatic bacteriuria is uncommon and, when present, rarely lasts more than 2 days. Pyuria, on the other hand, is common but infrequently associated with bacteriuria or symptoms. These data strongly support recommendations not to screen for or treat asymptomatic bacteriuria or pyuria in healthy, nonpregnant women.
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Affiliation(s)
- Thomas M Hooton
- Department of Medicine, University of Miami, Miami, Florida, USA
| | - Pacita L Roberts
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ann E Stapleton
- Department of Medicine, University of Washington, Seattle, Washington, USA
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