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Park J, Torosis M, Kim JH, Ackerman AL. U.S. primary care physician perceptions on barriers to providing guideline-driven care for UTI and recurrent UTI: a qualitative study. BMC PRIMARY CARE 2024; 25:234. [PMID: 38951826 PMCID: PMC11218267 DOI: 10.1186/s12875-024-02477-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 06/11/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Urinary tract infections (UTI) affect almost two-thirds of all women during their lives and many experience recurrent infections. There are evidence-based guidelines from multiple international societies for evaluation and treatment; however, recent claims-based analyses have demonstrated that adherence to these guidelines is poor. This study seeks to understand the barriers experienced by U.S. primary care providers (PCPs) to providing guideline-based care for UTI and recurrent UTI (rUTI). METHODS Semi-structured interviews of 18 PCPs, recruited from the greater Los Angeles area, examined real-world clinical management of UTI/rUTI episodes, decisions to refer to subspecialty care, and resources guiding counseling and management. Grounded theory methodology served to analyze interview transcripts and identify preliminary and major themes. RESULTS Participants expressed the desire to obtain urine cultures for each cystitis episode, but felt pressured to make compromises by patient demands or barriers to care. PCPs had lower thresholds to empirical treatment if patients had a history of rUTIs, were elderly, or declined evaluation. Laboratory data was minimally utilized in clinical decision-making: urinalyses were infrequently considered when interpreting culture data. PCPs treated a broad set of urologic and non-urologic symptoms as UTI, even with negative cultures. PCPs did not feel comfortable initiating UTI prophylaxis, instead seeking specialist evaluation for anatomic causes. They were unaware of management guidelines, typically utilizing UpToDate® as their primary resource. Few evidence-based UTI prevention interventions were recommended by providers. CONCLUSIONS Low availability of succinct and clear professional guidelines are substantial barriers to appropriate UTI/rUTI care. Poor useability of clinical guidance documents results in substantial confusion about the role of preventative measures and additional diagnostic testing. Difficulties in patient access to care providers lead to expectations for presumptive treatment. Future studies are needed to determine if improved educational materials for providers and/or management algorithms can improve guideline concordance of UTI management.
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Affiliation(s)
- Jennifer Park
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA
| | - Michele Torosis
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA
| | - Ja-Hong Kim
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA
- Department of Urology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - A Lenore Ackerman
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Box 951738, Los Angeles, CA, 90095-1738, USA.
- Department of Urology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, 90095, USA.
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Tchesnokova V, Larson L, Basova I, Sledneva Y, Choudhury D, Solyanik T, Heng J, Bonilla TC, Pasumansky I, Bowers V, Pham S, Madziwa LT, Holden E, Tartof SY, Ralston JD, Sokurenko EV. Gut resident Escherichia coli profile predicts the eighteen-month probability and antimicrobial susceptibility of urinary tract infections. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.05.24305377. [PMID: 38645148 PMCID: PMC11030298 DOI: 10.1101/2024.04.05.24305377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Community-acquired UTI is the most common bacterial infection managed in general medical practice that can lead to life-threatening outcomes. While UTIs are primarily caused by Escherichia coli colonizing the patient's gut, it is unclear whether the gut resident E. coli profiles can predict the person's risks for UTI and optimal antimicrobial treatments. Thus, we conducted an eighteen-month long community-based observational study of fecal E. coli colonization and UTI in women aged 50 years and above. Methods and Findings We enrolled a total of 1,804 women distributed among age groups 50-59 yo (437 participants), 60-69 yo (632), 70-79 yo (532), and above 80 yo (203), lacking antibiotic prescriptions for at least one year. The provided fecal samples were plated for the presence of E. coli and other enterobacteria resistant to trimethoprim/sulfamethoxazole (TMP/STX), ciprofloxacin (CIP) and 3rd generation cephalosporins (3GC). E. coli was also characterized as belonging to the pandemic multi-drug resistant clonal groups ST131 (subclone H30) and ST1193. Following sample collection, the women were monitored for 18 months for occurrence of UTI.E. coli was cultured from 90.8% fecal samples, with 24.1% containing bacteria resistant to TMP/STX, 19.4% to CIP, and 7.9% to 3GC. In 62.5% samples, only all-susceptible E. coli were present. Overall, there were no age-related differences in resistance prevalence. However, while the total E. coli H30 and ST1193 carriage rates were similar (4.3% and 4.2%, respectively), there was a notable increase of H30 carriage with age (P = .001), while carriage decreased with age for ST1193 (P = .057).Within 18 months, 184 women (10.2%) experienced at least one episode of UTI - 10.9% among the gut E. coli carriers and 3.0% among the non-carriers (P=.0013). The UTI risk among carriers of E. coli H30 but not ST1193 was significantly above average (24.3%, P = .0004). The UTI probability increased with age, occurring in 6.4% of 50-59 yo and 19.7% of 80+ yo (P<.001), with the latter group being especially at high risk for UTI, if they were colonized by E. coli H30 (40.0%, P<.001).E. coli was identified in 88.1% of urine samples, with 16.1% resistant to TMP/STX, 16.1% to CIP, 4.2% to 3GC and 73.1% to none of the antibiotics. Among tested urinary E. coli resistant to antibiotics, 86.1% matched the resistance profile of E. coli in the fecal samples, with the clonotyping and whole genome sequencing confirming the matching strains' identity. Positive predictive value (PPV) of using gut resistance profiles to predict UTI pathogens' susceptibility to TMP/STX, CIP, 3GC and all three antibiotics were 98.4%, 98.3%, 96.6% and 95.3%, respectively. Corresponding negative predictive values (NPV) were 63.0%, 54.8%, 44.4% and 75.8%, respectively. The AUC ROC curve values for the accuracy of fecal diagnostic testing for the prediction of UTI resistance ranged .86-.89. The fecal test-guided drug-bug mismatch rate for empirical (pre-culture) prescription of TMP-SXT or CIP is reduced to ≤2% in 89.6% of patients and 94.8% of patients with an optional 3GC prescription. Conclusion The resistance profile and clonal identity of gut colonizing E. coli, along with the carrier's age, can inform personalized prediction of a patients' UTI risk and the UTI pathogen's antibiotic susceptibility within an 18-month period.
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Affiliation(s)
- Veronika Tchesnokova
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Lydia Larson
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Irina Basova
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Yulia Sledneva
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Debarati Choudhury
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Thalia Solyanik
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Jennifer Heng
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Teresa Cristina Bonilla
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Isaac Pasumansky
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Victoria Bowers
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Sophia Pham
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
| | - Lawrence T. Madziwa
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466, USA
| | - Erika Holden
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466, USA
| | - Sara Y. Tartof
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, 100 S Los Robles, Pasadena, CA 91101, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, 100 S Los Robles, Pasadena, CA 91101, USA
| | - James D. Ralston
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466, USA
| | - Evgeni V. Sokurenko
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA 98195, USA
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Li ZP, Li J, Li TL, Song ZY, Gong XZ. Uropathogenic Escherichia coli infection: innate immune disorder, bladder damage, and Tailin Fang II. Front Cell Infect Microbiol 2024; 14:1322119. [PMID: 38638825 PMCID: PMC11024302 DOI: 10.3389/fcimb.2024.1322119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
Background Uropathogenic Escherichia coli (UPEC) activates innate immune response upon invading the urinary tract, whereas UPEC can also enter bladder epithelial cells (BECs) through interactions with fusiform vesicles on cell surfaces and subsequently escape from the vesicles into the cytoplasm to establish intracellular bacterial communities, finally evading the host immune system and leading to recurrent urinary tract infection (RUTI). Tailin Fang II (TLF-II) is a Chinese herbal formulation composed of botanicals that has been clinically proven to be effective in treating urinary tract infection (UTI). However, the underlying therapeutic mechanisms remain poorly understood. Methods Network pharmacology analysis of TLF-II was conducted. Female Balb/C mice were transurethrally inoculated with UPEC CFT073 strain to establish the UTI mouse model. Levofloxacin was used as a positive control. Mice were randomly divided into four groups: negative control, UTI, TLF-II, and levofloxacin. Histopathological changes in bladder tissues were assessed by evaluating the bladder organ index and performing hematoxylin-eosin staining. The bacterial load in the bladder tissue and urine sample of mice was quantified. Activation of the TLR4-NF-κB pathway was investigated through immunohistochemistry and western blotting. The urinary levels of interleukin (IL)-1β and IL-6 and urine leukocyte counts were monitored. We also determined the protein expressions of markers associated with fusiform vesicles, Rab27b and Galectin-3, and levels of the phosphate transporter protein SLC20A1. Subsequently, the co-localization of Rab27b and SLC20A1 with CFT073 was examined using confocal fluorescence microscopy. Results Data of network pharmacology analysis suggested that TLF-II could against UTI through multiple targets and pathways associated with innate immunity and inflammation. Additionally, TLF-II significantly attenuated UPEC-induced bladder injury and reduced the bladder bacterial load. Meanwhile, TLF-II inhibited the expression of TLR4 and NF-κB on BECs and decreased the urine levels of IL-1β and IL-6 and urine leukocyte counts. TLF-II reduced SLC20A1 and Galectin-3 expressions and increased Rab27b expression. The co-localization of SLC20A1 and Rab27b with CFT073 was significantly reduced in the TLF-II group. Conclusion Collectively, innate immunity and bacterial escape from fusiform vesicles play important roles in UPEC-induced bladder infections. Our findings suggest that TLF-II combats UPEC-induced bladder infections by effectively mitigating bladder inflammation and preventing bacterial escape from fusiform vesicles into the cytoplasm. The findings suggest that TLF-II is a promising option for treating UTI and reducing its recurrence.
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Affiliation(s)
| | | | | | | | - Xue-zhong Gong
- Department of Nephrology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Sanchez GV, Kabbani S, Tsay SV, Bizune D, Hersh AL, Luciano A, Hicks LA. Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use. Telemed J E Health 2024; 30:951-962. [PMID: 37856146 DOI: 10.1089/tmj.2023.0229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.
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Affiliation(s)
- Guillermo V Sanchez
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Angelina Luciano
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Kazmi SY, Fathima K, Khan N, Kulsum SN, Faraz A. Sensitivity Profile of Fosfomycin, Nitrofurantoin, and Co-trimoxazole Against Uropathogens Isolated From UTI Cases in a Secondary Care Center, KSA. Cureus 2024; 16:e53999. [PMID: 38476810 PMCID: PMC10928802 DOI: 10.7759/cureus.53999] [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] [Accepted: 02/02/2024] [Indexed: 03/14/2024] Open
Abstract
Background Fosfomycin, nitrofurantoin, and co-trimoxazole are cheap and effective first-line oral antimicrobials in cases of uncomplicated cystitis in males and non-pregnant females. Fosfomycin and nitrofurantoin are called urinary antiseptics because these two drugs are primarily excreted in the kidney and concentrated in the urine without systemic effect. The present study was designed to evaluate the in vitro activities of fosfomycin, nitrofurantoin, and co-trimoxazole against uropathogens isolated at King Khalid Hospital Al-Majmaah, KSA. Methods The study was conducted at the King Khalid Hospital Al Majmaah, KSA, from September 1, 2021, until February 28, 2022. The patients' urine samples were inoculated on the Cystein Lactose Electrolytes Deficient (CLED) medium, and uropathogens were isolated. The organisms' identification and sensitivity testing against cotrimoxazole, fosfomycin, and nitrofurantoin was conducted using a Microscan automated analyzer, the MicroScan WalkAway Beckman Coulter, Sacramento, CA, USA. Results The study comprised non-repeat 137 patients who were either admitted to the hospital or treated as outpatients, yielding a total of 147 isolates. Nitrofurantoin showed a lower resistance rate, around 20% (n = 29), followed by fosfomycin at 23% (n = 34). The resistance rate of cotrimoxazole was 43% (n = 63). Overall, nitrofurantoin and fosfomycin showed relatively lower resistance against all isolates. Conclusions Being cheap and effective, we propose that fosfomycin and nitrofurantoin be used as first-line treatments in patients presenting with uncomplicated UTIs.
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Affiliation(s)
| | - Kauser Fathima
- Pathology and Laboratory Medicine, Tumair General Hospital, Tumair, SAU
| | - Nazia Khan
- Basic Sciences, Majmaah University, AlMajmaah, SAU
| | | | - Ali Faraz
- Basic Sciences, Majmaah University, AlMajmaah, SAU
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Nero A, Weber M, Reveles KR, Carreno JJ. Population based cohort to examine association between geospatial antibiotic factors and urinary tract infection outcomes. Am J Infect Control 2023; 51:1017-1022. [PMID: 36736381 DOI: 10.1016/j.ajic.2023.01.011] [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: 10/07/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) pose a significant health care burden. Outpatient antibiotic geospatial factors (eg, geographic prescribing and geographic resistance) may be associated with inpatient outcomes. This study examined the relationship between these factors, severe UTI, and hospitalization for severe UTI. METHODS The first cohort included hospitalized, female, Medicare beneficiaries, aged >50 years. The primary outcome was severe UTI (defined as CSS diagnosis code of 159 with an APR-DRG severity of illness code of 3 or 4). The association between geospatial first-line prescribing (FLP) and severe UTI was assessed. The second cohort examined the association between these geospatial FLP and risk of hospitalization with severe UTI. Multivariable regression was used to produce adjusted odds ratios and adjusted risk ratios. RESULTS In the first cohort (n = 14,474), low FLP was not associated with severe UTI (P = .87) in univariable analysis. In multivariable analysis, low FLP was associated with severe UTI was (aOR: 1.08 [95% CI 1.00, 1.16]). In the second cohort (n = 2,972,174), the admission rate was 47.0 and 49.8 per 10,000 (low FLP vs high FLP, respectively [P < .001]). The aRR for admission was 1.26 (95% CI 1.14, 1.39) in areas with low FLP. CONCLUSIONS This study suggests that geospatial antibiotic factors may influence inpatient outcomes in women aged >50 with UTI. Further research is needed to corroborate our findings.
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Affiliation(s)
- Alexa Nero
- Albany College of Pharmacy and Health Sciences, Albany, NY
| | - Mckayla Weber
- Albany College of Pharmacy and Health Sciences, Albany, NY
| | - Kelly R Reveles
- The University of Texas at Austin, College of Pharmacy, Austin, TX; University of Texas Health San Antonio, Pharmacotherapy Education and Research Center, San Antonio, TX
| | - Joseph J Carreno
- Albany College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Albany, NY.
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Ku JH, Bruxvoort KJ, Salas SB, Varley CD, Casey JA, Raphael E, Robinson SC, Nachman KE, Lewin BJ, Contreras R, Wei RX, Pomichowski ME, Takhar HS, Tartof SY. Multidrug Resistance of Escherichia coli From Outpatient Uncomplicated Urinary Tract Infections in a Large United States Integrated Healthcare Organization. Open Forum Infect Dis 2023; 10:ofad287. [PMID: 37426945 PMCID: PMC10326677 DOI: 10.1093/ofid/ofad287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/19/2023] [Indexed: 07/11/2023] Open
Abstract
Background Urinary tract infections (UTIs) cause significant disease and economic burden. Uncomplicated UTIs (uUTIs) occur in otherwise healthy individuals without underlying structural abnormalities, with uropathogenic Escherichia coli (UPEC) accounting for 80% of cases. With recent transitions in healthcare toward virtual visits, data on multidrug resistance (MDR) (resistant to ≥3 antibiotic classes) by care setting are needed to inform empiric treatment decision making. Methods We evaluated UPEC resistance over time by care setting (in-person vs virtual), in adults who received outpatient care for uUTI at Kaiser Permanente Southern California between January 2016 and December 2021. Results We included 174 185 individuals who had ≥1 UPEC uUTI (233 974 isolates) (92% female, 46% Hispanic, mean age 52 years [standard deviation 20]). Overall, prevalence of UPEC MDR decreased during the study period (13% to 12%) both in virtual and in-person settings (P for trend <.001). Resistance to penicillins overall (29%), coresistance to penicillins and trimethoprim-sulfamethoxazole (TMP-SMX) (12%), and MDR involving the 2 plus ≥1 antibiotic class were common (10%). Resistance to 1, 2, 3, and 4 antibiotic classes was found in 19%, 18%, 8%, and 4% of isolates, respectively; 1% were resistant to ≥5 antibiotic classes, and 50% were resistant to none. Similar resistance patterns were observed over time and by care setting. Conclusions We observed a slight decrease in both class-specific antimicrobial resistance and MDR of UPEC overall, most commonly involving penicillins and TMP-SMX. Resistance patterns were consistent over time and similar in both in-person and virtual settings. Virtual healthcare may expand access to UTI care.
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Affiliation(s)
- Jennifer H Ku
- Correspondence: Jennifer H. Ku, PhD, MPH, Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101 ()
| | - Katia J Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - S Bianca Salas
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Cara D Varley
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Oregon Health & Science University-Portland State University, School of Public Health, Portland, Oregon, USA
| | - Joan A Casey
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Eva Raphael
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah C Robinson
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Keeve E Nachman
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bruno J Lewin
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Kaiser Permanente Southern California and Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rong X Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Magdalena E Pomichowski
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Harpreet S Takhar
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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Florea A, Casey JA, Nachman K, Price LB, Pomichowski ME, Takhar HS, Quinlivan V, Childs LD, Davis MF, Wei R, Hong V, Ku JH, Liu CM, Pressman A, Robinson S, Bruxvoort KJ, Salas SB, Tartof SY. Impact of California's Senate Bill 27 on Antimicrobial-Resistant Escherichia coli Urinary Tract Infection in Humans: Protocol for a Study of Methods and Baseline Data. JMIR Res Protoc 2023; 12:e45109. [PMID: 37145842 PMCID: PMC10199382 DOI: 10.2196/45109] [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: 01/17/2023] [Revised: 03/17/2023] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Overuse of antibiotics contributes to antimicrobial resistance (AMR) and is a growing threat to human health worldwide. Previous work suggests a link between antimicrobial use in poultry and human AMR extraintestinal pathogenic Escherichia coli (E coli) urinary tract infections (UTIs). However, few US-based studies exist, and none have comprehensively assessed both foodborne and environmental pathways using advanced molecular and spatial epidemiologic methods in a quasi-experimental design. Recently, California enacted Senate Bill 27 (SB27), which changed previous policy to require a veterinarian's prescription for the use of antibiotic drugs, and which banned antibiotic use for disease prevention in livestock. This provided an opportunity to evaluate whether SB27 will result in a reduction in antimicrobial-resistant infections in humans. OBJECTIVE We describe in detail the methods implemented to achieve the overarching objective of this study to evaluate the impact of SB27 on downstream antibiotic resistance rates in human UTIs. METHODS A summary of the overall approach and the partnerships between Columbia University, George Washington University (GWU), Johns Hopkins Bloomberg School of Public Health, Kaiser Permanente Southern California (KPSC) Research and Evaluation, the Natural Resources Defense Council, Sanger Institute at Stanford University, Sutter Health Center for Health Systems Research, the University of Cambridge, and the University of Oxford is presented. The collection, quality control testing, and shipment of retail meat and clinical samples are described. Retail meat (chicken, beef, turkey, and pork) was purchased from stores throughout Southern California from 2017 to 2021. After processing at KPSC, it was shipped to GWU for testing. From 2016 to 2021, after clinical specimens were processed for routine clinical purposes and immediately before discarding, those with isolated colonies of E coli, Campylobacter, and Salmonella from KPSC members were collected and processed to be shipped for testing at GWU. Detailed methods of the isolation and testing as well as the whole-genome sequencing of the meat and clinical samples at GWU are described. KPSC electronic health record data were used to track UTI cases and AMR patterns among the cultured specimens. Similarly, Sutter Health electronic health record data were used to track UTI cases in its Northern California patient population. RESULTS From 2017 to 2021, overall, 12,616 retail meat samples were purchased from 472 unique stores across Southern California. In addition, 31,643 positive clinical cultures were collected from KPSC members during the same study period. CONCLUSIONS Here, we presented data collection methods for the study, which was conducted to evaluate the impact of SB27 on downstream antibiotic resistance rates in human UTI. To date, it is one of the largest studies of its kind to be conducted. The data collected during this study will be used as the foundation for future analyses specific to the various objectives of this large body of work. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/45109.
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Affiliation(s)
- Ana Florea
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Joan A Casey
- Columbia University Mailman School of Public Health, New York City, NY, United States
| | - Keeve Nachman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lance B Price
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Magdalena E Pomichowski
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Harpreet S Takhar
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Vanessa Quinlivan
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Lee D Childs
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Meghan F Davis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Rong Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Vennis Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Jennifer H Ku
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Cindy M Liu
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Alice Pressman
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, United States
| | - Sarah Robinson
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, United States
| | - Katia J Bruxvoort
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - S Bianca Salas
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, United States
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9
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Gander JC, Goodrich G, McDonald B, McCracken CE, Tavel HM, Davis TL, Weinfield NS, Ritzwoller DP, Roblin DW. Virtual Care and Urinary Tract Infection Management: Comparing Ancillary Service Orders and Patient Order Fulfillments Between Virtual and In-person Encounters During the COVID-19 Pandemic in the United States. Med Care 2023; 61:S21-S29. [PMID: 36893415 PMCID: PMC9994568 DOI: 10.1097/mlr.0000000000001805] [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: 03/11/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, more health care issues were being managed remotely. Urinary tract infections (UTIs) are being managed more often using telehealth although few reports compare the rate of UTI ancillary service orders placed and fulfilled during these visits. OBJECTIVES We aimed to evaluate and compare the rate of ancillary service orders and order fulfillments in incident UTI diagnoses between virtual and in-person encounters. RESEARCH DESIGN The retrospective cohort study involved 3 integrated health care systems: Kaiser Permanente (KP) Colorado, KP Georgia, and KP Mid-Atlantic States. SUBJECTS We included incident UTI encounters from adult primary care data from January 2019 to June 2021. MEASURES Data were categorized as: prepandemic (January 2019-March 2020), COVID-19 Era 1 (April 2020-June 2020), and COVID-19 Era 2 (July 2020-June 2021). UTI-specific ancillary services included medication, laboratory, and imaging. Orders and order fulfillments were dichotomized for analyses. Weighted percentages for orders and fulfillments were calculated using inverse probability treatment weighting from logistic regression and compared between virtual and in-person encounters using χ2 tests. RESULTS We identified 123,907 incident encounters. Virtual encounters increased from 13.4% prepandemic to 39.1% in COVID-19 Era 2. Ancillary service orders from virtual encounters were not placed as often as in-person encounters. However, the weighted percentage for ancillary service order fulfillment across all services remained above 65.3% across sites and eras, with many fulfillment percentages above 90%. CONCLUSIONS Our study reported a high rate of order fulfillment for both virtual and in-person encounters. Health care systems should encourage providers to place ancillary service orders for uncomplicated diagnoses, such as UTI, to provide enhanced access to patient-centered care.
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Affiliation(s)
- Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | - Glenn Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Bennet McDonald
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | | | - Heather M. Tavel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Teaniese L. Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | - Nancy S. Weinfield
- Kaiser Permanente Mid-Atlantic Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | | | - Douglas W. Roblin
- Kaiser Permanente Mid-Atlantic Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
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Werneburg GT, Lewis KC, Vasavada SP, Wood HM, Goldman HB, Shoskes DA, Li I, Rhoads DD. Urinalysis exhibits excellent predictive capacity for the absence of urinary tract infection. Urology 2023:S0090-4295(23)00197-8. [PMID: 36898589 DOI: 10.1016/j.urology.2023.02.028] [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: 10/17/2022] [Accepted: 02/18/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVES To assess predictive value of urinalysis for negative urine culture and absence of urinary tract infection, re-evaluate the microbial growth threshold for positive urine culture result, and describe antimicrobial resistance features. Urine culture is associated with 27% of U.S. hospitalizations, and unnecessary antibiotic prescription is a main antibiotic resistance contributor. SUBJECTS AND METHODS Urinalyses with urine culture from women ages 18-49 from 2013 to 2020 were studied. Clinically-diagnosed urinary tract infection (CUTI) was defined as 1) uropathogen growth, 2) documented diagnosis of urinary tract infection, and 3) antibiotic prescription. Sensitivity, specificity, and diagnostic predictive values were used to assess urinalysis performance in predicting isolation of a uropathogen by culture and in detection of CUTI. RESULTS 12,252 urinalyses were included. 41% of urinalyses were associated with positive urine culture and 1287 (10.5%) with CUTI. Negative urinalysis exhibited high predictive accuracy for negative urine culture (specificity 90.3%, PPV 87.3%) and absence of CUTI (specificity 92.2%, PPV 97.4%). 24% of patients not meeting the CUTI definition were still prescribed antibiotics. 22% of cultures associated with CUTI exhibited growth less than 100,000 CFU/ml. Escherichia coli was implemented as causing 70% of CUTIs, and 4.2% of these produced an extended spectrum beta-lactamase. CONCLUSIONS Negative urinalysis exhibits high predictive accuracy for absence of CUTI. A reporting threshold of 10,000 CFU/ml is more clinically appropriate than a 100,000 CFU/ml cutpoint. Reflex culture based on urinalysis results could complement clinical judgement and improve laboratory and antibiotic stewardship in pre-menopausal women.
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Affiliation(s)
- Glenn T Werneburg
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Kevin C Lewis
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sandip P Vasavada
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Hadley M Wood
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Howard B Goldman
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel A Shoskes
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ina Li
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel D Rhoads
- Department of Laboratory Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Infection Biology Program, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Increased Levels of (p)ppGpp Correlate with Virulence and Biofilm Formation, but Not with Growth, in Strains of Uropathogenic Escherichia coli. Int J Mol Sci 2023; 24:ijms24043315. [PMID: 36834725 PMCID: PMC9962837 DOI: 10.3390/ijms24043315] [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: 12/21/2022] [Revised: 01/26/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
Urinary tract infections are one of the most frequent bacterial diseases worldwide. UPECs are the most prominent group of bacterial strains among pathogens responsible for prompting such infections. As a group, these extra-intestinal infection-causing bacteria have developed specific features that allow them to sustain and develop in their inhabited niche of the urinary tract. In this study, we examined 118 UPEC isolates to determine their genetic background and antibiotic resistance. Moreover, we investigated correlations of these characteristics with the ability to form biofilm and to induce a general stress response. We showed that this strain collection expressed unique UPEC attributes, with the highest representation of FimH, SitA, Aer, and Sfa factors (100%, 92.5%, 75%, and 70%, respectively). According to CRA (Congo red agar) analysis, the strains particularly predisposed to biofilm formation represented 32.5% of the isolates. Those biofilm forming strains presented a significant ability to accumulate multi-resistance traits. Most notably, these strains presented a puzzling metabolic phenotype-they showed elevated basal levels of (p)ppGpp in the planktonic phase and simultaneously exhibited a shorter generation time when compared to non-biofilm-forming strains. Moreover, our virulence analysis showed these phenotypes to be crucial for the development of severe infections in the Galleria mellonella model.
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Casey JA, Tartof SY, Davis MF, Nachman KE, Price L, Liu C, Yu K, Gupta V, Innes GK, Tseng HF, Do V, Pressman AR, Rudolph KE. Impact of a Statewide Livestock Antibiotic Use Policy on Resistance in Human Urine Escherichia coli Isolates: A Synthetic Control Analysis. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:27007. [PMID: 36821707 PMCID: PMC9945560 DOI: 10.1289/ehp11221] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND On 1 January 2018, California implemented Senate Bill 27 (SB27), banning, for the first time in the United States, routine preventive use of antibiotics in food-animal production and any antibiotic use without a veterinarian's prescription. OBJECTIVES Our objective was to assess whether SB27 was associated with decreased antimicrobial resistance among E. coli isolated from human urine. METHODS We used U.S. nationwide monthly state-level data from BD Insights Research Database (Becton, Dickinson, and Co.) spanning 1 January 2013 to 30 June 2021 on antibiotic-resistance patterns of 30-d nonduplicate E. coli isolated from urine. Tested antibiotic classes included aminoglycosides, extended-spectrum cephalosporins (ESC), fluoroquinolones, and tetracyclines. Counts of tested and not-susceptible (resistant and intermediate, hereafter resistant) urine isolates were available by sex, age group (<65, 65+ year), month, and state. We applied a synthetic control approach to estimate the causal effect of SB27 on resistance patterns. Our approach created a synthetic California based on a composite of other states without the policy change and contrasted its counterfactual postpolicy trends with the observed postpolicy trends in California. FINDINGS We included 7.1 million E. coli urine isolates, 90% among women, across 33 states. From 2013 to 2017, the median (interquartile range) resistance percentages in California were 11.9% (7.4, 17.6), 13.8% (5.8, 20.0), 24.6% (9.6, 36.4), 7.9% (2.1, 13.1), for aminoglycosides, ESC, fluoroquinolones, and tetracyclines, respectively. SB27 was associated with a 7.1% reduction in ESC resistance (p-value for joint null: <0.01), but no change in resistance to aminoglycosides, fluoroquinolones, or tetracyclines. DISCUSSION Further research is needed to determine the role of SB27 in the observed reduction in ESC resistance E. coli in human populations, particularly as additional states implement similar legislation. https://doi.org/10.1289/EHP11221.
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Affiliation(s)
- Joan A. Casey
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Sara Y. Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Meghan F. Davis
- Department of Environmental Health & Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Molecular and Comparative Pathobiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Keeve E. Nachman
- Department of Environmental Health & Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins Center for a Livable Future, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Risk Sciences and Public Policy Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lance Price
- Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Cindy Liu
- Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Kalvin Yu
- Medical and Scientific Affairs, Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA
| | - Vikas Gupta
- Medical and Scientific Affairs, Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA
| | - Gabriel K. Innes
- Yuma Center of Excellence for Desert Agriculture (YCEDA), University of Arizona, Yuma, Arizona, USA
| | - Hung Fu Tseng
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Vivian Do
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Alice R. Pressman
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Kara E. Rudolph
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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13
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Holcomb DA, Quist AJL, Engel LS. Exposure to industrial hog and poultry operations and urinary tract infections in North Carolina, USA. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 853:158749. [PMID: 36108846 PMCID: PMC9613609 DOI: 10.1016/j.scitotenv.2022.158749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 06/15/2023]
Abstract
An increasing share of urinary tract infections (UTIs) are caused by extraintestinal pathogenic Escherichia coli (ExPEC) lineages that have also been identified in poultry and hogs with high genetic similarity to human clinical isolates. We investigated industrial food animal production as a source of uropathogen transmission by examining relationships of hog and poultry density with emergency department (ED) visits for UTIs in North Carolina (NC). ED visits for UTI in 2016-2019 were identified by ICD-10 code from NC's ZIP code-level syndromic surveillance system and livestock counts were obtained from permit data and aerial imagery. We calculated separate hog and poultry spatial densities (animals/km2) by Census block with a 5 km buffer on the block perimeter and weighted by block population to estimate mean ZIP code densities. Associations between livestock density and UTI incidence were estimated using a reparameterized Besag-York-Mollié (BYM2) model with ZIP code population offsets to account for spatial autocorrelation. We excluded metropolitan and offshore ZIP codes and assessed effect measure modification by calendar year, ZIP code rurality, and patient sex, age, race/ethnicity, and health insurance status. In single-animal models, hog exposure was associated with increased UTI incidence (rate ratio [RR]: 1.21, 95 % CI: 1.07-1.37 in the highest hog-density tertile), but poultry exposure was associated with reduced UTI rates (RR: 0.86, 95 % CI: 0.81-0.91). However, the reference group for single-animal poultry models included ZIP codes with only hogs, which had some of the highest UTI rates; when compared with ZIP codes without any hogs or poultry, there was no association between poultry exposure and UTI incidence. Hog exposure was associated with increased UTI incidence in areas that also had medium to high poultry density, but not in areas with low poultry density, suggesting that intense hog production may contribute to increased UTI incidence in neighboring communities.
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Affiliation(s)
- David A Holcomb
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Arbor J L Quist
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lawrence S Engel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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14
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Li L, Li Y, Yang J, Xie X, Chen H. The immune responses to different Uropathogens call individual interventions for bladder infection. Front Immunol 2022; 13:953354. [PMID: 36081496 PMCID: PMC9445553 DOI: 10.3389/fimmu.2022.953354] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
Urinary tract infection (UTI) caused by uropathogens is the most common infectious disease and significantly affects all aspects of the quality of life of the patients. However, uropathogens are increasingly becoming antibiotic-resistant, which threatens the only effective treatment option available-antibiotic, resulting in higher medical costs, prolonged hospital stays, and increased mortality. Currently, people are turning their attention to the immune responses, hoping to find effective immunotherapeutic interventions which can be alternatives to the overuse of antibiotic drugs. Bladder infections are caused by the main nine uropathogens and the bladder executes different immune responses depending on the type of uropathogens. It is essential to understand the immune responses to diverse uropathogens in bladder infection for guiding the design and development of immunotherapeutic interventions. This review firstly sorts out and comparatively analyzes the immune responses to the main nine uropathogens in bladder infection, and summarizes their similarities and differences. Based on these immune responses, we innovatively propose that different microbial bladder infections should adopt corresponding immunomodulatory interventions, and the same immunomodulatory intervention can also be applied to diverse microbial infections if they share the same effective therapeutic targets.
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Affiliation(s)
- Linlong Li
- The School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Yangyang Li
- The School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Jiali Yang
- The School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Xiang Xie
- The School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
- Public Center of Experimental Technology, Model Animal and Human Disease Research of Luzhou Key Laboratory, Southwest Medical University, Luzhou, China
- *Correspondence: Xiang Xie, ; Huan Chen,
| | - Huan Chen
- The School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
- Nucleic Acid Medicine of Luzhou Key Laboratory, Southwest Medical University, Luzhou, China
- *Correspondence: Xiang Xie, ; Huan Chen,
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15
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Urinary Tract Infections Caused by Uropathogenic Escherichia coli Strains—New Strategies for an Old Pathogen. Microorganisms 2022; 10:microorganisms10071425. [PMID: 35889146 PMCID: PMC9321218 DOI: 10.3390/microorganisms10071425] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 02/04/2023] Open
Abstract
Urinary tract infections (UTIs) are among the most common infections worldwide. Uropathogenic Escherichia coli (UPECs) are the main causative agent of UTIs. UPECs initially colonize the human host adhering to the bladder epithelium. Adhesion is followed by the bacterial invasion of urothelial epithelial cells where they can replicate to form compact aggregates of intracellular bacteria with biofilm-like properties. UPEC strains may persist within epithelial urothelial cells, thus acting as quiescent intracellular bacterial reservoirs (QIRs). It has been proposed that host cell invasion may facilitate both the establishment and persistence of UPECs within the human urinary tract. UPEC strains express a variety of virulence factors including fimbrial and afimbrial adhesins, invasins, iron-acquisition systems, and toxins, which cooperate to the establishment of long lasting infections. An increasing resistance rate relative to the antibiotics recommended by current guidelines for the treatment of UTIs and an increasing number of multidrug resistant UPEC isolates were observed. In order to ameliorate the cure rate and improve the outcomes of patients, appropriate therapy founded on new strategies, as alternative to antibiotics, needs to be explored. Here, we take a snapshot of the current knowledge of coordinated efforts to develop innovative anti-infective strategies to control the diffusion of UPECs.
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16
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Elser H, Rowland ST, Tartof SY, Parks RM, Bruxvoort K, Morello-Frosch R, Robinson SC, Pressman AR, Wei RX, Casey JA. Ambient temperature and risk of urinary tract infection in California: A time-stratified case-crossover study using electronic health records. ENVIRONMENT INTERNATIONAL 2022; 165:107303. [PMID: 35635960 PMCID: PMC9233468 DOI: 10.1016/j.envint.2022.107303] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND In the United States (US), urinary tract infections (UTI) lead to more than 10 million office visits each year. Temperature and season are potentially important risk factors for UTI, particularly in the context of climate change. METHODS We examined the relationship between ambient temperature and outpatient UTI diagnoses among patients followed from 2015 to 2017 in two California healthcare systems: Kaiser Permanente Southern California (KPSC) and Sutter Health in Northern California. We identified UTI diagnoses in adult patients using diagnostic codes and laboratory records from electronic health records. We abstracted patient age, sex, season of diagnosis, and linked community-level Index of Concentration at the Extremes (ICE-I, a measure of wealth and poverty concentration) based on residential address. Daily county-level average ambient temperature was assembled from the Parameter-elevation Regressions on Independent Slopes Model (PRISM). We implemented distributed lag nonlinear models (DLNM) to assess the association between UTI and lagged daily temperatures. Main analyses were confined to women. In secondary analyses, we stratified by season, healthcare system, and community-level ICE-I. RESULTS We observed 787,186 UTI cases (89% among women). We observed a threshold association between ambient temperature and UTI among women: an increase in daily temperature from the 5th percentile (6.0 ˚C) to the mean (16.2 ˚C) was associated with a 3.2% (95% CI: 2.4, 3.9%) increase in same-day UTI diagnosis rate, whereas an increase from the mean to 95th percentile was associated with no change in UTI risk (0.0%, 95% CI: -0.7, 0.6%). In secondary analyses, we observed the clearest monotonic increase in the rate of UTI diagnosis with higher temperatures in the fall. Associations did not differ meaningfully by healthcare system or community-level ICE-I. Results were robust to alternate model specifications. DISCUSSION Increasing temperature was related to higher rate of outpatient UTI, particularly in the shoulder seasons (spring, autumn).
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Affiliation(s)
- Holly Elser
- Department of Neurology, Hospital of the University of Pennsylvania, United States
| | - Sebastian T Rowland
- Environmental Health Sciences, Columbia Mailman School of Public Health, New York, NY, United States
| | - Sara Y Tartof
- Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States; Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Robbie M Parks
- Environmental Health Sciences, Columbia Mailman School of Public Health, New York, NY, United States; Earth Institute, Columbia University, New York, NY, United States
| | - Katia Bruxvoort
- Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States; Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rachel Morello-Frosch
- Department of Environment, Science, Policy, and Managmeent, UC Berkeley, Berkeley, CA, United States; School of Public Helath, UC Berkeley, Berkeley, CA, United States
| | - Sarah C Robinson
- Sutter Health Center for Health Systems Research, Walnut Creek, CA, United States
| | - Alice R Pressman
- Sutter Health Center for Health Systems Research, Walnut Creek, CA, United States; Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA, United States
| | - Rong X Wei
- Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Joan A Casey
- Environmental Health Sciences, Columbia Mailman School of Public Health, 722 West 168th Street, Room 1206, New York, NY 212-304-5502, United States.
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17
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Bladder epithelial cell phosphate transporter inhibition protects mice against uropathogenic Escherichia coli infection. Cell Rep 2022; 39:110698. [PMID: 35443182 DOI: 10.1016/j.celrep.2022.110698] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/12/2022] [Accepted: 03/28/2022] [Indexed: 12/20/2022] Open
Abstract
Urinary tract infections are predominantly caused by uropathogenic Escherichia coli (UPEC). UPEC infects bladder epithelial cells (BECs) via fusiform vesicles, escapes into the cytosol to evade exocytosis, and establishes intracellular bacterial communities (IBCs) for the next round of infection. The UPEC vesicle escape mechanism remains unclear. Here we show that UPEC senses host immune responses and initiates escape by upregulating a key phospholipase. The UPEC phospholipase PldA disrupts the vesicle membrane, and pldA expression is activated by phosphate reduction in vesicles. The host phosphate transporter PIT1 is located on the fusiform vesicle membrane, transporting phosphate into the cytosol. UPEC infection upregulates PIT1 via nuclear factor κB (NF-κB), resulting in phosphate reduction. Silencing PIT1 blocks UPEC vesicle escape in BECs, inhibits IBC formation in mouse bladders, and protects mice from UPEC infection. Our results shed light on pathogenic bacteria responding to intracellular phosphate shortage and tackling host defense and provide insights for development of new therapeutic agents to treat UPEC infection.
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18
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Dunne MW, Aronin SI, Yu KC, Watts JA, Gupta V. A multicenter analysis of trends in resistance in urinary Enterobacterales isolates from ambulatory patients in the United States: 2011-2020. BMC Infect Dis 2022; 22:194. [PMID: 35227203 PMCID: PMC8883240 DOI: 10.1186/s12879-022-07167-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/14/2022] [Indexed: 01/28/2023] Open
Abstract
Background Urinary tract infections (UTIs), which are usually caused by bacteria in the Enterobacterales family, are a common reason for outpatient visits. Appropriate empiric therapy for UTIs requires an understanding of antibiotic resistance in the community. In this nationwide study, we examined trends in antibiotic resistance in urinary Enterobacterales isolates from ambulatory patients in the United States (US). Methods We analyzed the antimicrobial susceptibility profiles (extended-spectrum beta-lactamase [ESBL]-producing phenotype and not susceptible [NS] to beta-lactams, trimethoprim/sulfamethoxazole [TMP/SMX], fluoroquinolones [FQ], or nitrofurantoin [NFT]) of 30-day non-duplicate Enterobacterales isolates from urine cultures tested at ambulatory centers in the BD Insights Research Database (2011–2020). The outcome of interest was the percentage of resistant isolates by pathogen and year. Multi-variable generalized estimating equation models were used to assess trends in resistance over time and by additional covariates. Results A total of 338 US facilities provided data for > 2.2 million urinary Enterobacterales isolates during the 10-year study. Almost three-quarters (72.8%) of Enterobacterales isolates were Escherichia coli. Overall unadjusted resistance rates in Enterobacterales isolates were 57.5%, 23.1%, 20.6%, and 20.2% for beta-lactams, TMP/SMX, FQ, and NFT, respectively, and 6.9% had an ESBL-producing phenotype. Resistance to two or more antibiotic classes occurred in 16.4% of isolates and 5.5% were resistant to three or more classes. Among isolates with an ESBL-producing phenotype, 70.1%, 59.9%, and 33.5% were NS to FQ, TMP/SMX, and NFT, respectively. In multivariable models, ESBL-producing and NFT NS Enterobacterales isolates increased significantly (both P < 0.001), while other categories of resistance decreased. High rates (≥ 50%) of beta-lactam and NFT resistance were observed in Klebsiella isolates and in non-E. coli, non-Klebsiella Enterobacterales isolates. Conclusions Antimicrobial resistance was common in urinary Enterobacterales isolates. Isolates with an ESBL-producing phenotype increased by about 30% between 2011 and 2020, and significant increases were also observed in NFT NS Enterobacterales isolates. Resistance rates for all four antibiotic classes were higher than thresholds recommended for use as empiric therapy. Non-E. coli Enterobacterales isolates showed high levels of resistance to commonly used empiric antibiotics, including NFT. These data may help inform empiric therapy choices for outpatients with UTIs. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07167-y.
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Affiliation(s)
- Michael W Dunne
- Bill & Melinda Gates Medical Research Institute, Cambridge, MA, USA.,Iterum Therapeutics, Old Saybrook, Connecticut, USA
| | | | - Kalvin C Yu
- Becton, Dickinson and Company, 1 Becton Drive, Franklin Lakes, NJ, 07417, USA
| | - Janet A Watts
- Becton, Dickinson and Company, 1 Becton Drive, Franklin Lakes, NJ, 07417, USA
| | - Vikas Gupta
- Becton, Dickinson and Company, 1 Becton Drive, Franklin Lakes, NJ, 07417, USA.
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19
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Applying Diagnostic Stewardship to Proactively Optimize the Management of Urinary Tract Infections. Antibiotics (Basel) 2022; 11:antibiotics11030308. [PMID: 35326771 PMCID: PMC8944608 DOI: 10.3390/antibiotics11030308] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/05/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection.
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Sarshar M, Scribano D, Limongi D, Zagaglia C, Palamara AT, Ambrosi C. Adaptive strategies of uropathogenic Escherichia coli CFT073: from growth in lab media to virulence during host cell adhesion. Int Microbiol 2022; 25:481-494. [PMID: 35106679 DOI: 10.1007/s10123-022-00235-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/23/2021] [Accepted: 01/17/2022] [Indexed: 12/15/2022]
Abstract
Urinary tract infections (UTIs) are a major concern in public health. The prevalent uropathogenic bacterium in healthcare settings is Escherichia coli. The increasing rate of antibiotic-resistant strains demands studies to understand E. coli pathogenesis to drive the development of new therapeutic approaches. This study compared the gene expression profile of selected target genes in the prototype uropathogenic E. coli (UPEC) strain CFT073 grown in Luria Bertani (LB), artificial urine (AU), and during adhesion to host bladder cells by semi-quantitative real-time PCR (RT-PCR) assays. AU effectively supported the growth of strain CFT073 as well as other E. coli strains with different lifestyles, thereby confirming the appropriateness of this medium for in vitro models. Unexpectedly, gene expression of strain CFT073 in LB and AU was quite similar; conversely, during the adhesion assay, adhesins and porins were upregulated, while key global regulators were downregulated with respect to lab media. Interestingly, fimH and papGII genes were significantly expressed in all tested conditions. Taken together, these results provide for the first time insights of the metabolic and pathogenic profile of strain CFT073 during the essential phase of host cell adhesion.
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Affiliation(s)
- Meysam Sarshar
- Research Laboratories, Bambino Gesù Children's Hospital, IRCCS, 00146, Rome, Italy
| | - Daniela Scribano
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185, Rome, Italy.,Dani Di Giò Foundation-Onlus, 00193, Rome, Italy
| | - Dolores Limongi
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, IRCCS San Raffaele Rome, 00166, Rome, Italy
| | - Carlo Zagaglia
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185, Rome, Italy
| | - Anna Teresa Palamara
- Department of Infectious Diseases, Istituto Superiore Di Sanità, 00161, Rome, Italy.,Department of Public Health and Infectious Diseases, Sapienza University of Rome, Laboratory affiliated to Institute Pasteur Italia- Cenci Bolognetti Foundation, 00185, Rome, Italy
| | - Cecilia Ambrosi
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, IRCCS San Raffaele Rome, 00166, Rome, Italy.
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21
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González-Villalobos E, Ribas-Aparicio RM, Belmont-Monroy L, Aparicio-Ozores G, Manjarrez-Hernández HÁ, Gavilanes-Parra S, Balcázar JL, Molina-López J. Identification and characterization of class 1 integrons among multidrug-resistant uropathogenic Escherichia coli strains in Mexico. Microb Pathog 2021; 162:105348. [PMID: 34871727 DOI: 10.1016/j.micpath.2021.105348] [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: 09/13/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
This study aimed to identify and characterize integrons among multidrug-resistant (MDR) uropathogenic Escherichia coli (UPEC) from outpatients in Mexico City, Mexico. PCR assays were used to screen for the presence of class 1, 2 and 3 integrons, whose PCR products were sequenced to identify the inserted gene cassettes within the variable regions. Out of 83 tested strains, 53 (63.9%) were positive for the presence of class 1 integrons, whereas no integrons were detected in the remaining strains, regardless of their classes. Most of the strains carrying the intI1 gene belonged to the extraintestinal B2 (41.5%) and commensal A (32.1%) phylogroups, and to a lesser extent, the extraintestinal D (20.8%) and commensal B1 (5.7%) phylogroups. Moreover, 8 different gene cassette arrangements were detected, with dfrA17 and aadA5 being the most common (32.1% of the class 1 integron-positive strains), which confer resistance to trimethoprim/sulfamethoxazole and aminoglycosides, respectively. Our results suggest that class 1 integrons are widely distributed among MDR-UPEC strains in Mexico, which may directly or indirectly contribute to the selection of MDR strains. These findings are important for a better understanding of the factors and mechanisms that promote multidrug resistance among UPEC strains.
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Affiliation(s)
- Edgar González-Villalobos
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, 11340, Mexico; Unidad Periférica de Investigación Básica y Clínica en Enfermedades Infecciosas, Departamento de Salud Pública, División de Investigación, Facultad de Medicina, UNAM, Mexico City, 04510, Mexico; Laboratorio de Patogenicidad Bacteriana, Unidad de Hemato-Oncología e Investigación, Hospital Infantil de México Federico Gómez, Facultad de Medicina, UNAM, Mexico City, 06720, Mexico; Catalan Institute for Water Research (ICRA), Girona, 17003, Spain.
| | - Rosa María Ribas-Aparicio
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, 11340, Mexico.
| | - Laura Belmont-Monroy
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, 11340, Mexico; Unidad Periférica de Investigación Básica y Clínica en Enfermedades Infecciosas, Departamento de Salud Pública, División de Investigación, Facultad de Medicina, UNAM, Mexico City, 04510, Mexico; Laboratorio de Patogenicidad Bacteriana, Unidad de Hemato-Oncología e Investigación, Hospital Infantil de México Federico Gómez, Facultad de Medicina, UNAM, Mexico City, 06720, Mexico.
| | - Gerardo Aparicio-Ozores
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), Mexico City, 11340, Mexico.
| | - H Ángel Manjarrez-Hernández
- Departamento de Salud Pública, Facultad de Medicina, UNAM. Mexico City, 04510, Mexico; Unidad Periférica de Patogénesis Bacteriana, Hospital General Dr. Manuel Gea González, Tlalpan, Mexico City, 14080, Mexico.
| | - Sandra Gavilanes-Parra
- Departamento de Salud Pública, Facultad de Medicina, UNAM. Mexico City, 04510, Mexico; Unidad Periférica de Patogénesis Bacteriana, Hospital General Dr. Manuel Gea González, Tlalpan, Mexico City, 14080, Mexico.
| | - José Luis Balcázar
- Catalan Institute for Water Research (ICRA), Girona, 17003, Spain; University of Girona. Girona, 17004, Spain.
| | - José Molina-López
- Unidad Periférica de Investigación Básica y Clínica en Enfermedades Infecciosas, Departamento de Salud Pública, División de Investigación, Facultad de Medicina, UNAM, Mexico City, 04510, Mexico; Laboratorio de Patogenicidad Bacteriana, Unidad de Hemato-Oncología e Investigación, Hospital Infantil de México Federico Gómez, Facultad de Medicina, UNAM, Mexico City, 06720, Mexico.
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22
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Lodise TP, Henriksen AS, Hadley T, Patel N. US-Focused Conceptual Health Care Decision-Analytic Models Examining the Value of Pivmecillinam Relative to Current Standard-of-Care Agents Among Adult Patients With Uncomplicated Urinary Tract Infections due to Enterobacterales. Open Forum Infect Dis 2021; 8:ofab380. [PMID: 34660834 PMCID: PMC8516593 DOI: 10.1093/ofid/ofab380] [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: 02/12/2021] [Accepted: 07/27/2021] [Indexed: 12/26/2022] Open
Abstract
Background Pivmecillinam is approved for the treatment of adults with uncomplicated urinary tract infection (uUTI) in Canada and Europe and is pending United States (US) Food and Drug Administration submission for consideration for approval. US-focused health care decision-analytics were developed to define the value of an agent like pivmecillinam relative to current standard-of-care (SOC) agents among adult patients with Enterobacterales uUTIs based on its improved microbiologic activity against common Enterobacterales. Methods The model population was 100 theoretical adult outpatients with Enterobacterales uUTIs under 4 different uUTI first-line empiric treatment scenarios (ie, pivmecillinam, nitrofurantoin, trimethoprim-sulfamethoxazole [SXT], or fluoroquinolones). The total mean uUTI-related 30-day costs, including inappropriate treatment costs, were calculated for each regimen. The range of pivmecillinam regimen costs that conferred cost savings relative to the current SOC agents based on its potentially improved microbiologic activity against common Enterobacterales was determined. Results The 30-day uUTI-related costs associated with nitrofurantoin, SXT, and fluoroquinolones were $655.61, $687.57, and $659.69, respectively. The pivmecillinam neutral regimen cost thresholds that resulted in the same uUTI-related 30-day per-patient costs for nitrofurantoin, SXT, and fluoroquinolones were $83.50, $115.45, and $87.58, respectively. The overall antimicrobial susceptibility improvement required with pivmecillinam fixed at $200/regimen, for it to be cost savings relative to SOC agents, was 28%. Conclusions The analyses suggests that an agent like pivmecillinam, if approved in the US, has the potential to reduce the economic burden associated with inappropriate treatment of adult outpatients with uUTIs, especially in patients at high risk for an Enterobacterales uUTI that is resistant to SOC agents.
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Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | | | | | - Nimish Patel
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
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Redondo-Sánchez J, del Cura-González I, Díez-Izquierdo L, Rodríguez-Barrientos R, Rodríguez-Cabrera F, Polentinos-Castro E, López-Miguel M, Marina-Ono L, Llamosas-Falcón L, Gil-de Miguel Á. Trends in urinary tract infection hospitalization in older adults in Spain from 2000-2015. PLoS One 2021; 16:e0257546. [PMID: 34587191 PMCID: PMC8480842 DOI: 10.1371/journal.pone.0257546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 09/05/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To analyze trends in urinary tract infection hospitalization (cystitis, pyelonephritis, prostatitis and non-specified UTI) among patients over 65 years in Spain from 2000–2015. Methods We conducted a retrospective observational study using the Spanish Hospitalization Minimum Data Set (CMBD), with codifications by the International Classification of Diseases (ICD-9). We collected data on sex, age, type of discharge, main diagnosis, comorbid diagnosis, length of stay, and global cost. All the hospitalizations were grouped by age into three categories: 65–74 years old, 75–84 years old, and 85 years old and above. In the descriptive statistical analysis, crude rates were defined as hospitalizations per 1,000 inhabitants aged ≥65. To identify trends over time, we performed a Joinpoint regression. Results From 2000–2015, we found 387,010 hospitalizations coded as UTIs (54,427 pyelonephritis, 15,869 prostatitis, 2643 cystitis and 314,071 non-specified UTI). The crude rate of hospitalization for UTIs between 2000 and 2015 ranged from 2.09 in 2000 to 4.33 in 2015 Rates of hospitalization were higher in men than in women, except with pyelonephritis. By age group, higher rates were observed in patients aged 85 years or older, barring prostatitis-related hospitalizations. Joinpoint analyses showed an average annual percentage increase (AAPC) in incidence rates of 4.9% (95% CI 3.2;6.1) in UTI hospitalizations. We observed two joinpoints, in 2010 and 2013, that found trends of 5.5% between 2000 and 2010 (95% CI 4.7;6.4), 1.5% between 2010 and 2013 (95% CI -6.0;9.6) and 6.8% between 2013 and 2015 (95% CI -0.3;14.4). Conclusions The urinary infection-related hospitalization rate in Spain doubled during the period 2000–2015. The highest hospitalization rates occurred in men, in the ≥85 years old age group, and in non-specified UTIs. There were increases in all types of urinary tract infection, with non-specified UTIs having the greatest growth. Understanding these changing trends can be useful for health planning.
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Affiliation(s)
- Jesús Redondo-Sánchez
- Ramon y Cajal Health Care Center, Alcorcón, Primary Care Management, Madrid Health Service, Madrid, Spain
- Department of Medical Specialties and Public Health, University Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Isabel del Cura-González
- Department of Medical Specialties and Public Health, University Rey Juan Carlos, Alcorcón, Madrid, Spain
- Research Unit, Primary Care Management, Madrid Health Service, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC) ISCIII, Madrid, Spain
| | | | - Ricardo Rodríguez-Barrientos
- Research Unit, Primary Care Management, Madrid Health Service, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC) ISCIII, Madrid, Spain
- Biosanitary Research and Innovation Foundation of Primary Care (FIIBAP), Madrid, Spain
- * E-mail:
| | | | - Elena Polentinos-Castro
- Research Unit, Primary Care Management, Madrid Health Service, Madrid, Spain
- Health Services Research on Chronic Patients Network (REDISSEC) ISCIII, Madrid, Spain
| | - Miguel López-Miguel
- Ciudades Health Care Center, Getafe, South Family and Community Care Teaching Unit, Madrid, Spain
| | | | - Laura Llamosas-Falcón
- Preventive Medicine and Public Health, 12 de Octubre University Hospital, Madrid, Spain
| | - Ángel Gil-de Miguel
- Department of Medical Specialties and Public Health, University Rey Juan Carlos, Alcorcón, Madrid, Spain
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Enfrentamiento ambulatorio de las infecciones del tracto urinario en adultos, una mirada infectológica. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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25
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Casey JA, Rudolph KE, Robinson SC, Bruxvoort K, Raphael E, Hong V, Pressman A, Morello-Frosch R, Wei RX, Tartof SY. Sociodemographic Inequalities in Urinary Tract Infection in 2 Large California Health Systems. Open Forum Infect Dis 2021; 8:ofab276. [PMID: 34189179 PMCID: PMC8231389 DOI: 10.1093/ofid/ofab276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022] Open
Abstract
Background Urinary tract infection (UTI) accounts for a substantial portion of outpatient visits and antibiotic prescriptions in the United States. Few studies have considered sociodemographic factors including low socioeconomic status (SES)—which may increase residential crowding, inappropriate antibiotic prescribing, or comorbidities—as UTI or multidrug-resistant (MDR) UTI risk factors. Methods We used 2015–2017 electronic health record data from 2 California health care systems to assess whether 3 sociodemographic factors—use of Medicaid, use of an interpreter, and census tract–level deprivation—were associated with overall UTI or MDR UTI. UTIs resistant to ≥3 antibiotic classes were considered MDR. Results Analyses included 601 352 UTI cases, 1 303 455 controls, and 424 977 urinary Escherichia coli isolates from Kaiser Permanente Southern California (KPSC) and Sutter Health in Northern California. The MDR prevalence was 10.4% at KPSC and 12.8% at Sutter Health. All 3 sociodemographic factors (ie, use of Medicaid, using an interpreter, and community deprivation) were associated increased risk of MDR UTI. For example, using an interpreter was associated with a 36% (relative risk [RR], 1.36; 95% CI, 1.31 to 1.40) and 28% (RR, 1.28; 95% CI, 1.22 to 1.34) increased risk of MDR UTI at KPSC and Sutter Health, respectively, adjusted for SES and other potential confounding variables. The 3 sociodemographic factors were only weakly associated with UTI overall. Conclusions We found low SES and use of an interpreter to be novel risk factors for MDR UTI in the United States.
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Affiliation(s)
- Joan A Casey
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Correspondence: Joan A. Casey, Columbia University Mailman School of Public Health, 722 W 168th St, Rm 1206, New York, NY 10032-3727 ()
| | - Kara E Rudolph
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Sarah C Robinson
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Katia Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Eva Raphael
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Vennis Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Alice Pressman
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Rachel Morello-Frosch
- Department of Environmental Science, Policy and Management and School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Rong X Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California and Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Outpatient antibiotic prescribing for common infections via telemedicine versus face-to-face visits: Systematic literature review and meta-analysis. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e24. [PMID: 36168456 PMCID: PMC9495625 DOI: 10.1017/ash.2021.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/19/2021] [Accepted: 06/24/2021] [Indexed: 12/20/2022]
Abstract
Objective: To evaluate the frequency of antibiotic prescribing for common infections via telemedicine compared to face-to-face visits. Design: Systematic literature review and meta-analysis. Methods: We searched PubMed, CINAHL, Embase (Elsevier platform) and Cochrane CENTRAL to identify studies comparing frequency of antibiotic prescribing via telemedicine and face-to-face visits without restrictions by publish dates or language used. We conducted meta-analyses of 5 infections: sinusitis, pharyngitis, otitis media, upper respiratory infection (URI) and urinary tract infection (UTI). Random-effect models were used to obtain pooled odds ratios (ORs). Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic test. Results: Among 3,106 studies screened, 23 studies (1 randomized control study, 22 observational studies) were included in the systematic literature review. Most of the studies (21 of 23) were conducted in the United States. Studies were substantially heterogenous, but stratified analyses revealed that providers prescribed antibiotics more frequently via telemedicine for otitis media (pooled odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04–1.52; I2 = 31%) and pharyngitis (pooled OR, 1.16; 95% CI, 1.01–1.33; I2 = 0%). We detected no significant difference in the frequencies of antibiotic prescribing for sinusitis (pooled OR, 0.86; 95% CI, 0.70–1.06; I2 = 91%), URI (pooled OR, 1.18; 95% CI, 0.59–2.39; I2 = 100%), or UTI (pooled OR, 2.57; 95% CI, 0.88–7.46; I2 = 91%). Conclusions: Telemedicine visits for otitis media and pharyngitis were associated with higher rates of antibiotic prescribing. The interpretation of these findings requires caution due to substantial heterogeneity among available studies. Large-scale, well-designed studies with comprehensive assessment of antibiotic prescribing for common outpatient infections comparing telemedicine and face-to-face visits are needed to validate our findings.
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Matsui Y, Hu Y, Rubin J, de Assis RS, Suh J, Riley LW. Multilocus sequence typing of Escherichia coli isolates from urinary tract infection patients and from fecal samples of healthy subjects in a college community. Microbiologyopen 2020; 9:1225-1233. [PMID: 32189451 PMCID: PMC7294302 DOI: 10.1002/mbo3.1032] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/14/2020] [Accepted: 03/06/2020] [Indexed: 11/10/2022] Open
Abstract
Community-acquired urinary tract infections (UTIs) are one of the most common bacterial infections worldwide. Escherichia coli is the most common cause of community-acquired UTI. In general, UTI results from E. coli in the intestine that enters the bladder via the urethra. However, whether these E. coli strains that cause UTI represent members of the intestinal commensal E. coli or a distinct subgroup of pathogenic E. coli remains unestablished. Here, we analyzed E. coli isolates from fecal samples of healthy volunteers and urine samples of UTI patients obtained from a university-affiliated health center. The E. coli isolates were genotyped by multilocus sequence typing (MLST). From May to October 2018, we analyzed 89 E. coli isolates from 76 (75%) rectal swabs from 113 unique healthy volunteers. We also analyzed 106 (27%) E. coli isolates from 398 unique urine samples collected between August and October 2018. Fecal and urine E. coli isolates each contained 31 distinct sequence types (STs). Nine STs were shared by fecal and urine E. coli isolates, which accounted for approximately 50% of urine isolates typed by MLST. Among the shared genotypes, ST10 and ST131 were significantly more frequently found in fecal samples, whereas ST95 and ST127 were significantly more frequently recovered from UTI samples. ST73 was found only among urine samples. These E. coli genotypes clustered and fluctuated over time. These observations suggest that E. coli genotypes found to cause UTI transiently colonize the intestine and that their primary reservoir may reside outside of the human intestine.
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Affiliation(s)
- Yusuke Matsui
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, USA
| | - Yuan Hu
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Julia Rubin
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, USA
| | - Reginara Souza de Assis
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Joy Suh
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, USA
| | - Lee W Riley
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, USA
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