Asymptomatic bacteriuria:

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

PURPOSE OF REVIEW

The aim of this review is to focus on epidemiology, pathogenesis, risk factors, management, and complications of UTI in people with diabetes as well as reviewing the association of SGLT-2 inhibitors with genitourinary infections.

RECENT FINDINGS

Individuals diagnosed with T2DM are more prone to experiencing UTIs and recurrent UTIs compared to individuals without T2DM. T2DM is associated with an increased risk of any genitourinary infections (GUI), urinary tract infections (UTIs), and genital infections (GIs) across all age categories. SGLT2 inhibitors are a relatively new class of anti-hyperglycemic agents, and studies suggest that they are associated with an increased risk of genitourinary infections. The management of diabetes and lifestyle modifications with a patient-centric approach are the most recognized methods for preventing critical long-term complications including genitourinary manifestations of diabetes. The available data regarding the association of SGLT-2 inhibitors with genitourinary infections is more comprehensive compared to that with UTIs. Further research is needed to better understand the mechanisms underlining the association between SGLT-2 inhibitors and genital infections and UTIs.

Effect of microbiology comment nudging on antibiotic use in asymptomatic bacteriuria: A before-and-after quasi-experimental study

OBJECTIVE

To describe the effect of a microbiology comment nudge on antibiotic use for asymptomatic bacteriuria (ASB).

DESIGN

Single-center, before-and-after, quasi-experimental study.

SETTING

Community-based, public, not-for-profit teaching hospital in the southeastern United States.

PARTICIPANTS

Adult inpatients with a positive urine culture and the absence of urinary tract infection signs and symptoms.

INTERVENTION

Implementation of a microbiology comment nudge on urine cultures.

RESULTS

In total, 204 patients were included in the study. Antibiotics were less likely to be continued beyond 72 hours in the postimplementation group: 57 (55%) of 104 versus 38 (38%) of 100 (P = .016). They were less likely to have antibiotics continued beyond 48 hours: 60 (58%) of 104 versus 43 (43%) of 100 (P = .036). They were also less likely to have antibiotics prescribed at discharge 35 (34%) of 104 versus 20 (20%) of 100 (P = .028). In addition, they had fewer total antibiotic days of therapy: 4 (IQR, 1-6) versus 1 (IQR, 0-6) (P = .022).

CONCLUSION

Microbiology comment nudging may contribute to less antibiotic utilization in patients with ASB.

Are the Diagnosis and Treatment of Acute Cystitis in the Premenopausal, Pregnant, and Postmenopausal Women the Same? A Review of the Literature

Importance

Acute cystitis is a common condition diagnosed in women. The diagnosis and treatment of this condition change throughout a woman's life. Understanding the differences in diagnosis and treatment in premenopausal, pregnant, and postmenopausal woman increases the likelihood of treatment success and decreases risk of complications from untreated or suboptimally treated infections.

Objective

The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of acute cystitis and the similarities and differences of these aspects of the condition in the premenopausal, pregnant, and postmenopausal woman.

Evidence Acquisition

A PubMed, Web of Science, and CINAHL search was undertaken with the years 1990 to 2020 searched.

Results

There were 393 articles identified, with 103 being the basis of review. Multiple risk factors for acute cystitis have been identified and are largely consistent throughout a woman's lifetime with few exceptions. The diagnoses by group with common diagnostic tools, such as urinalysis, vary in specificity and sensitivity between these groups. Management also varies between groups, with pregnancy having specific limitations related to drug safety in regard to possible fetal effects posed by certain medications commonly used to treat acute cystitis.

Conclusions

Acute cystitis not only varies in presentation throughout a woman's lifespan, but also in appropriate diagnosis and treatment. Treatment of acute cystitis does have some commonalities between the groups; however, there are contraindications unique to each group. These differences are paramount to not only ensuring appropriate treatment but also treatment success.

Relevance

Acute cystitis is a common condition with different diagnostic and management recommendations throughout a woman's lifespan.

A review of the current concepts in canine urinary tract infections

Traditionally, urinary tract infections (UTIs) have been categorised as either uncomplicated or complicated in veterinary medicine, with treatment differing for the two categories. In human medicine, there is an additional category: Asymptomatic bacteriuria, which is the presence of bacteriuria without symptoms of infection. Escherichia coli (E.coli) is the most common bacterial species involved in UTIs in dogs. Clinical signs can be absent in dogs with complicated UTIs, and this has been likened to asymptomatic bacteriuria (ASB) in people and has been termed subclinical bacteriuria (SBU) with the treatment recommendations for SBU in dogs have been adapted from human recommendations. There is a shift in the current treatment of UTIs to help minimise the development of antimicrobial resistance. Routine screening of dogs with conditions that may predispose them to UTIs has been discouraged as has the treatment of SBU. This has been due to the increase in antimicrobial resistance (AMR).

Optimal timing to screen for asymptomatic bacteriuria during pregnancy: first vs. second trimester

OBJECTIVES

Although current guidelines advice to screen for asymptomatic bacteriuria during pregnancy, little is known about the best moment of testing. The goal of this study is to analyze the optimal timing (first vs. second trimester) to screen for asymptomatic bacteriuria during pregnancy.

METHODS

A retrospective cohort analysis, comparing patients that were screened for asymptomatic bacteriuria in the first vs. second trimester was performed. The main question was to compare the rate of positive urinary culture in both trimesters. Study included patients all followed a prenatal consultation at the University Hospital of Brussels between 2012 and 2017. Other outcomes considered were the nature of identified germs, treatments, possible risk and confounding factors (age, BMI, gravidity-parity-abortus [GPA], type of conception, ethnicity, education, prior urinary tract infection (UTI), diabetes, hypertension, prior preterm delivery and sickle cell disease) and complications (UTI, preterm delivery, preterm rupture of the membranes and chorio-amnionitis).

RESULTS

A total of 2,005 consecutive files were reviewed, 655 concerned patients screened during the first trimester group and 1,350 in the second trimester group. Asymptomatic bacteriuria was present in only 71 cases (3.54%), 23 in the first trimester group (3.50%) and 48 in the second trimester group (3.55%). Escherichia coli was the most frequently identified germ (37 cases (1.8%), 14 in the first trimester group and 23 in the second trimester group). Our logistic regression analysis shows no statistical difference according to the moment the urinary culture was done for the presence of asymptomatic bacteriuria (E. coli or others), for its association with hospitalization for pyelonephritis, preterm contractions, preterm pre-labor rupture of the membranes (PPROM) and/or preterm delivery.

CONCLUSIONS

If recommendations remain to screen for asymptomatic bacteriuria at least once during pregnancy, this study indicates that the moment of testing (first vs. second trimester) has no clinical impact on obstetrical outcomes.

The necessity of treating asymptomatic bacteriuria with antibiotics in the perioperative period of joint arthroplasty: a metaanalysis

Background/aim

Oral antibiotics are usually used to treat asymptomatic bacteriuria during the perioperative period of joint replacement. However, there is no unified conclusion as to whether asymptomatic bacteriuria causes infection around joint prostheses, and the efficacy of antibiotics is unknown.

Materials and methods

We systematically searched PubMed, CNKI, Ovid, Cochrane Library, EMBASE, manual research, and references of relevant articles up to January 1, 2020, to identify and compare observational studies. The Cochrane systematic review method was used, and Review Manager 5.3 software was used for analysis.

Results

Nine articles were included in the analysis, involving 29,844 cases of joint arthroplasty and 2366 cases of asymptomatic bacteriuria. Periprosthetic joint infection had a significantly higher incidence in the asymptomatic bacteriuria group than in the nonasymptomatic bacteriuria group (Odds Ratio: OR = 3.15, 95% CI: 1.23–8.02, P = 0.02). Seven of the nine articles reported the use of antibiotics for treating perioperative asymptomatic bacteriuria and there was no significant difference in the incidence of periprosthetic joint infection between the two groups (OR = 1.64, 95% CI: 0.84–3.23, P = 0.15).

Conclusion

The occurrence of asymptomatic bacteriuria in the perioperative period of joint arthroplasty is a risk factor for periprosthetic joint infection, and the use of antibiotics for asymptomatic bacteriuria does not change the rate of incidence.

Antibiotic stewardship in direct-to-consumer telemedicine consultations leads to high adherence to best practice guidelines and a low prescription rate

OBJECTIVE

To analyze the antibiotic prescription rate in low-risk patients evaluated at a telemedicine program that adopts antibiotic stewardship protocols.

METHODS

Adult patients who accessed a single direct-to-consumer telemedicine center (Jan/2019-Feb/2020) were retrospectively enrolled. Diseases amenable to antimicrobial treatment were classified under five diagnostic groups: upper respiratory tract infection (URI), acute pharyngotonsillitis (PT), acute sinusitis (AS), urinary tract infection (UTI), and acute diarrhea (AD). Physicians were trained on and advised to strictly follow the current guideline recommendations supported by institutional antibiotic stewardship protocols, readily available online during consultations. We analyzed the antibiotic prescription rate among patients, referral rate, and antibiotic class through descriptive statistics.

RESULTS

A total of 2328 patients were included in the study. A total of 2085 (89·6%) patients were discharged with usual recommendations, medication (if needed), and instructions about red flags, while 243 (10·4%) were referred to a face-to-face consultation. Among the discharged patients, the antibiotic prescription rates by the diagnostic group were URI - 2·5%, PT - 35·0%, AS - 51·8%, UTI - 91.6%, and AD - 1·6%. In most cases, prescribed antibiotics were in line with institutional stewardship protocols.

CONCLUSIONS

Low prescription rate of antibiotics can be achieved using antibiotic stewardship protocols at direct-to-consumer telemedicine consultations, showing high adherence to international guidelines. These results reinforce telemedicine as a cost-effective and safe strategy for the initial assessment of acute non-urgent symptoms.

A Qualitative Investigation of the Acceptability and Feasibility of a Urinary Tract Infection Patient Information Leaflet for Older Adults and Their Carers

Urinary tract infections (UTIs) can be life threatening in older adults. The aim of this study was to primarily understand the acceptability and feasibility of using a UTI leaflet for older adults in care homes and the community. Qualitative interviews and focus groups informed by the Theoretical Domains Framework were conducted in 2019 with 93 participants from two English areas where a UTI leaflet for older adults had been introduced to improve self-care advice. Discussions were conducted with care staff (carers and nurses), older adults, general practice staff (GPs, nurses and health care assistants), and other relevant stakeholders and covered experiences of using the leaflet; its implementation; and barriers and facilitators to use. Participants deemed the leaflet an acceptable tool. Clinicians and care staff believed that having information in writing would reinforce their messages to older adults. Care staff reported that some older adults may find the information overwhelming. Where implemented, care staff used the leaflet as an educational guide. Clinicians requested the leaflet in electronic and paper formats to suit preferences. Implementation barriers included lack of awareness of the leaflet, lack of staffing and resource, and weak working relationships between care homes and general practices. It is recommended that regional strategies must include plans for dissemination to care homes, training, promotion and easy access to the leaflet. Improvements to the leaflet consisted of inclusion of antibiotic course length, D-mannose, atrophic vaginitis and replacement of less alarmist terminology such as ‘life threatening’.

Molecular determinants of disease severity in urinary tract infection

The most common and lethal bacterial pathogens have co-evolved with the host. Pathogens are the aggressors, and the host immune system is responsible for the defence. However, immune responses can also become destructive, and excessive innate immune activation is a major cause of infection-associated morbidity, exemplified by symptomatic urinary tract infections (UTIs), which are caused, in part, by excessive innate immune activation. Severe kidney infections (acute pyelonephritis) are a major cause of morbidity and mortality, and painful infections of the urinary bladder (acute cystitis) can become debilitating in susceptible patients. Disease severity is controlled at specific innate immune checkpoints, and a detailed understanding of their functions is crucial for strategies to counter microbial aggression with novel treatment and prevention measures. One approach is the use of bacterial molecules that reprogramme the innate immune system, accelerating or inhibiting disease processes. A very different outcome is asymptomatic bacteriuria, defined by low host immune responsiveness to bacteria with attenuated virulence. This observation provides the rationale for immunomodulation as a new therapeutic tool to deliberately modify host susceptibility, control the host response and avoid severe disease. The power of innate immunity as an arbitrator of health and disease is also highly relevant for emerging pathogens, including the current COVID-19 pandemic.

Swiss consensus recommendations on urinary tract infections in children

The kidneys and the urinary tract are a common source of infection in children of all ages, especially infants and young children. The main risk factors for sequelae after urinary tract infections (UTI) are congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction. UTI should be considered in every child with fever without a source. The differentiation between upper and lower UTI is crucial for appropriate management. Method of urine collection should be based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. Treatment of UTI should be based on practical considerations regarding age and presentation with adjustment of the initial antimicrobial treatment according to antimicrobial sensitivity testing. All children, regardless of age, should have an ultrasound of the urinary tract performed after pyelonephritis. In general, antibiotic prophylaxis is not recommended.Conclusion: Based on recent data and in line with international guidelines, multidisciplinary Swiss consensus recommendations were developed by members of Swiss pediatric infectious diseases, nephrology, and urology societies giving the clinician clear recommendations in regard to diagnosis, type and duration of therapy, antimicrobial treatment options, indication for imaging, and antibiotic prophylaxis. What is Known: • Urinary tract infections (UTI) are a common and important clinical problem in childhood. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children less than 2 years of age. • Method of urine collection is based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. What is New: • Vesicoureteric reflux (VUR) remains a risk factor for UTI but per se is neither necessary nor sufficient for the development of renal scars. Congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction play a more important role as causes of long-term sequelae. In general, antibiotic prophylaxis is not recommended. • A switch to oral antibiotics should be considered already in young infants. Indications for invasive imaging are more restrictive and reserved for patients with abnormal renal ultrasound, complicated UTI, and infections with pathogens other than E. coli.

Subclinical bacteriuria and surgical site infections in dogs with cranial cruciate ligament disease

OBJECTIVE

To determine the prevalence of subclinical bacteriuria (SBU) in dogs with cranial cruciate ligament (CCL) disease, the clinical variables and clinicopathologic data associated with SBU, and the incidence of surgical site infections (SSI) in dogs with and without SBU.

STUDY DESIGN

Prospective, clinical cohort study.

ANIMALS

One hundred fifty-five dogs with CCL disease.

METHODS

Dogs had a urinalysis, sediment examination, and aerobic urine culture performed. Age, breed, sex, body weight, body condition score, clinical history, and physical examination findings were recorded. Dogs with SBU were not treated for bacteriuria or with postoperative antibiotics. Standard perioperative antimicrobials were provided for all dogs. Dogs that received nonsteroidal anti-inflammatory drugs were not excluded. Dogs that underwent an osteotomy were followed for at least 1 year to determine incidence of SSI. Outcomes and variables associated with SBU were assessed.

RESULTS

In 155 dogs with CCL disease, the prevalence of SBU was 6.5%, and SBU occurred exclusively in female dogs (11.4%). The incidence of SSI was 22.3% (25/112). Two of six dogs with SBU and 23/106 dogs without SBU developed SSI. Organisms isolated from SSI were different from those isolated from urine.

CONCLUSION

The prevalence of SBU in dogs with CCL disease was similar to that in other studies in which SBU was evaluated in various populations of dogs.

CLINICAL SIGNIFICANCE

Screening for and treatment of SBU may not be beneficial prior to tibial osteotomy for CCL disease. Additional studies are required to determine whether dogs with SBU have a greater risk of SSI.

Gauging the Risk Factors for Asymptomatic Bacteriuria in Type-2 Diabetic Women: A Case-Control Study

Background There is conflicting literature pertaining to the risk factors of asymptomatic bacteriuria (ASBU) in diabetic women. ASBU is a well-established risk factor for frequent urinary tract infections (UTIs), and the risk factors that predispose diabetic women to ASBU should, therefore, be evaluated.  Objectives This study aims to discern these aforesaid risk factors in type-2 diabetic women, define a population subset at particularly high risk for ASBU, and gauge the efficacy inherent in adhering to an antibiotic regimen in combatting ASBU.  Methods An analytical, case-control study was conducted at the Diabetic Clinic of the Holy Family Hospital (HFH), Rawalpindi, Pakistan. The participants included were type-2 diabetic women reporting to the clinic for routine follow-up. Six hundred and sixty-seven urine samples from these type-2 diabetic women were evaluated. Positive cases were those in which patients were diagnosed with ASBU according to the guidelines, while those with no ASBU constituted the control group. Common risk factors for UTI were excluded in both groups. Age, socioeconomic status, hygiene practices, and contraceptive use were matched between cases and controls.  Results Nineteen percent of type-2 diabetic women presented with ASBU in our study. The significant risk factors for ASBU were a higher HbA1c level (OR 1.97), more years since the initial diagnosis of diabetes (OR 1.49), a prior UTI history (OR 2.49), excessive antibiotic use (OR 2.72), sodium-glucose cotransporter-2 (SGLT2) inhibitor use (OR 1.75), and proteinuria (OR 1.88) in the multivariate model. Body mass index (BMI), age of the patients, pyuria, and voiding dysfunction manifested no association with ASBU. Antibiotic use was significantly associated with the type of bacterial species precipitating the ASBU.  Conclusion The clinicians must keep in mind the association between the various patient parameters and ASBU, especially in prescribing antibiotics to diabetic women. More studies are needed to further elaborate on these risk factors and revise the patient management in at-risk cases for ASBU and UTIs.

Is Non-Steroidal Anti-Inflammatory Therapy Non-Inferior to Antibiotic Therapy in Uncomplicated Urinary Tract Infections: a Systematic Review

BACKGROUND

Amid growing antimicrobial resistance, there is an increasing focus on antibiotic stewardship efforts to reduce inappropriate antibiotic prescribing. In this context, novel approaches for treating infections without antibiotics are being explored. One such strategy is the use of non-steroidal anti-inflammatory drugs (NSAIDs) for uncomplicated urinary tract infections (UTIs). Therefore, we conducted a systematic review of randomized controlled trials to evaluate the rates of symptom resolution and infectious complications in adult women with uncomplicated UTIs treated with antibiotics versus NSAIDs.

METHODS

We systematically searched PubMed, CINHAL, Scopus, Web of Science Core Collection, EMBASE, and ClinicalTrials.gov from inception until January 13, 2020, for randomized controlled trials comparing NSAIDs with antibiotics for treatment of uncomplicated UTIs in adult women. Studies comparing symptom resolution between groups were eligible. Two authors screened all studies independently and in duplicate; data were abstracted using a standardized template. Risk of bias was assessed using the Cochrane Collaboration tool.

RESULTS

Five randomized trials that included 1309 women with uncomplicated UTI met inclusion criteria. Three studies (1130 patients) favored antibiotic therapy in terms of symptom resolution. Two studies (179 patients) found no difference between NSAIDs and antibiotics in terms of symptom resolution. Three studies reported rates of pyelonephritis, two of which found higher rates in patients treated with NSAIDs versus antibiotics. Between two studies that reported this outcome (747 patients), patients randomized to NSAIDs received fewer antibiotic prescriptions compared with those in the antibiotics group. Three studies were at low risk of bias, one had an unclear risk of bias, and one was at high risk of bias.

DISCUSSION

For the outcomes of symptom resolution and complications in adult women with UTI, evidence favors antibiotics over NSAIDs.

PROSPERO

CRD42018114133.

Hyperthyroidism is not a risk factor for subclinical bacteriuria in cats: A prospective cohort study

Background

Subclinical bacteriuria is defined as a positive bacterial urine culture in the absence of clinical evidence of urinary tract infection (UTI). Studies have reported that hyperthyroid cats have UTIs (mostly subclinical) with prevalence rates of 12%‐22%. Consequently, clinicians consider hyperthyroidism a risk factor for development of subclinical bacteriuria, and many recommend urine culture when evaluating hyperthyroid cats.

Objectives

To compare the prevalence of subclinical bacteriuria (based on positive urine culture) in untreated hyperthyroid cats to that in euthyroid cats of similar age and sex.

Animals

Three hundred and ninety‐three hyperthyroid cats presented for radioiodine treatment and 131 euthyroid cats (≥7 years of age) presented for routine examination. Cats with signs of lower urinary tract disease were excluded.

Methods

Prospective cohort study. Both hyperthyroid and euthyroid cats had urine collected by cystocentesis for complete urinalysis and culture. Data pertaining to age, sex, body condition, and serum thyroxine and creatinine concentrations also were acquired. Logistic regression was performed to evaluate for potential risk factors for subclinical bacteriuria.

Results

Hyperthyroid cats showed a low prevalence of subclinical bacteriuria (4.3%), which did not differ from that found in euthyroid cats (4.6%). Of the signalment factors evaluated, only female sex was a significant risk factor (odds ratio [OR], 6.9; P = .002). Furthermore, positive urine cultures were more likely in specimens with dilute urine concentration (<1.035), pyuria, or microscopic bacteriuria.

Conclusions and Clinical Importance

Hyperthyroid cats are not at risk for subclinical bacteriuria. In the absence of lower urinary tract signs, no clinical benefit exists in routinely performing urine cultures when evaluating hyperthyroid cats.

Antimicrobial Agents and Urinary Tract Infections

Urinary Tract Infections (UTIs); second-ranking infectious diseases are regarded as a significant global health care problem. The UTIs annually cost tens of millions of dollars for governments worldwide. The main reason behind these costs is incorrect or indefinite treatment. There are a wide range of gram-negative and grampositive bacteria which may cause UTIs in males and females, children and adults. Among gram-negative bacteria, some members of Enterobacteriaceae such as Escherichia coli (E.coli) strains have significant contribution in UTIs. Uropathogenic E.coli (UPEC) strains are recognized as typical bacterial agents for UTIs. Thus, sharp and accurate diagnostic tools are needed for detection and identification of the microbial causative agents of UTIs. In parallel with the utilization of suitable diagnostic methods-to reduce the number of UTIs, effective and definite treatment procedures are needed. Therefore, the prescription of accurate, specific and effective antibiotics and drugs may lead to a definite treatment. However, there are many cases related to UTIs which can be relapsed. Due to a diversity of opportunistic and pathogenic causative microbial agents of UTIs, the treatment procedures should be achieved by the related antimicrobial agents. In this review, common and effective antimicrobial agents which are often prescribed for UTIs caused by UPEC will be discussed. Moreover, we will have a sharp look at their (antimicrobials) molecular treatment mechanisms.

Antibiotics for asymptomatic bacteriuria in pregnancy

BACKGROUND

Asymptomatic bacteriuria is a bacterial infection of the urine without any of the typical symptoms that are associated with a urinary infection, and occurs in 2% to 15% of pregnancies. If left untreated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth. This is an update of a review last published in 2015.

OBJECTIVES

To assess the effect of antibiotic treatment for asymptomatic bacteriuria on the development of pyelonephritis and the risk of low birthweight and preterm birth.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 4 November 2018, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening. Trials using a cluster-RCT design and quasi-RCTs were eligible for inclusion, as were trials published in abstract or letter form, but cross-over studies were not.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 15 studies, involving over 2000 women. Antibiotic treatment compared with placebo or no treatment may reduce the incidence of pyelonephritis (average risk ratio (RR) 0.24, 95% confidence interval (CI) 0.13 to 0.41; 12 studies, 2017 women; low-certainty evidence). Antibiotic treatment may be associated with a reduction in the incidence of preterm birth (RR 0.34, 95% CI 0.13 to 0.88; 3 studies, 327 women; low-certainty evidence), and low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; 6 studies, 1437 babies; low-certainty evidence). There may be a reduction in persistent bacteriuria at the time of delivery (average RR 0.30, 95% CI 0.18 to 0.53; 4 studies; 596 women), but the results were inconclusive for serious adverse neonatal outcomes (average RR 0.64, 95% CI 0.23 to 1.79, 3 studies; 549 babies). There were very limited data on which to estimate the effect of antibiotics on other infant outcomes, and maternal adverse effects were rarely described. Overall, we judged only one trial at low risk of bias across all domains; the other 14 studies were assessed as high or unclear risk of bias. Many studies lacked an adequate description of methods, and we could only judge the risk of bias as unclear, but in most studies, we assessed at least one domain at high risk of bias. We assessed the quality of the evidence for the three primary outcomes with GRADE software, and found low-certainty evidence for pyelonephritis, preterm birth, and birthweight less than 2500 g.

AUTHORS' CONCLUSIONS

Antibiotic treatment may be effective in reducing the risk of pyelonephritis in pregnancy, but our confidence in the effect estimate is limited given the low certainty of the evidence. There may be a reduction in preterm birth and low birthweight with antibiotic treatment, consistent with theories about the role of infection in adverse pregnancy outcomes, but again, the confidence in the effect is limited given the low certainty of the evidence. Research implications identified in this review include the need for an up-to-date cost-effectiveness evaluation of diagnostic algorithms, and more evidence to learn whether there is a low-risk group of women who are unlikely to benefit from treatment of asymptomatic bacteriuria.

Impact of urinary tract infection on nursing and healthcare-associated pneumonia

Nursing and healthcare-associated pneumonia (NHCAP), a concept of pneumonia proposed by the Japanese Respiratory Society, mostly occurs among elderly people in long-term care facilities. Similarly, the risk of urinary tract infection (UTI) also increases with age, with UTIs common among those in long-term care. Therefore, NHCAP is sometimes complicated by the presence of a UTI. However, pneumonia complicated by a UTI has not been clinically well characterized. We retrospectively analyzed 376 patients with NHCAP admitted to our hospital over a three-year period. Sixty-seven patients (17.8%) showed complications by a UTI. Patients with a UTI had lower renal function (higher blood urea nitrogen [P = 0.001], higher creatinine [P = 0.001]), lower systolic blood pressure (P = 0.04), higher A-DROP scores (P = 0.005) and higher positive blood culture rates (P = 0.03) than those without a UTI. Furthermore, based on urine, sputum and blood culture results, nearly half of the microorganisms (4/7) in blood cultures were identical with those of urine, suggesting that a concurrent UTI increases positive blood culture rates. Multivariate analysis showed that UTI was not an independent factor associated with 30-day mortality (P = 0.17), although patients with a UTI showed higher 30-day mortality (P = 0.04) than those without a UTI in univariate analysis. In summary, patients with NHCAP and a UTI were more prone to complications than those without a UTI, although UTI itself did not affect the prognosis of patients with NHCAP. A concurrent UTI had a negative impact on the severity of NHCAP.

Evidence-Informed Practice: Diagnostic Questions in Urinary Tract Infections in the Elderly

Introduction

Routine interventions in the practice of medicine often lack definitive evidence or are based on evidence that is either not high quality or of only modest-to-marginal effect sizes. An abnormal urinalysis in an elderly patient presenting to the emergency department (ED) with non-specific symptoms represents one condition that requires an evidence-informed approach to diagnosis and management of either asymptomatic bacteriuria or urinary tract infection (UTI). The emergency provider often will not have access to urine cultures, and the risks associated with antibiotic use in the elderly are not without potentially significant side effects.

Methods

We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin.

Results

Serum procalcitonin, a peptide that undergoes proteolysis into calcitonin, has been demonstrated to quickly and reliably rise in patients with severe bacterial infections, and may serve as a potentially sensitive and specific marker for identification of bacterial illness.

Conclusion

In the absence of validated risk scores for diagnosing UTI in elderly patients presenting to the ED, there may be a role for the use of procalcitonin in this patient population.

Clinical Profile of Asymptomatic Bacteriuria in Type 2 Diabetes Mellitus: An Eastern India Perspective

INTRODUCTION

Asymptomatic bacteriuria (ASB), believed to precede symptomatic urinary tract infection (UTI) in diabetes mellitus, has geographical variation in microbial pattern and risk factors. However, data from the Eastern part of India are still lacking.

MATERIALS AND METHODS

A prospective longitudinal study was performed over 80 otherwise healthy type 2 diabetes patients with a follow-up for one year to (1) estimate the prevalence of ASB and its association with age, gender, duration of diabetes, and renal and glycemic status; and (2) identify the antibiotic sensitivity pattern of uropathogens as well as evaluate the usefulness of microbial pattern as a predictor of symptomatic UTI.

RESULTS

ASB was prevalent in 21.25% of type 2 diabetes population in our study. Klebsiella sp emerged as the commonest cause among males. The only risk factor for ASB was found to be long-standing type 2 diabetes. There was no association with age, gender, or recent glycemic status. Bacteriuric patients with worse baseline HbA1C values were at greater risk of UTI. Female diabetic patients with ASB due to Escherichia coli had significantly greater risk of developing UTI within one year.

CONCLUSION

A large-scale prospective study reproducing similar findings will genuinely obviate the need to review recommendations on screening of ASB due to E. coli in females with long-standing diabetes and poor glycemic control. Early adoption of stringent HbA1C lowering strategy and measures to improve genital hygiene can help prevent symptomatic UTI in these patients.

International Society for Companion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats

Urinary tract disease is a common clinical presentation in dogs and cats, and a common reason for antimicrobial prescription. This document is a revision and expansion on the 2011 Antimicrobial Use Guidelines for Treatment of Urinary Tract Disease in Dogs and Cats, providing recommendations for diagnosis and management of sporadic bacterial cystitis, recurrent bacterial cystitis, pyelonephritis, bacterial prostatitis, and subclinical bacteriuria. Issues pertaining to urinary catheters, medical dissolution of uroliths and prophylaxis for urological procedures are also addressed.

Phenotypic and Genotypic Characterization of Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Asymptomatic Bacteriuria in Pregnancy

Asymptomatic bacteriuria (ASB) has been consistently observed in pregnancy. However, there is a paucity of data on the prevalence and characteristics of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in ASB in pregnant women. Therefore, we sought to investigate ESBL-producing and multidrug-resistant Enterobacteriaceae in antenatal women with ASB. Urine samples were collected from 310 asymptomatic pregnant women attending primary antenatal clinics and screened for significant bacteriuria. Isolates of Enterobacteriaceae were phenotypically tested for their ESBL production. ESBL genes (CTX-M, TEM, and SHV genes) were then amplified by polymerase chain reaction (PCR). Multiplex PCRs were used to perform phylogenetic typing of ESBL-producing Escherichia coli isolates and to examine the commonality of sequence type 131 (ST131)-O25b and ST131-O16. A total of 103 (33.2%) pregnant women were positive for significant bacteriuria (80 Enterobacteriaceae). Of these isolates, 32.5% (n = 26) were ESBL producers and had a higher rate of multidrug resistance than non-ESBL producers. Genotypic characterization of ESBL-producing isolates showed that 84.6% had the bla_CTX-M gene (bla_CTX-M-15 = 77.3%; bla_CTX-M-9 = 18.2%). None of the isolates were of the TEM or SHV type. Half of the ESBL-producing E. coli isolates were of the phylogroup B2, and 4 (20%) isolates were of the ST131-O16 clonal subgroup. This study is the first in Egypt to provide evidence for the high prevalence of ESBL-producing Enterobacteriaceae in pregnant women with ASB. It also represents an important step toward genotypic characterization of this resistant form of bacteria, which may be useful for future antimicrobial studies.

Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis

OBJECTIVES

To critically appraise and evaluate the diagnostic value of symptoms and signs in identifying UTI in older adult outpatients, using evidence from observational studies.

METHODS

We searched Medline and Medline in process, Embase and Web of Science, from inception up to September 2017. We included studies assessing the diagnostic accuracy of symptoms and/or signs in predicting UTI in outpatients aged 65 years and above. Study quality was assessed using the QUADAS-2 tool.

RESULTS

We identified 15 eligible studies of variable quality, with a total of 12,039 participants (range 65-4259), and assessed the diagnostic accuracy of 66 different symptoms and signs in predicting UTI. A number of symptoms and signs typically associated with UTI, such as nocturia, urgency and abnormal vital signs, were of limited use in older adult outpatients. Inability to perform a number of acts of daily living were predictors of UTI: For example, disability in feeding oneself, + ve LR: 11.8 (95% CI 5.51-25.2) and disability in washing one's hands and face, + ve LR: 6.84 (95% CI 4.08-11.5).

CONCLUSIONS

The limited evidence of varying quality shows that a number of symptoms and signs traditionally associated with UTI may have limited diagnostic value in older adult outpatients.

The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents

Objectives:

To identify a set of signs and symptoms most likely to indicate uncomplicated cystitis in non-catheterized nursing home residents ≥ 65 years of age using consensus based methods informed by a literature review.

Design:

Literature review and modified Delphi survey with strict inclusion criteria.

Setting and Participants:

Expert panel of 20 physicians certified in geriatric medicine and / or medical direction, actively practicing in post-acute and long-term care settings.

Methods:

The authors performed a literature review to produce a comprehensive list of potential signs and symptoms of presumptive uncomplicated cystitis, including non-specific “quality control” items deemed unlikely to indicate uncomplicated cystitis. The expert panel rated their agreement for each sign/symptom using a 5-point Likert scale (1= strongly disagree to 5= strongly agree). Agreed upon signs and symptoms were summarized using a diagnostic algorithm for easy clinical use.

Results:

The literature review identified 16 signs and symptoms that were evaluated in three Delphi survey rounds. The response rate was 100% for round one and 95% for the second two rounds. Consensus agreement for inclusion was achieved for dysuria on round one with exclusion of the three quality controls, and “offensive smelling urine”. Consensus in the second round was reached for including 4 additional items (gross hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round three evaluated dysuria alone and combinations of symptoms. Consensus that dysuria alone is sufficient for diagnosis of cystitis was not reached.

Conclusions/Implications

The panel identified 5 signs and symptoms likely indicative of uncomplicated cystitis in nursing home residents and developed a diagnostic algorithm that can be used to promote antibiotic stewardship in nursing homes. Given similarities in populations, the algorithm may also be applicable to the older adult and the broader post-acute / long-term care populations.

Ultrasound screening for pyelectasis in pregnant women. Clinical necessity or "art for art's sake"?

Renal pelvicalyceal dilatation is caused by urine retention in the upper urinary tract. It is referred to as pyelectasis in medical literature. This term does not indicate the cause that leads to the dilatation of and urine retention in the renal pelvicalyceal system. Mild pelvicalyceal dilatation during pregnancy is usually considered to be physiological in nature – it can occur in up to 90% of pregnant women. Retention is more common in the right kidney, in primigravidae, in the second half of pregnancy and in multiple pregnancies. Pyelectasis during pregnancy rarely causes clinical symptoms and often does not require treatment. Nevertheless, urine retention in the renal pelvicalyceal system is conducive to the development of asymptomatic bacteriuria and may be a risk factor for recurrent urinary tract infections, pyelonephritis and acute kidney failure; it may also cause renal colic. In consequence, this condition can lead to intrauterine infection and premature labor in the pregnant woman and to prematurity, anemia, congenital pneumonia or sepsis in the child. In a study conducted at the 3^rd Department of Gynecology of the Medical University of Lublin it was concluded that unilateral pyelectasis of more than 20 cm³ is associated with a significant increase in the risk of asymptomatic bacteriuria. This volume corresponds to grade 3 and/or 4 pelvicalyceal dilatation according to the Society for Fetal Urology/European Federation of Societies for Ultrasound in Medicine and Biology classification. The pyelectasis volume measuring method using three-dimensional ultrasound scanning included in the criteria for the assessment of asymptomatic bacteriuria was assessed as sensitive and specific. The ultrasound-based evaluation of the kidneys for the presence of pyelectasis and its grade in pregnant women has some clinical implications. It allows for identifying cases with an increased risk of asymptomatic bacteriuria, which requires treatment in pregnant women. Screening during pregnancy for pyelectasis seems to be important in preventing asymptomatic bacteriuria from progressing to symptomatic urinary tract infection.

Antibiotics for asymptomatic bacteriuria in kidney transplant recipients

BACKGROUND

Asymptomatic bacteriuria, defined as bacteriuria without signs or symptoms of urinary tract infection (UTI), occurs in 17% to 51% of kidney transplant recipients and is thought to increase the risk for a subsequent UTI. No consensus exists on the role of antibiotics for asymptomatic bacteriuria in kidney transplantation.

OBJECTIVES

To assess the benefits and harms of treating asymptomatic bacteriuria in kidney transplant recipients with antimicrobial agents to prevent symptomatic UTI, all-cause mortality and the indirect effects of UTI (acute rejection, graft loss, worsening of graft function).

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 1 September 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs in any language assessing treatment of asymptomatic bacteriuria in kidney transplant recipients at any time-point after transplantation.

DATA COLLECTION AND ANALYSIS

Two authors independently determined study eligibility, assessed quality and extracted data. Primary outcomes were incidence of symptomatic UTI and incidence of antimicrobial resistance. Other outcomes included incidences of all-cause mortality, graft loss, graft rejection, graft function, hospitalisation for UTI, adverse reactions to antimicrobial agents and relapse or persistence of asymptomatic bacteriuria. We expressed dichotomous outcomes as absolute risk difference (RD) or risk ratio (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) with 95% CI. Data were pooled using the random effects model.

MAIN RESULTS

We included two studies (212 participants) comparing antibiotics versus no treatment, and identified three on-going studies. Overall, incidence of symptomatic UTI varied between 19% and 31% in the groups not treated for asymptomatic bacteriuria. Antibiotic treatment had uncertain effects on preventing symptomatic UTI (2 studies, 200 participants: RR 0.86, 95% CI 0.51 to 1.45). Risk for selecting multidrug-resistant organisms was uncertain with antibiotic treatment (1 study, 112 participants: RR 1.21, 95% CI 0.60 to 2.41). Persistence of asymptomatic bacteriuria was high regardless of treatment. Antibiotics also have uncertain effects on other important patient and graft outcomes, for instance on all-cause mortality (1 study, 112 participants: RR 2.23, 95% CI 0.21 to 23.86), graft loss (1 study, 112 participants: RR 1.11, 95% CI 0.07 to 17.36), acute rejection (1 study, 112 participants: RR 0.93, 95% CI 0.44 to 1.97), hospitalisation for UTI (1 study, 112 participants: RR 0.74, 95% CI 0.13 to 4.27), graft function (2 studies, 200 participants, MD in serum creatinine concentration -0.06 mg/dL, 95% CI -0.19 to 0.08) and adverse reactions (1 study, 112 participants: no severe adverse event attributable to the antibiotic treatment). Evidence quality was low for all outcomes.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to support routinely treating kidney transplant recipients with antibiotics in case of asymptomatic bacteriuria after transplantation, but data are scarce. Further studies assessing routine antibiotic treatment would inform practice and we await the results of three ongoing randomised studies, which may help resolve existing uncertainties.

Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections

Urinary tract infections (UTIs) are infectious diseases that commonly occur in communities. Although several international guidelines for the management of UTIs have been available, clinical characteristics, etiology and antimicrobial susceptibility patterns may differ from country to country. This work represents an update of the 2011 Korean guideline for UTIs. The current guideline was developed by the update and adaptation method. This clinical practice guideline provides recommendations for the diagnosis and management of UTIs, including asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. This guideline targets community-acquired UTIs occurring among adult patients. Healthcare-associated UTIs, catheter-associated UTIs, and infections in immunocompromised patients were not included in this guideline.

Pyelonephritis in Dogs: Retrospective Study of 47 Histologically Diagnosed Cases (2005-2015)

Background

The clinicopathologic aspects of pyelonephritis have not been reported in companion animals.

Hypothesis/Objectives

To evaluate the prevalence of pyelonephritis diagnosed in dogs in a academic referral population, describe the clinical signs and the diagnostic test results in dogs with pyelonephritis, and identify concurrent disorders in order to determine potential risk factors for pyelonephritis.

Animals

Forty‐seven dogs with a histopathologic diagnosis of pyelonephritis from the teaching hospitals of three Canadian veterinary colleges.

Methods

Retrospective case series. Review of medical records and renal histologic sections.

Results

Pyelonephritis was diagnosed in 0.4–1.3% of the cases at necropsy. Clinical signs included anorexia or inappetence (n = 27, 57%), lethargy (n = 24, 51%), vomiting (n = 17, 36%), and dehydration (n = 12, 25%). Thirty‐five dogs (75%) had concomitant disease(s). Escherichia coli was the most common pathogen isolated (37%). Pyelonephritis was classified as acute (n = 12, 26%), subacute (n = 9, 19%), and chronic (n = 26, 55%) disease; and mild (n = 7, 15%), moderate (n = 11, 24%), and severe (n = 28, 61%). Fever was significantly associated with histopathologically subacute pyelonephritis (P = 0.01).

Conclusions

In referral hospitals, pyelonephritis has a very low prevalence at necropsy. Nonspecific clinical presentation, concomitant diseases, and high variability in the diagnostic tests results make the antemortem diagnosis of pyelonephritis challenging. Neither the histopathologic stage nor the severity of the pyelonephritis was associated with fever, lumbar pain, or signs of a urinary tract infection (ie, lower urinary tract infection, upper urinary tract infection, or both) except for subacute pyelonephritis which was associated with fever.

Evaluation and management of Staphylococcus aureus bacteriuria: an updated review

BACKGROUND AND AIMS

There is little guidance regarding the evaluation and management of patients with Staphylococcus aureus bacteriuria (SABU). Here, we aimed to provide an up-to-date review of the literature.

METHODS

We searched PubMed, Scopus, and clinical trial registries for articles evaluating the epidemiology of SABU, risk factors of SABU, the association of SABU with urinary tract infection, bacteremia and invasive S. aureus infections, and the management of patients with SABU.

RESULTS

S. aureus is an uncommon isolate in urine cultures. It is more common among certain patients, e.g., patients with indwelling urinary tract devices or prior urinary tract instrumentation. SABU may represent asymptomatic bacteriuria, primary urinary tract infection, or hematogenous seeding of the urinary tract associated with other foci of infection. SABU may also serve as the focus for subsequent bacteremia and invasive infections. We did not find any clinical trials regarding the management of patients with SABU.

CONCLUSIONS

Based on our review, we suggest an algorithmic approach for the evaluation and management of patients with SABU. However, evidence from clinical trials is lacking and there are several gaps in the current literature. These are discussed in this review.

Significance of Asymptomatic Bacteriuria

Since the recognition of asymptomatic bacteriuria (ABU), several studies have questioned its significance. It is a very common condition, observed in many healthy individuals. Current guidelines mandate that ABU should not be treated in all cases, as it does not seem to improve the outcome. Conditional restrictions for treatment of ABU can be relaxed in certain situations, with minimal exceptions to the rule.

Epidemiology and outcome of antimicrobial resistance to gram-negative pathogens in bacteriuric kidney transplant recipients

BACKGROUND

In kidney transplant recipients, episodes of bacteriuria are often treated regardless of the presence of symptoms because of the lack of clear treatment guidelines suggesting otherwise. This practice may lead to the development of antimicrobial resistance. Our aim was to determine the incidence, determinants, and impact of antimicrobial resistance in kidney transplant recipients with gram-negative bacteriuria.

METHOD

We conducted a single-center, retrospective cohort study in patients who underwent kidney transplantation between January 2008 and June 2013. To identify risk factors for the development of resistance, we used a logistic regression model with generalized estimating equations to account for within-subject correlation.

RESULTS

Among the 318 patients who underwent kidney transplantation during the study period, 147 patients developed 555 gram-negative episodes of bacteriuria. Resistance to trimethoprim-sulfamethoxazole and quinolones, and production of extended-spectrum β-lactamase (ESBL) occurred in 52%, 21%, and 5% of isolated microorganisms, respectively. An increased risk of resistance to quinolones and production of ESBL were associated with concomitant diabetes (odds ratio [OR]: 2.29, 95% confidence interval [CI]: 1.11-4.74), the first year post transplantation (OR: 2.88, 95% CI: 1.36-6.09), and antibiotic treatment in the previous 6 months (OR: 3.36, 95% CI: 1.66-6.81). This resistance profile was also associated with the presence of symptoms, a longer duration of antibiotic treatment, and a higher rate of hospitalization.

CONCLUSION

Antimicrobial resistance to quinolones and production of ESBL were commonly seen, and were shown to demonstrate an adverse impact on outcomes in kidney transplant recipients with gram-negative bacteriuria. The decision on treatment for asymptomatic bacteriuria should be made with caution, given the potential for the selection of resistant strains.

Management of Asymptomatic Bacteriuria, Urinary Catheters and Symptomatic Urinary Tract Infections in Patients Undergoing Surgery for Joint Replacement: A Position Paper of the Expert Group 'Infection' of swissorthopaedics

In this position paper, we review definitions related to this subject and the corresponding literature. Our recommendations include the following statements. Asymptomatic bacteriuria, asymptomatic leukocyturia, urine discolouration, odd smell or positive nitrite sediments are not an indication for antimicrobial treatment. Antimicrobial treatment of asymptomatic bacteriuria does not prevent periprosthetic joint infection, but is associated with adverse events, costs and antibiotic resistance development. Urine analyses or urine cultures in asymptomatic patients undergoing orthopaedic implants should be avoided. Indwelling urinary catheters are the most frequent reason for healthcare-associated urinary tract infections and should be avoided or removed as soon as possible.

Functional urological disorders: a sensitized defence response in the bladder-gut-brain axis

Functional urological and gastrointestinal disorders are interrelated and characterized by a chronic course and considerable treatment resistance. Urological disorders associated with a sizeable functional effect include overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Poor treatment outcomes might be attributable to untreated underlying psychological and psychiatric disorders, as the co-occurrence of functional urological and gastrointestinal disorders with mood and anxiety disorders is common. The hypothetical bladder-gut-brain axis (BGBA) is a useful framework under which this interaction can be studied, suggesting that functional disorders represent a sensitized response to earlier threats such as childhood adversity or previous traumatic events, resulting in perceived emotional and bodily distress - the symptoms of functional disorders. Psychological and physical stress pathways might contribute to such alarm falsification, and neuroticism could be a risk factor for the co-occurrence of functional disorders and affective conditions. Additionally, physical threat - either from external sources or internal sources such as infection - might contribute to alarm falsification by influencing body-brain crosstalk on homeostasis and, therefore, affecting mood, cognition, and behaviour. Multidisciplinary research and an integrated care approach is, therefore, required to further elucidate and remediate functional urological and gastrointestinal polymorphic phenotypes.

Molecular Basis of Acute Cystitis Reveals Susceptibility Genes and Immunotherapeutic Targets

Tissue damage is usually regarded as a necessary price to pay for successful elimination of pathogens by the innate immune defense. Yet, it is possible to distinguish protective from destructive effects of innate immune activation and selectively attenuate molecular nodes that create pathology. Here, we identify acute cystitis as an Interleukin-1 beta (IL-1β)-driven, hyper-inflammatory condition of the infected urinary bladder and IL-1 receptor blockade as a novel therapeutic strategy. Disease severity was controlled by the mechanism of IL-1β processing and mice with intact inflammasome function developed a moderate, self-limiting form of cystitis. The most severe form of acute cystitis was detected in mice lacking the inflammasome constituents ASC or NLRP-3. IL-1β processing was hyperactive in these mice, due to a new, non-canonical mechanism involving the matrix metalloproteinase 7- (MMP-7). ASC and NLRP-3 served as transcriptional repressors of MMP7 and as a result, Mmp7 was markedly overexpressed in the bladder epithelium of Asc^-/- and Nlrp3^-/- mice. The resulting IL-1β hyper-activation loop included a large number of IL-1β-dependent pro-inflammatory genes and the IL-1 receptor antagonist Anakinra inhibited their expression and rescued susceptible Asc^-/- mice from bladder pathology. An MMP inhibitor had a similar therapeutic effect. Finally, elevated levels of IL-1β and MMP-7 were detected in patients with acute cystitis, suggesting a potential role as biomarkers and immunotherapeutic targets. The results reproduce important aspects of human acute cystitis in the murine model and provide a comprehensive molecular framework for the pathogenesis and immunotherapy of acute cystitis, one of the most common infections in man.

Infections continue to threaten human health as pathogenic organisms outsmart available therapies with remarkable genetic versatility. Fortunately, microbial versatility is matched by the flexibility of the host immune system which provide a rich source of novel therapeutic concepts. Emerging therapeutic solutions include substances that strengthen the immune system rather than killing the bacteria directly. Selectivity is a concern, however, as boosting of the antibacterial immune response may cause collateral tissue damage. This study addresses how the host response to urinary bladder infection causes acute cystitis and how this response can be attenuated in patients who suffer from this very common condition. We identify the cytokine Interleukin-1 beta (IL-1β) as a key immune response determinant in acute cystitis and successfully treat mice with severe acute cystitis by inhibiting IL-1β or the enzyme MMP-7 that processes IL-1β to its active form. Finally, we detect elevated levels of these molecules in urine samples from patients with cystitis, suggesting clinical relevance and a potential role of IL-1β and MMP-7 both as therapeutic targets and as biomarkers of infection. These findings provide a much needed, molecular framework for the pathogenesis and treatment of acute cystitis.

Increased infection risk after hip hemiarthroplasty in institutionalized patients with proximal femur fracture

In patients undergoing hip hemiarthroplasty (HHA) secondary to proximal femur fracture, acute periprosthetic joint infection (PJI) is one of the most important complications. We have detected an increased risk of PJI in chronic institutionalized patients (CIPs), and a higher number of early postoperative infections are caused by Gram-negative bacteria (GNB), not covered by the current prophylaxis (cefazolin in noninstitutionalized patients (NIPs) and cotrimoxazole in CIPs). We sought to compare infection characteristics between NIPs and CIPs, analyzing predisposing factors, causative pathogens, and antibiotic prophylaxis-related microbiological characteristics. We performed a retrospective review of our prospective institutional database to identify all patients consecutively admitted for HHA to treat proximal femur fracture at our centre between 2011 and 2013. PJI was diagnosed in 21 of 381 (5.51%) patients, with 10 of 105 (9.52%) in the CIP group and 11 of 276 (3.99%) in the NIP group, and statistical significance was achieved. GNB accounted for PJI in 14 (66.67%) patients. We detected a single case of methicillin-resistant Staphylococcus aureus (MRSA) infection in the NIP group. We confirm a higher risk of acute PJI among institutionalized patients, commonly caused by Gram-negative microorganisms, which are not covered by the current prophylaxis. New prophylactic strategies should be investigated in order to reduce this problem.

Diabetes Mellitus has no Significant Influence on the Prevalence of Antenatal Asymptomatic Bacteriuria

INTRODUCTION

Diabetes is a known risk factor for asymptomatic bacteriuria (ASB). However, the influence of diabetes on antenatal ASB was previously not addressed.

AIM

The prevalence of ASB, effect of risk factors and type of isolates and susceptibility patterns were studied in diabetic pregnancy.

MATERIALS AND METHODS

A total of 311 pregnant women were recruited for this study of which 103 were diabetic and 208 non-diabetic. A clean catch midstream urine samples were collected and cultured. The isolates were identified and antibiotic sensitivity was studied. The data was analysed by Chi-square test.

RESULTS

The prevalence of ASB in diabetic pregnancy was 38.83% (40/10(3); 95% CI: 23.73 - 53.94) and in non-diabetic pregnancy was 37.98% (79/208; CI: 27.28- 48.68). The odds ratio was not significant 1.0225 (95% CU: 0.65 - 1.599; p=0.922) and associated factors such as age and gestational period had no effect. The major isolates were Escherichia coli (25.0%), Staphylococcus aureus (22.5%), Coagulase negative staphylococci (CONS) (20.00%), and Klebsiella pneumonia (20.00%) in diabetic pregnancy and CONS (31.7%), E.coli (24.0%) and K.pneumonia (16.5%) in non-diabetic pregnancy. The isolates of diabetic pregnancy showed highest susceptibility to nitrofurantoin (56.4%), gentamicin (38.5%) and cotrimoxazole (38.5%) whereas that of non-diabetic pregnancy to gentamicin (43.0%), azithromycin (32.9%) and norfloxacin (30.4). There was no significant (p<0.05) difference in the type and susceptibly of the isolates between diabetic and non-diabetic pregnancy.

CONCLUSION

Diabetes has no significant influence on the prevalence of ASB in diabetic pregnancy both in terms of isolates and antibiotic susceptibility pattern.

The Basics of Bacteriuria: Strategies of Microbes for Persistence in Urine

Bacteriuria, the presence of bacteria in urine, is associated with asymptomatic, as well as symptomatic, urinary tract infection (UTI). Bacteriuria underpins some of the dynamics of microbial colonization of the urinary tract, and probably impacts the progression and persistence of infection in some individuals. Recent molecular discoveries in vitro have elucidated how some key bacterial traits can enable organisms to survive and grow in human urine as a means of microbial fitness adaptation for UTI. Several microbial characteristics that confer bacteruric potential have been identified including de novo synthesis of guanine, relative resistance to D-serine, and catabolism of malic acid. Microbial characteristics such as these are increasingly being defined through the use of synthetic human urine (SHU) in vitro as a model to mimic the in vivo environment that bacteria encounter in the bladder. There is considerable variation in the SHU model systems that have been used to study bacteriuria to date, and this influences the utility of these models. In this review, we discuss recent advances in our understanding of bacteruric potential with a focus on the specific mechanisms underlying traits that promote the growth of bacteria in urine. We also review the application of SHU in research studies modeling UTI and discuss the chemical makeup, and benefits and limitations that are encountered in utilizing SHU to study bacterial growth in urine in vitro.

The yin-yang driving urinary tract infection and how proteomics can enhance research, diagnostics, and treatment

Bacterial urinary tract infections (UTIs) afflict millions of people worldwide both in the community and the hospital setting. The onset, duration, and severity of infection depend on the characteristics of the invading pathogen (yin), as well as the immune response elicited by the infected individual (yang). Uropathogenic Escherichia coli (UPEC) account for the majority of UTIs, and extensive investigations by many scientific groups have elucidated an elaborate pathogenic UPEC life cycle, involving the occupation of extracellular and intracellular niches and the expression of an arsenal of virulence factors that facilitate niche occupation. This review will summarize the current knowledge on UPEC pathogenesis; the host immune responses elicited to combat infection; and it will describe proteomics approaches used to understand UPEC pathogenesis, as well as drive diagnostics and treatment options. Finally, new strategies are highlighted that could be applied toward furthering our knowledge regarding host-bacterial interactions during UTI.

Antibiotics for asymptomatic bacteriuria in pregnancy

BACKGROUND

Asymptomatic bacteriuria occurs in 2% to 10% of pregnancies and, if not treated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth.

OBJECTIVES

To assess the effect of antibiotic treatment for asymptomatic bacteriuria on the development of pyelonephritis and the risk of low birthweight and preterm birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomized trials comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Fourteen studies, involving almost 2000 women, were included. Antibiotic treatment compared with placebo or no treatment reduced the incidence of pyelonephritis (average risk ratio (RR) 0.23, 95% confidence interval (CI) 0.13 to 0.41; 11 studies, 1932 women; very low quality evidence). Antibiotic treatment was also associated with a reduction in the incidence of low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; six studies, 1437 babies; low quality evidence) and preterm birth (RR 0.27, 95% CI 0.11 to 0.62; two studies, 242 women; low quality evidence). A reduction in persistent bacteriuria at the time of delivery was seen (average RR 0.30, 95% CI 0.18 to 0.53; four studies; 596 women). There were very limited data on which to estimate the effect of antibiotics on other infant outcomes and maternal adverse effects were rarely described.Overall, all 14 studies were assessed as being at high or unclear risk of bias. While many studies lacked an adequate description of methods and the risk of bias could only be assessed as unclear, in almost all studies there was at least one domain where the risk of bias was judged as high. The three primary outcomes were assessed with GRADE software and given a quality rating. Evidence for pyelonephritis, preterm birth and birthweight less than 2500 g was assessed as of low or very low quality.

AUTHORS' CONCLUSIONS

While antibiotic treatment is effective in reducing the risk of pyelonephritis in pregnancy, the estimate of the effect is very uncertain because of the very low quality of the evidence. The reduction in low birthweight and preterm birth with antibiotic treatment is consistent with theories about the role of infection in adverse pregnancy outcomes, but this association should be interpreted with caution given the very poor quality of the included studies.

Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management

Urinary tract infections are more common, more severe, and carry worse outcomes in patients with type 2 diabetes mellitus. They are also more often caused by resistant pathogens. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. The new anti-diabetic sodium glucose cotransporter 2 inhibitors have not been found to significantly increase the risk of symptomatic urinary tract infections. Symptoms of urinary tract infection are similar to patients without diabetes, though some patients with diabetic neuropathy may have altered clinical signs. Treatment depends on several factors, including: presence of symptoms, severity of systemic symptoms, if infection is localized in the bladder or also involves the kidney, presence of urologic abnormalities, accompanying metabolic alterations, and renal function. There is no indication to treat diabetic patients with asymptomatic bacteriuria. Further studies are needed to improve the treatment of patients with type 2 diabetes and urinary tract infections.

Prospective audit and feedback in antimicrobial stewardship: is there value in early reviewing within 48 h of antibiotic prescription?

Antimicrobial stewardship programme (ASP) methodologies are not well defined, with most preferring to wait ≥72-96 h following antibiotic prescription before reviewing patients. However, we hypothesise that early ASP reviews and interventions are beneficial and do not adversely impact patient safety. This study aimed to evaluate the impact of early ASP interventions within 48 h of antibiotic prescription on patient outcomes and safety. A prospective review of ASP interventions made within 48 h of antibiotic prescription in Singapore General Hospital (SGH) from January to December 2012 was conducted. Patient demographics and outcomes were extracted from the database maintained by the ASP team. For culture-directed treatment, there was a shorter mean duration of therapy (DOT) in the accepted group compared with the rejected group (2.26 days vs. 5.56 days; P<0.001). ASP interventions did not alter the length of hospital stay (LOS), 30-day mortality, 14-day Clostridium difficile infection (CDI), 30-day re-admissions and 14-day re-infection (all P>0.05). For empirical treatment, a shorter DOT (3.61 days vs. 6.25 days; P<0.001) and decreased 30-day all-cause mortality (P=0.003) and infection-related mortality (P=0.002) were observed among patients in the accepted group compared with the rejected group. There was no significant difference in LOS, 14-day CDI and 30-day re-admission (all P>0.05). In conclusion, acceptance of early interventions recommended by ASP in SGH was associated with a reduction in DOT without compromising patient safety. This is evident even during empirical therapy when not all clinical information was available.

Interleukin-6 concentrations in the urine and dipstick analyses were related to bacteriuria but not symptoms in the elderly: a cross sectional study of 421 nursing home residents

Background

Up to half the residents of nursing homes for the elderly have asymptomatic bacteriuria (ABU), which should not be treated with antibiotics. A complementary test to discriminate between symptomatic urinary tract infections (UTI) and ABU is needed, as diagnostic uncertainty is likely to generate significant antibiotic overtreatment. Previous studies indicate that Interleukin-6 (IL-6) in the urine might be suitable as such a test. The aim of this study was to investigate the association between laboratory findings of bacteriuria, IL-6 in the urine, dipstick urinalysis and newly onset symptoms among residents of nursing homes.

Methods

In this cross sectional study, voided urine specimens for culture, urine dipstick and IL-6 analyses were collected from all residents capable of providing a voided urine sample, regardless of the presence of symptoms. Urine specimens and symptom forms were provided from 421 residents of 22 nursing homes. The following new or increased nonspecific symptoms occurring during the previous month were registered; fatigue, restlessness, confusion, aggressiveness, loss of appetite, frequent falls and not being herself/himself, as well as symptoms from the urinary tract; dysuria, urinary urgency and frequency.

Results

Recent onset of nonspecific symptoms was common among elderly residents of nursing homes (85/421). Urine cultures were positive in 32% (135/421), Escherichia coli was by far the most common bacterial finding. Residents without nonspecific symptoms had positive urine cultures as often as those with nonspecific symptoms with a duration of up to one month. Residents with positive urine cultures had higher concentrations of IL-6 in the urine (p < 0.001). However, among residents with positive urine cultures there were no differences in IL-6 concentrations or dipstick findings between those with or without nonspecific symptoms.

Conclusions

Nonspecific symptoms among elderly residents of nursing homes are unlikely to be caused by bacteria in the urine. This study could not establish any clinical value of using dipstick urinalysis or IL-6 in the urine to verify if bacteriuria was linked to nonspecific symptoms.